By Michael J. Cannavo, "The PACSman"

At RSNA 2015, hospital decision-makers walked the exhibit hall show floor trying to figure out exactly where PACS fits in their long-range strategic plans. Does it remain as it is today, primarily as a standalone radiology system, does it join other clinical imaging systems like cardiology to become an Integrated imaging Solution (IIS) or does it become a part of an enterprise-wide electronic health record (EHR)? The answer, not surprisingly, is all of the above.

There are a host of variables that make up the role PACS plays in an organization. Ultimately PACS will play a major role in an integrated EHR as well, but when depends on things like the hospital size, budget and available resources to assist with the connectivity. David Smarro, CEO of INFINITT North America, agrees with this assessment. “Smaller hospitals are still pretty departmentalized, so it will take a while for Enterprise Imaging (EI) to be embraced by these entities.



In general, they don’t have the budget or the infrastructure for enterprise imaging solutions right now. In the larger hospital market, the enterprise component is mainly the archiving and the access/distribution of images, and the integration with the EMR and Health Information Exchanges (HIEs). These larger facilities are moving to consolidate their archives and reduce the number of vendors they have to work with."

He continued, “The industry is moving to an enterprise solution, in that we are moving away from siloed architectures, but that will take time. On the viewer side, the radiologists will not be giving up their PACS or the deep functionality that has been developed to meet their reading/diagnostic requirements. The cardiology department will not be willing to give up their PACS either, and the workflow gains they have won by consolidating their modalities into a single viewing and reporting environment.”

Several industry insiders agreed with Smarro’s overall view, yet took a slightly different approach. “The starting point is really your definition of enterprise PACS. The marketplace is moving toward enterprise imaging but is still focused on radiology imaging. It’s more of an evolution than replacing PACS,” said Mats Björnemo, vice president of product management at Sectra Imaging IT Solutions AB. “Enterprise imaging is becoming an important component of what end users see and want to develop. It’s not just about radiology anymore, but an integrated part of the entire enterprise. Radiology is no longer considered an island with the transition to valuebased radiology.

When one looks at the buzz words in the market in the past few years and the underlying trends, the impression is that we are shifting from a deconstructed to constructed PACS/best of suite approach. Customers want clinical benefits and one point of contact. That is not saying they go with a monolithic IT approach, but instead will require open application program interfaces (APIs) and standards compliance to achieve their end goals. I don’t see us going back to traditional PACS. ”

Lenny Reznik, vice president of marketing at Agfa HealthCare, believes in using what you have to get where you are going. “PACS, as traditionally defined, is a siloed information system for radiology and cardiology, where enterprise imaging (EI) is the ‘new’ PACS. We consider enterprise imaging to be a single comprehensive patient imaging record that enables multi-specialty collaboration and have adopted a platform strategy to deliver this. We can integrate whatever the customer is looking for using a single modular platform as they move forward. We’re not telling the customer to throw anything away but rather to pull all the parts together using interoperability standards.”

Tomer Levy, general manager of workflow and infrastructure at McKesson, says his company takes the same basic approach and elaborates further. “Electronic imaging isn’t about replacing PACS per se, but rather getting more from your PACS and connecting different PACS together. This becomes relevant as more organizations deal with mergers and acquisitions and need to be able to implement the enterprise imaging strategies that span across the enterprise. What everyone’s imaging is about is implementing imaging across the enterprise — making more of your PACS, if you will — and creating an interoperable workflow across the entire enterprise. “

Interoperability was without a doubt the leading area of interest at RSNA 2015. There has been a lot of discussion around both DICOM and IHE (Integrating the Healthcare Environment) standards and how vendors have adhered to them. As Levy of McKesson indicated, integrating disparate clinical systems is key, given the marketplace consolidation. It is also important in implementing new technologies like breast tomosynthesis and other applications. Typically there is a two- to five-year delay from the time a standard is formally adopted by the various DICOM and IHE committees until it is implemented by the vendors. This causes a bit of confusion with end users who hear about a new standard and expect its adoption by the vendors to be nearly instantaneous.

Sectra’s Bjornemo points out, “Consolidation of imaging, integration of diagnostics, radiology and pathology working together, is not just managing the data but seeing how it develops the clinical practice, and improving the diagnostic side is key. Open APIs and standards compliance and the ability to connect systems needs to continue to create a richer clinical context for users. There is also a shift toward quantitative imaging — allowing health care to become more data-driven — and bringing it all together makes the value of this data even greater.”

James Brusco, product manager, PACS, for Siemens Medical Solutions USA Inc. states, “In choosing an enterprise imaging solution such as a DICOM/Multimedia VNA (Vendor Neutral Archive) with viewer capability, customers should focus on flexibility and modularity so that they can purchase features and modules which suit their needs. You also need upward and outward scalability to expand the solution’s capacity and to add additional features and modules without fork lifting out the initial purchase.”

So what are the factors that a hospital needs to consider when choosing a system? Interestingly, price isn’t really a major consideration any longer since there are so many other options available. Software-only solutions, also known as SaaS (Software as a Service) is a direction that many vendors are moving toward. Also known as on-demand software, SaaS is a software licensing and delivery model where software is licensed on a subscription basis and is centrally hosted. SaaS is typically accessed by using a Web browser, and is often the driving force behind enterprise imaging strategies. One of the biggest selling points for SaaS is the potential to reduce IT support costs by outsourcing hardware and software maintenance and support.

INFINITT’s Smarro identified several trends going on within hospitals. “One of the trends we see is hospitals moving away from the hardware purchase with the PACS vendor. The years of ’rack ‘em and stack ‘em’ are long gone. Others want software-only solutions but lack the resources to perform the integration. We have gone full circle again with a modified version of the vendor providing the hardware and software solution. Internal resource availability is key, but unfortunately there are fewer resources to use in most facilities. “

The market has changed in the past few years from one where hardware is on site to one where the physical location of the hardware is immaterial. IT organizations are challenged by the limitations of today’s servers, which are designed to run just one operating system and application at a time. As a result, even small data centers have to deploy many servers, each operating at just 5 to 15 percent of capacity — highly inefficient by any standard. Virtualization uses software like VMWare to simulate the existence of hardware and create a virtual computer system. Doing this allows businesses to run more than one virtual system — and multiple operating systems and applications — on a single server. This can provide economies of scale and greater efficiency.

Smarro shared how this change has impacted his company’s approach to PACS, stating, “We used to deliver racks of servers but now they’re only interested in the software loaded on their VMware. That depends on the ability of the customer though. Some hospitals want their own VM that’s hosting everything. That can be problematic because you can’t hold a vendor accountable to the SLA (Service Level Agreement) if their system is intermixed with other systems. We are seeing some of the large institutions that have tried that and are now moving away from it. They want the PACS in its own infrastructure so the system doesn’t become overburdened and slow down PACS performance.”

When asked about what else was important, Smarro talked about how the Information Technology department is impacting the global design of PACS. “Scalability is a major issue, but not just scalability to include greater volumes of data. You need the ability to scale up in complexity as well, which is where interoperability also comes in.

With a well-designed VNA you can manage the data from other systems while leaving the other systems alone. In this case, the enterprise viewer sits on top of the VNA. You also want the VNA option for off-site disaster recovery to comply with HIPAA. Reliability is another key issue, as is responsive service. Hospitals today want support for multiple sites and multiple departments. They also want support beyond DICOM. Another important factor is ongoing product development and an upgrade path that gives you a way to upgrade to the latest version without the pain of a forklift upgrade.”

Sectra’s Bjornemo agrees with this approach as well. “A lot of hospitals have invested in VNAs over the past few years, but outside of consolidating data to the IT side of the house there really wasn’t as much clinical benefit. We need to look closer at the clinical side of IT as well as radiology, and how it is leveraged by end users. EMR integration is driving clinical workflows and how they all work together is critical. Stability, performance, resilience, capability, workflow efficiency, support services, are all items that are crucial to being looked at more closely.”

Agfa’s Reznik keeps it simpler. “Number one is interoperability, whether it’s into the EMR or other aspects of the imaging space. It can’t be a departmental silo anymore — those days are long over.” There was an emphasis on health IT and image sharing at last year’s RSNA show as well. Some people suggested it’s a sign that HIMSS (Healthcare Information and Management Systems Society) is becoming a more industry-relevant event. Indeed, at last year’s HIMSS annual meeting in Orlando there was a huge focus on VNAs, interoperability solutions and similar items.

Interestingly, some of the biggest vendors in the electronic health record/electronic medical record (EHR/EMR) space, including Cerner, Epic , Allscripts, and others, either do not offer products, or are not considered by most to be major players in the electronic imaging (EI) space. Of the top 10 vendors identified by Beckers Health IT and CIO review, only GE and McKesson are considered players in the EI space. It would be nice to think that will change with a few pending acquisitions on the horizon, but the reality is that most of these vendors prefer to play in the space they are comfortable in and instead maintain Swiss neutrality with all vendors and interface to every market player instead.

Agfa is under the umbrella of convergence and knows it has to play with everyone. Reznik said, “The days of specialty standalone vendors are limited. When we look at the IT space in general it is the platform vendors (Epic, Cerner, et al.), from an applications standpoint, who are the longterm winners in the EHR space, not the imaging players, so we all need to play well together.”

The cloud has always been a major area of interest, but interestingly, many vendors use it for remote hosting vs. primary data and image storage. This is not universal by any means, but just an overall trend. INFINITT, for example, sees customers moving to a hybrid version of the cloud with a combination of on-site and some off-site storage. “Customers want to keep control of their data, but the volume of data is growing too large, plus they also need offsite backup. No one wants to go back to tape. One of our large university hospitals will keep 1 years’ data on site with a special caching server while all other data resides in the cloud,” said Smarro.

Where the technology is heading is a matter of intense interest for vendors and end users alike. Siemens’ Brusco summed up what every other vendor felt. “PACS is continuing to evolve toward providing more intelligent tools, automated workflows, and the ability to read diagnostic images from remote locations. Enterprise Imaging continues to evolve from basic DICOM VNA functionality into more modular solutions that can provide additional benefits such as multimedia archiving, zero-footprint viewing, image exchange, patient portal, multifunction and batch importing, and other related capabilities.”

PACS continues to evolve to meet the ever-changing demands of an evolving marketplace. The future for PACS is different for sure, but remains bright for a technology that few, if any, feel they can live without anymore.