More and more hospitals aspire to the holy grail of a picture archiving and communications system (PACS) with its obvious benefits and power. But the multimillion-dollar price tag for a typical PACS installation is beyond the capability of most small and medium-size institutions. Some vendors are offering scaled down systems with less capability and speed, while others are experimenting with a new form of business called ASP, or application service provider. ASPs offer many potential benefits for patients and providers, but they also offer challenges and problems and should be approached with caution by hospitals and imaging centers until the industry sorts itself out and/or standards and policies are established to guide buyers and vendors.

In theory, ASPs offer hospitals a sophisticated PACS system with integrated on-site acquisition modalities and interpretation quality hardware, but off-site storage, distribution, and archiving services in real time over the Internet or some other form of secure, direct connection. The off-site facilities are shared by multiple institutions, producing economies of scale. The images are usually distributed via Web server and viewed in clinical settings with a simple Internet browser, simplifying distribution and software upgrades. The ASP provides technical support and manages the system and all technical personnel. Aside from PACS, the other services ASPs might provide include: full radiology information system (RIS) functionality, disaster recovery, subspecialty over-reads, primary interpretation, night coverage, 3-D services, and online continuing medical education. ASPs typically charge for the services by the examination or transaction, eliminating up-front capital costs, although, with some vendors, examinations may cost more to service during the first years of operation.

The benefits are many. ASPs may make it possible for smaller institutions and imaging centers to enjoy the benefits of PACS. They reduce the need to operate a complex computer network and the difficulties of finding and managing a qualified staff. They offer access to the latest applications with quick upgrades and technical support from a central site. ASPs should also be easier to scale up as an institution grows.

All of this is theoretical. In fact, ASPs take on many forms and leave many questions unanswered. The combination of ASP and radiology is less than a year old, so we are still operating in the Wild West as vendors determine what they can reasonably offer and hospitals discover what works. Early adopters should perform due diligence with extra care, making certain they have detailed contracts that include escape clauses, detailed data migration plans, and other protections.

Different flavors

A limited number of vendors are offering a full-service ASP model, while others are carving out different niches in hopes of filling different needs. Some ASPs supply only image retrieval and Web distribution, without long-term archiving, so hospitals will have to continue to store film. Others offer to build and manage a complete on-site PACS system, still charging by the examination and assigning to operations what would normally be a capital expense. Some ASPs will install and manage some of the digital modalities and workstations as part of their per examination charge; others will expect the hospital to provide up-front capital to install the equipment.

Here are some questions to consider: How reliable and stable is the vendor? What happens to the images if the vendor goes out of business? Who owns the images and can they easily be converted to standard formats and/or transferred to other systems? Has the vendor made adequate provisions for backup and disaster recovery? How reliable and secure is the Internet connection or other network line, and does it offer enough bandwidth (ie, is it fast enough)? Does the vendor have a financial incentive to eliminate all the hospital?s film as quickly as possible, or will duplication erode any expected savings? Can the hospital?s existing information system handle the ASP?s requirements, or will the hospital have to spend additional funds upgrading infrastructure?

Hospitals must carefully review the precise scope of services and carefully calculate the costs of various alternatives over a multiyear period, a sometimes head-spinning task not unlike trying to choose the best long-distance carrier or wireless service provider with multiple calling plans, except with far more serious consequences.

As the industry develops, both hospitals and vendors need guidance to protect themselves from serious mistakes and problems. Existing organizations like the American College of Radiology, the Radiological Society of North America, and the Society of Computer Applications in Radiology should consider developing a set of policies and recommendations defining minimum acceptable configurations for ASPs with clear requirements for on-site backup, security, and exit strategies, including a path for exporting and migrating data to other vendors. ASPs have the potential to change the delivery of radiology information as we know it today; our job is to see that this change is a positive one for us, and our patients.

Keith J. Dreyer, MD, is vice chairman of radiology, Massachusetts General Hospital, assistant professor of radiology, Harvard Medical School, Boston, and a member of the Decisions in Axis Imaging News editorial advisory board.