PACS veterans eye storage, compatibility for new units

Since early adopters began purchasing PACS in the 1990s, the technology has come of age. Those first systems, in many cases, have simply aged. While first-time buyers still make up the bulk of PACS sales, vendors expect a growing market for upgrade and replacement sales.

Some radiology departments are finding that their platforms are no longer supported or are cumbersome compared with current models. Others are looking for integration and storage options that better mesh with the hospital-wide IT strategy. Still others need to better support a growing business model. Regardless, the decision making is an elaborate process that involves more stakeholders than ever.

At Hurley Medical Center in Flint, MI, both radiologists and hospital IT staff took an active interest when the radiology department upgraded to a new PACS platform in January. The hospital is planning a RIS upgrade in April. Software, integration between PACS and RIS, and user-friendliness are among the factors the stakeholders consider as their radiology informatics structure evolves, according to RIS/PACS specialist Carole Carpenter.

"You always lose something in the translation when you go from HIS to RIS to PACS or anything else," she said. "The industry is definitely getting better with integration standards, however."

Hurley bought its first RIS in 1999 and its first PACS in 2001. The systems are managing the 115,000 or so cases the hospital sees per year, but the facility has filed a certificate-of-need request for a new CT scanner, preferably a 64-slice model to augment its current single- and dual-slice units. The resulting onslaught of images could max out its storage, so Carpenter is also looking to upgrade that this summer. And Hurley is beginning to investigate purchasing a new PACS in 2006.

Whether a facility ends up replacing or upgrading often relates to whether a system was updated over the years of its use or was a one-time purchase with no subsequent upgrades, said Henri "Rik" Primo, director of marketing and strategic relationships for Siemens' image management division.

"The bottom line is if you have to buy a completely new PACS, it means you didn't upgrade your system over the past three or four years," he said. "Some departments build in ongoing operational costs, and it doesn't hit them all at once. In many cases, if you're replacing an outmoded PACS, you'll find that the rest of the IT systems are in similar shape, and the RIS and HIS are also outdated."

Not upgrading or replacing is not an option in an era when a single CT scan can produce thousands of images. That changes some of the dynamics of the financial planning for early adopters, who five years ago might have expected to pay for their PACS with film savings. In the years that followed, they realized those savings, and PACS became integral to department functioning.

At the same time, IT systems were coming of age in different parts of the hospital, and a PACS or RIS decision once spearheaded by a radiology department may have more stakeholders today, including hospital informatics staff, executives, and other clinicians who will interact with images and reports from workstations around the hospital. As at Hurley, radiologists' needs and wants for image control and manipulation are key, but they are weighed alongside other factors:

- compatibility with the hospital information system and its various contributing systems;

- possibility of migrating multiple data archives to a common storage solution for economies of scale; and

- the financial incentives for purchasing multiple hospital IT packages from a single vendor.

At Radiology Ltd. in Tucson, AZ, radiologists chose a replacement PACS based on their own work preferences. The practice owns four outpatient imaging centers and has reading contracts with four local hospitals, each of which has its own RIS, patient identification system, and information systems, with varying levels of sophistication. Integration, for the moment, is not a pressing concern, but creating a virtual network was. All the facilities are linked to allow subspecialists to read appropriate cases regardless of location, and a Web server enables referring physicians to access studies remotely, according to PACS administrator Ron Cornett.

"The big driver for us was functional tools: How can the images be delivered to the radiologists for minimal manipulation and most efficient reading?" he said.

At the other end of the spectrum, everyone at Cedars-Sinai Medical Center in Los Angeles had a say in the radiology department's plan to move from its old platform to a new one.

"The CEO, COO, CMO, CIO, and CFO all approved our upgrade to a new PACS, and our IT department played a significant role in the approval process," said David Brown, PACS/RIS manager. "One IT director is also director of the surgical ICUs and has been a champion for the attending physicians. For the whole approval process, we've had presentations and meetings for all the parties involved."

Cedars-Sinai installed PACS in late 1999 and early 2000 after first transitioning from a network of ICU soft-copy review stations that displayed digitized films to a true filmless environment as part of a Y2K upgrade. Higher volumes and plans to build a new imaging center made a film-based workflow unappealing.

The medical center has stretched its existing PACS platform to the limit with 44 workstations and 386,000 cases a year and a store-and-forward archive that is barely keeping pace. The facility actually has four PACS in place: radiology, ultrasound, echocardiography, and the cardiac cath lab. At the moment, each has its own storage, but eventually all four will migrate to a common RAID-based system that is cheaper to scale in bulk than separate systems.

The storage situation plays heavily into Cedars-Sinai's strategy to make its informatics investments more cost-efficient. An intelligent storage management software will sort cases by type and keep or discard them based on preset criteria. A mammogram may stay in the system for 25 years, for example, while a standard study may be kept for a much shorter time.

Building better infrastructure will help, too. Diagnostic workstations will be connected to gigabit Ethernet, resulting in improved radiologist efficiency. The PACS Web server used to average 50 visits a day but now averages 400, and it supports more than 700 PCs located on the clinical units, improving attending physician efficiency.

COST OF DOING BUSINESS

One major distinction between a first-time and repeat PACS purchase is the finance mentality. Whereas a radiology department might have weighed a new MR unit versus a PACS in 1998, that purchase quickly becomes a line item that is maintained in following years.

The cost of the transition to a new PACS is significant even when staying with the same vendor, but Cedars-Sinai will again go with an upfront capital purchase for its vendor's new platform. Other facilities, including Hurley, plan their expenditures on a predictable lease arrangement, usually with a buyout option at the end of the term. For Cedars-Sinai, Brown investigated leases as well as a variety of application service provider scenarios to pick up hardware and software separately. He still includes film savings as a part of the equation, though more as an indicator of how infeasible it would be not to have PACS.

"Our savings on film is huge. We still spend over $218,000 a year on film for mammography and surgery and referrers who want it, but if we stayed on film it would cost us $1.5 million today," he said.

A PACS in the OR is in the works, Brown said.

On pace with their more sophisticated hardware and software, vendors are offering more customizable options for financing and, increasingly, service.

"We see a movement toward more creative financing: leases or ASP arrangements, etc." said Dave Mahoney, vice president of sales for eMed. "Clients are putting it in their yearly budget. Service contracts are following suit, and vendors are offering discounts for commitments and multiyear plans, or setting up deals in which the customer is responsible for hardware and the vendor for software."

Five to eight years ago, storage was a huge drain on resources. Custom-packaged storage solutions were part of many PACS purchases and required major expenditures to keep up with media space requirements. Today, storage is a commodity.

"PACS' price point has come down, especially in storage media. RAID, tape, and optical disks are all less expensive today," said Tom Wilton, health information sales specialist for Kodak's health imaging group. "In the past, archiving was a big part of the cost, but now we offer buy-as-you-need RAID archives with 146-GB drives, and the size could double in 2005. No one is rushing to spend for long-term storage."

SLOW AND STEADY CONVERSION

At Cedars-Sinai, Brown expected to take delivery of his new servers in mid-January and to convert the radiology workstations from the old system to the new over a single weekend. The department will operate during the transition with a certain amount of safety-oriented redundancy: Modalities will feed into the old PACS, and the old PACS will feed to the new PACS, which in turn will deliver to the workstations. One by one, he will bring the modalities over to feed directly into the new PACS.

On the radiologist front, a major consideration is training. It turns out that users need just as much training moving from one PACS to another as they do when starting up a filmless work environment for the first time. Training at Cedars-Sinai began several weeks before the workstation conversion date, with support staff and booster training scheduled in the weeks following.

The hardware conversion will take longer. Once the front-end processes are working smoothly, Brown and his team will address the back end of the system, including migrating data from the old PACS to the new.

"We want to minimize any interruptions from the conversion to PACS. Some things we'll do quickly, others slowly," he said. "We'll keep our old PACS online to be queried, and we'll revisit the data migration issue after we go live. Ultimately, the hardware will be difficult to support, but we will deal with it in a controlled fashion."

Radiology Ltd. has found that nearly two years after its conversion from its initial PACS to a new system, the process is not complete. In 2003 it migrated systems and converted from a tape archive to a mirrored storage area network environment. The 500,000 to 600,000 cases that come in from its eight hospital or imaging center sites have already filled up 7 TB of storage, but Cornett keeps the old tape archive handy.

"We had two years of data on our Web server from our teleradiology service, but we probably lost 20% of that when we migrated," he said. "We have a three-person reconciliation team to go through our upcoming case list and correct the medical record numbers from the old and new systems and different hospitals and pull the priors off the tape as needed."

While the transitions aren't seamless, they are becoming part of the price of doing business, industry observers note.

"Anyone who has had PACS, despite some initial pain, won't go back to a film-based environment," Wilton said.

Ms. Lowers is special projects editor for Diagnostic Imaging.

Sizing up bells and whistles

Storage, scalability, and enterprise compatibility are top motivators for making a replacement PACS purchase, but Amicas CEO Hamid Tabatabaie outlined other features that could tip the scales:

Old PACS

- Login limited to certain workstations

- 3D limited to dedicated workstation or trained staff

- Expensive incremental growth costs for expansion

- Expensive support contracts-up to 30% of PACS cost annually

- Downtime, scheduled and unscheduled, of several hours weekly

New PACS

- Personalized tool set available upon login from anywhere

- Built-in 3D manipulation tools

- Commodity cost structure for work stations and storage

- Cheaper, more customized service arrangements

- Downtime limited to minutes per week