Internet image-management technology, always immensely scalable and cost effective, is now a contender for mainstream picture archiving and communications system (PACS) installations. In his legendary 1997 book, The Innovator’s Dilemma,1 Clayton Christensen, president and founder of Innosight and a professor of business administration at the Harvard Business School, describes the difference between sustaining and disruptive technology. He then shows how well-managed, established companies lose out to upstarts when faced with a disruptive technology. Internet PACS has grown beyond its telemedicine and enterprise roots to provide speed, features, and ease of use that surpass those of proprietary PACS, even inside a large radiology department. Real-time work lists; fast, low-cost workstations; and 2-second access to all prior studies are the direct result of disruptive Internet-standard technology.

AMICAS’ Pioneering Role in Radiology

  • 1995 – In conjunction with MGH – AMICAS founders set out to solve a clinical problem: how to get images efficiently and cost effectively out of the radiology department
  • 1997 – Regulatory approval for the use of Web and compression
  • 1997 – 1999 AMICAS was the first to integrate images with the Electronic
    Medical Record and to have a scalable Enterprise Image Distribution system
  • 2000 – 1st software based PACS with a per procedure business model
  • 2001- 1st to incorporate use of lossless and compression throughout its product line from teleradiology to PACS, powered by its Forever Priors technology.

In this supplement, the pioneers of Internet image management (see Figure 1), along with their partners and customers, will present the state of the art in PACS and show how patients and radiology business benefit when the PACS universe includes referring physicians, community-based imaging centers, and the entire enterprise, along with radiologists in the hospital and at home.


What causes the innovator’s dilemma? Christensen describes two types of innovation: sustaining and disruptive technology. Sustaining technologies improve product performance when measured using current-market decision attributes. Each succeeding generation of sustaining technologies is better, on a cost-performance basis, when measured using those product characteristics that current customers value. Disruptive technologies, on the other hand, have worse performance, as determined using the same measures, when initially introduced to the market. When evaluated using one or more product attributes valued by fringe (or smaller and emerging) segments of the market, however, these disruptive technologies either deliver much better cost performance or make what was technically impossible possible. These fringe markets are where disruptive technologies gather a small foothold, typically supported by the least profitable customers and supplied by the least solid suppliers, most often undercapitalized start-ups.

The Internet Factor

Hamid Tabatabaie, President/CEO, AMICAS Inc, addresses the role of the Internet in transforming radiological communications.

Q:How has the Internet changed the landscape of diagnostic imaging?

Tabatabaie: Internet means different things to different people, and therein, perhaps, lies the power of this platform. Whether it is used to do a third-grade research project; to disseminate timely information to thousands involved in the relief efforts focused on the dreadful disaster of September 11, 2001; or to manage the affairs of a large company like Cisco efficiently, the ubiquitous, scalable nature of this platform is irresistible.

In my opinion, there are two fundamental and related promises for diagnostic imaging that are delivered by today’s Internet phenomenon. The first is that automation in this computer-intensive field will continuously be more reliable and affordable than any other technology approach. Second, the inevitable adoption of this affordable imaging platform by health care organizations of all sizes will result in patients’ receiving better care, wherever they may be. Clearly, the early adopters will have a competitive advantage.

Q:Where do you see AMICAS in the future?

Tabatabaie: As a technology company, we will always push the envelope and continue to work on fascinating products, features, and services. Our resolve and dedication to the use of standards, however, will allow us to collaborate with other technology companies in providing practical solutions to users. Today, we are delivering wireless adjuncts to our systems that allow physicians to see reports on their Internet-based cell phones and personal digital assistant devices and route images and reports to their designated computers. At RSNA 2001, we will demonstrate image distribution and display via wireless tablets. Tomorrow, do not be surprised if we also help eager patients to participate sensibly in their own care.

It is from this base that disruptive technologies eventually wreak havoc on legacy companies. Do you remember Digital Equipment Corp, Prime, Wang, Data General, and Nixdorf? Personal workstations made a whole generation of computer companies a distant memory. Some technical innovations can deliver much faster technology improvement than an existing market demands. As the speed, cost, and ease-of-use parameters of the disruptive technology improve, the disruptive technology builds from its beachhead in the fringe markets, where the disruptive technology’s unique attributes made the otherwise impossible possible, and starts making inroads into the lower-end portion of the larger existing market. Meanwhile, established companies tend to excel at methodically improving the product via sustaining technologies in an effort to keep profit margins from declining.


The Internet, software-only PACS, and PACS built around Joint Photographic Experts Group (JPEG) 2000 standards are the disruptive technologies for the new era of digital image management. The Internet defines the state of the art in scalability, ease of use, and universal access. Hardware, network, and storage standards enable software-only PACS to be supported and upgraded at a rate that paces commercial availability. Finally, JPEG 2000 image coding leverages a world of advanced research in image processing quality and speed. All three of these innovations drive rapid product improvement because they leverage investments outside of health care into the mainstream PACS market. Patients and radiology business are the beneficiaries.

After 6 years of rapid evolution, the current generation of Internet PACS can finally beat proprietary PACS inside the radiology department while still providing the enterprise and teleradiology features that are, at best, an afterthought in traditional PACS. For example, at the 2001 meeting of the Radiological Society of North America in Chicago, AMICAS, Inc, Newton, Mass, is introducing real-time work lists and a native JPEG 2000 diagnostic workstation that seamlessly integrates lossy and lossless image coding, as well as standards-based Forever Priors’ archiving technology.

Each of these innovations benefits the radiologist directly. Real-time work lists are much easier to personalize and can be used without distracting trips to the keyboard. They also reduce errors. Seamless integration of JPEG 2000 enables the workstation to access studies that were imaged in the hospital or a community imaging center or brought in by a patient on compact disc. Forever Priors makes it cost effective to have all prior studies one click, and 2 seconds, away.

This Intelligence Report shows how Internet PACS benefits patients and radiology business, as well as the clinician. The article by James H. Thrall, MD, on “Meeting Stakeholder Expectations in Radiology Through PACS”. The integration of patient care around the electronic medical record instead of the PACS is the topic of the second article. Enhancing radiology business and the role of the radiologist in patient care is the topic of the third article. Our last article discusses the key features and benefits of a state-of-the-art Internet PACS.

Six years of evolution at Internet speed presents a new solution to the problem of replacing film. Could a disruptive PACS technology ignite a disruptive change in radiology practice? We’ll see.

Adrian Gropper, MD, is chief technology officer for AMICAS Inc, Newton, Mass.


  1. Christensen CM. The Innovator’s Dilemma: When New Technologies Cause Great Firms To Fall. Boston: Harvard Business School Press; 1997.