By Michael “The PACSman” Cannavo

Famed ballet dancer Twyla Tharp once said, “The only thing I fear more than change is no change. The business of being static makes me nuts.” While medical imaging has changed and continues to change, it is more like a metamorphosis or evolution than a radical transformation. The basic form and function of PACS really hasn’t changed that significantly in over a decade, yet several improvements have been made to it.

Many of these changes are related to technological advancements while others are connected to addressing operational needs. Faster local and wide area networks are allowing for larger studies to be transmitted, and allow for real-time image processing in the advanced visualization arena. Faster CPU speeds and more advanced operating systems allow for items like zero footprint viewers (ZFV) that are browser-independent to be used.



Imaging has eliminated what one company calls the “silo syndrome." This is a technology deficiency that inhibits organizations from effectively distributing imaging and related data across a network. Instead, imaging has become one of many clinical systems that can be pulled together to help create the full electronic health record (EHR). This is crucial in helping to obtain Meaningful Use dollars for facilities and physicians as well as allowing for the creation of a personal health record (PHR).

Most estimates reveal that over 95 percent of hospitals in the U.S. employ some form of PACS, with a large majority of those on their second, third or even fourth generation PACS. About half of these facilities stick with the incumbent vendor and simply upgrade to the latest version of software (usually with a hardware refresh as well) while the balance switch vendors entirely. Those who stick with the same vendor will sometimes perform a PACS optimization as well. A PACS optimization is a detailed study of how their PACS is being used and ways end users can get the most out of the system. It includes looking at the hardware and software, archive and network for potential upgrades, evaluating the disaster recovery plans and discussing bottlenecks and issues. It features a full operational review that goes from check-in to check-out, reporting, advanced software use and areas of similar functionality.

It also includes use and optimization of the radiologists’ reading stations, change management protocols, policies and procedures review, legal reviews that include addressing records retention, ways to meet the MQSA (Mammography Quality Standards Act) requirements, dose management and reporting, critical results, and emergency room (ED) discrepancy reporting. It is important to have clearly defined roles and responsibilities for everyone involved with the PACS. This is crucial if a facility is to have a smooth running PACS.

Vendor-neutral archives (VNAs) have been a hot topic in recent years. Eric Rice, chief technology officer with VNA provider Mach7, explains: “Accessibility to unstructured clinical data, including radiology imaging, endoscopy videos, oncology reports and much more is no longer a ‘nice-to-have’ feature for health care systems. State and federal regulations and incentives are pushing health care systems to make available complete medical records to patients and enable the data to be exchanged between providers.

For many health care systems, this may not be a simple task. Even within a single enterprise’s radiology department there may be numerous PACS vendor solutions following M&A activities. With the right vendor-neutral technologies, however, these challenges can be simplified. The value of consolidating unstructured clinical media within a vendor-neutral archive goes beyond the core dollar value savings in storage costs. A vendor-neutral archive is your EMR for clinical media — your unstructured clinical data. Your EMR for clinical media can provide the platform for data access, exchange and sharing across your enterprise ecosystem of clinical applications.”

The VNA market has been in flux, with a host of mergers and acquisitions over the past year. These include: the sale of Lexmark/Perceptics Software (formerly Acuo) to a Chinese consortium in April; Fuji purchasing TeraMedica last year; Merge Healthcare’s purchase by IBM in 2015; and Philips’ recent deal with Hitachi Data Systems. Mach7 recently completed its merger with Australian provider 3D Medical Limited, although both companies will ostensibly remain the same. This has many end users wondering just how stable the VNA market really is at a time when enterprise-wide solutions are becoming the name of the game and a central data repository is needed most.

Mach7’s Rice continues: “Our industry finds [itself] in a typical technology situation where demands from users have pushed vendors to deliver technologies ahead of the standards. Traditional PACS vendors were driven to come up with architectures, designs and features ahead of the standards. Today, however, the standards exist to interoperate and provide the clinical features required. Sadly, we find ourselves stuck with the legacy of proprietary formats and integrations that have locked us into yesterday’s technology. As a provider of vendor-neutral technologies, our job is to untangle that web and to accelerate our market beyond the challenges of the past so that we can focus on advancing our industry.”

Medical image exchanges (MIEs), also known as medical image sharing (MIS), were first shown at RSNA in 2009 and have taken off in recent years. Rather than using traditional media, such as a CD or DVD, and either shipping the data out on disks or having patients carry it with them, this technology now allows for the sharing of these images using either the cloud or point-to-point communications, or both. MIS is used by hospitals, imaging centers, PCP’s offices and others, allowing clinicians to have immediate access to images and information from all clinical systems as opposed to waiting for physical media to arrive. DICOM and non-DICOM images are typically supported as are jpeg, mpeg, avi, pdf, doc and other file formats. Having access to a patient’s medical history improves the point-of-care service.

Patients are also able to receive their imaging exams electronically, without having to carry and store physical media. It also allows for the ability to see physicians in multiple locations and have studies available there as well. “The new value-based care models require new tools for imaging,” said Morris Panner, CEO of DICOM Grid, an MIE provider. “At first, clinicians deployed DICOM Grid to access imaging imprisoned by PACS and old-style VNA. The trend we’re seeing today is that radiologists are implementing true cloud VNA and image exchange to be at the center of the care network, which extends well beyond the hospital.”

There are well over a dozen vendors competing in the MIE marketplace in addition to all the major PACS providers, with physical, cloud and hybrid solutions all being offered as transport mechanisms. Many systems allow health care providers to use a cloud platform with the full image management stack including image exchange, VNA and an integrated universal (FDA 510k cleared) viewer, while others just use an MIE solution alone. Major health systems often leverage the MIS platform as an interoperability layer for imaging and running traditional PACS systems for their basic needs, but use a third-party provider like DICOM Grid for outside image management, archive and more.

Since the ransomware case that occurred at a southern California hospital in February, hospitals nationwide have been looking at ways that their security can be strengthened. This is especially important with PACS, where so many devices are interconnected, allowing for several ways to access the PACS server and other clinical systems by staging a back-door attack. Several PACS now use a combination of physical and virtual servers, and both need to be properly secured.

Third-party systems like MIEs typically involve a locally installed server, which sits behind the firewall, allowing secure transmissions with outside facilities, but not all are like this. Asking questions about how the system connects to other systems and devices eliminates much concern after the fact. Interoperability ranks as No. 1 in terms of importance among end users and vendors alike. With more use of the word “enterprise” than a Star Trek episode, health care has changed to look more closely at the big picture than the needs of the individual departments.

Everything needs to work seamlessly together. Nearly everyone in the medical imaging field is familiar with DICOM and HL-7 standards, but the Integrating the Healthcare Environment initiative, better known as IHE, is the future of medical imaging interconnectivity. The IHE website (www.ihe.net) states, “IHE is an initiative by health care professionals and industry to improve the way computer systems in health care share information. IHE promotes the coordinated use of established standards such as DICOM and HL-7 to address specific clinical needs in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement and enable care providers to use information more effectively.” Over a dozen clinical domains are addressed by IHE and more than 135 member organizations — professional societies, government agencies, provider organizations, HIT companies and others — have joined the IHE initiative worldwide.

IHE defines integration profiles that provide the framework for interoperability and holds “connectathons” that test and demonstrate interoperability and conformance to the standards. Tomer Levy, general manager, workflow and infrastructure at McKesson, highlights the trends that will drive interoperability. “Medical images cannot be interpreted without the clinical context if we want to achieve better quality and better outcomes. The clinical context resides either in the big health care IT systems, primarily the EMR, or in siloed IT systems across the enterprise or even beyond it.

“When choosing the next imaging vendor, and that may be for traditional PACS, a VNA or a workflow solution, make sure interoperability is a key consideration. And interoperability is a two-way street. A technology vendor needs not only to expose data through standard interface, but also to be able to consume data from other systems to be seamlessly incorporated into the different workflows that are managed by that system. A truly advanced system will be able to share workflows, not just the data.” There are a number of factors that should go into the selection of these important systems.

They include:
• Supporting the interoperability of systems to help streamline and simplify the complex processes so that customers can efficiently and effectively manage core operations.
• Understanding and supporting the distinctive workflow needed in the highly complex imaging and content management departments. Customers need to look beyond the simple feature/functionality to know what is needed to be successful and provide systems that are flexible in capability and expand to support future growth.
• Investing in the future of health care, which has unique needs for workflow and data management. The PACS, VNA or ECM vendor should have a long and proven record in health care and be committed to the market.

PACS is so much more than just a radiology system today and the changes to it are significant. The use of 3-D printing and modeling in conjunction with high resolution CT imaging and advanced visualization software have allowed surgeons to do much better surgical planning than before, and even allows for the creation of extremely cost-effective prosthetics.

PACS are also having to last longer as well. While five years was the typical replacement cycle, now PACS must last seven years or longer, yet still be able to support software updates and upgrades without having to do major hardware refreshes. These can still be challenging, as for every item you typically “gain” with an upgrade you typically lose another one that you may have gotten used to using on a regular basis. Sadly, most end users usually don’t realize this until after the upgrade or update has been completed because the right questions weren’t asked and none of the information was volunteered by the vendor.

PACS has a lot of things still going for it and will for quite some time. While PACS is mostly a replacement market today, the add-ons and newer technologies keep it interesting and allow it to become an integral part in creating the utopian electronic health record (EHR) that is the goal of each facility.