It was not difficult to gain the support of the governing boards at Rush North Shore Medical Center (RNSMC), Skokie, Ill, or Cayuga Medical Center, Ithaca, NY, for a picture archiving and communications system (PACS) installation, according to administrators at the two community hospitals. With radiologists now demanding the ability to read soft copy, with referring physicians wanting rapid image access via their office computers, and with technologists wanting to view images while the patient is still present, PACS was an idea whose time had come for RNSMC and Cayuga Medical Center.

Not long ago, installing a PACS was a formidable undertaking for a small hospital, but that may not be the case any longer if RNSMC and Cayuga Medical Center exemplify the broader picture. When these two hospitals discovered the web-based PACS of AMICAS, Boston, MA, and saw how easily it could be integrated with existing equipment, a PACS installation was something that administrators decided that they could afford.

Bruce Hall, Cayuga Medical Center’s vice president and CIO.

Bruce Hall, Cayuga Medical Center’s vice president and CIO, says, “We wanted to see that the return on investment (ROI) was going to be positive in a short period of time. There are now alternatives for PACS hardware and software, such as the system from AMICAS, that make that ROI possible.” Hall notes that community hospitals finally have PACS vendors to meet their needs. “In the past, it was necessary to go to the big hardware vendors, but now there are a number of vendors that do nothing but sell PACS software. Most 600-bed hospitals have already invested $8 million or so in building a PACS, but for every 600-bed facility still wanting a PACS there must be 10 or 20 hospitals in the 200-bed range that need one. It is a whole segment of the market that is just starting to blossom,” he says.


Leonard Berlin, MD, is chair of an eight-member radiology department at RNSMC.

Leonard Berlin, MD, is chair of an eight-member radiology department at RNSMC, a 270-bed hospital. RNSMC is affiliated with Rush-Presbyterian-St Luke’s Medical Center, Chicago. The arrangement is a loose affiliation, according to Berlin, in that RNSMC is “more or less autonomous financially.” If RNSMC hoped to install a PACS, Berlin says, it would clearly have to do so using its own resources. For Berlin, the need to install a PACS had become inescapable. “The real need came from the marketplace itself calling for a PACS,” he says. “I like to be on the front line. I’m prudent enough to know that we do not want to be first, but I do not want to be last.” One of RNSMC’s competitors had installed a PACS, but there were many such spurs to action. “We had some medical staff cross over from that hospital, and some of those staff members said, Aren’t you going to get a PACS?’ Then we got a new radiologist who had been trained on a PACS. When the radiologist applicants came for that job, one of the first questions they asked us was whether we were getting a PACS? If we were going to be current, we were going to have to get a PACS.”

RNSMC had already been heading in that direction. Kenneth D. Vitacco is administrative director of radiology at RNSMC. He explains that, in mid 2000, the hospital installed a radiology information system (RIS) from Misys Healthcare Systems, Raleigh, NC (then Sunquest Information System), a company partnered with AMICAS. “The RIS server sat down in the information services department and images from the modality were sent to the server,” he says. “Users could go to any computer in the hospital and access images, and could also be outside the hospital if they had access to the hospital network. Physicians could see their own patients’ images. That is how it started.”

Despite these advances, RNSMC was still processing, storing, and retrieving film. “We decided to turn what we had into a full-blown PACS,” Vitacco says, “so that, internally, we can go filmless.” The AMICAS PACS that RNSMC selected is about to become operational. “The first modalities will be MRI and CT, followed by ultrasound, digital radiography, and computed radiography; general radiography will be last,” Vitacco adds.

One of the advantages of the AMICAS system that Vitacco wanted for his hospital was the Forever Priors” technology that allows all images in storage to be accessed immediately. All the images will be stored on a series of hard disks that can be accessed on monitors anywhere in the hospital, Vitacco says. Once daily, images will also be backed up on tape automatically, and those tapes will be stored across the street from the hospital so that they will be available if they are needed for disaster recovery.

From the beginning, Vitacco had been urging RNSMC to choose an AMICAS system, which he had first seen demonstrated at a facility in North Carolina. RNSMC put together a five-person team to review and recommend a PACS vendor. “We looked at the big vendors, but we all voted for AMICAS,” Vitacco recalls. “They had the totally web-based system that we wanted,” he says. “It just made much more sense to buy a product that had web-browser software already integrated with its own software. The World Wide Web means ease of management and ease of integration, the cost is reasonable, and it is very easy to use from the user’s point of view.” If they wish to do so, users can access AMICAS from home.

Berlin estimates that RNSMC handles about 90,000 studies per year. He predicts that savings on film alone will make the PACS investment worthwhile, not to mention ease of use, immediate access, and an end to lost film. Vitacco has analyzed the expected film savings, and he anticipates that the breakeven point will be reached by the end of the 5-year contract that RNSMC signed with AMICAS. “We get 110,000 studies per year for a set fee,” he says. “We spent about half what the big vendors charge. The entire project, over 5 years, will cost about $2.4 million, and we’ll probably break even because of the money we’ll save in that time. We’ll have less storage and less staff.”

On the recommendation of AMICAS, RNSMC is beginning the PACS installation by putting work-list software in place for each modality. That software will respond to bar codes for each patient. The bar codes will integrate the PACS with the RIS . Vitacco says, “We won’t put a modality on the PACS until that modality’s work list is functional.” Steps like bar-coding each incoming patient will make fast image routing possible. Berlin says, “There is no question that this PACS will improve patient care. We will have immediate transmission of images to interventional radiology, the emergency department, the operating rooms, and the various wards in the hospital, as well as to the referring physicians on the outside. I see this as a clear-cut improvement in how we can manage our radiology service.”


Hall recently viewed the first on-screen images to come from his hospital’s PACS. “This is quite exciting for us,” he says. “We love this because we have spent the past 6 months doing due diligence and interviewing vendors. To see our images being captured and displayed is very fulfilling. We installed the hardware only a week before we were able to put the images up for display.”

Hall states that the reason that Cayuga Medical Center administrators and radiologists began arguing for a PACS was simple. “The concept we brought to our senior management team was the need to be digital in our radiology department,” he says. “We chose AMICAS because we wanted a vendor that could demonstrate that they could link with our MEDITECH hospital information system/RIS, and we wanted them to show us a site where they had already done so.”

Cayuga Medical Center was seeking other qualities that the AMICAS web-based system possessed. “We wanted flexibility in the software used for storage, as well as in the options for compression of images,” Hall says. From the radiologists came an even more defined demand. “They wanted easy-to-use workstations, with easy clicks from study to study,” Hall says. “They took the speed of getting the images for granted, but they did not take for granted the number of clicks. They checked and they counted the clicks; after all, they have to live with the workstations.”

Cayuga Medical Center’s main campus contains its hospital, which is licensed for 204 beds. It also has a smaller campus that contains a surgical care center, a women’s health center, and a walk-in outpatient facility. There are two other outpatient sites. According to Hall, Cayuga Medical Center began life as a county hospital, but was converted to a nonprofit medical corporation about 20 years ago. Today, it has eight radiologists on staff at its various sites and processes about 80,000 studies annually. Hall reports that Cayuga Medical Center had another pressing reason to install a PACS. It had just agreed to purchase two multislice CT scanners, and it wanted to have a PACS in place to handle the large number of digital images generated by those scanners. The CT scanners are to be installed soon, with one at the main hospital and the other at the subsidiary campus.

Before approving the PACS, the hospital’s board of directors needed to be assured that “our budget was such that we were not spending $2 million or more. We will have our PACS up and running, and I do not think that our budget will reach seven figures,” Hall says. He notes that Cayuga Medical Center, like RNSMC, will probably recoup most of its PACS investment through savings in film purchases, storage, and delivery. The hospital has added a full-time PACS administrator to be the primary support person for the system. AMICAS will train the staff. “Each radiologist will receive one day of dedicated (one-on-one) training, and I will receive administrative training,” Hall says. He adds that the PACS will have more impact than just speed and saved film. “It will help us with recruitment of radiologists. It will also help us in recruiting radiology technologists, who are very difficult to recruit. They will be able to focus more on patient care and diagnosis and less on administrative paperwork, so they will have a higher level of professional satisfaction.”

Of course, the AMICAS PACS will distribute images throughout the main hospital and to the outlying sites, which will be linked using T1 lines. Referring physicians will be able to access images for their patients over the World Wide Web once they have been given codes that permit them to get through the system’s electronic gates and firewalls. Patients will also benefit, Hall notes, because their images will be read and sent to their physicians more quickly. The images will also be of higher quality. “If patients need to take their studies with them, we’ll be able to put them on a CD-ROM,” Hall adds. He explains that the Cayuga Medical Center PACS will make use of three very fast servers linked to a storage area network (SAN) capable of supporting multiple terabytes of data. The SAN will be composed of a series of hard drives; the information on these drives will be immediately accessible. To maximize image-delivery speed, the hard drives in the SAN will be linked by high-speed fiber-optic cable.

Cayuga Medical Center radiologists will have seven reading stations of their own that use 20-in flat-screen monitors combined with dual 3K gray-scale flat screens. The 20-in flat-screen monitors will also be placed in the emergency department, in the intensive care unit, and in a film room set up for image viewing by referring physicians.

Unlike RNSMC, which is beginning its PACS implementation with CT and MRI, Cayuga Medical Center has chosen to install CR units in its emergency department and will begin its PACS use with those images. “That is being done so that the images can go back to the emergency-department physicians in almost real time,” Hall says. Eventually, instead of sending plain film, Cayuga Medical Center will send laser prints of electronic images to surgeons who request them. The laser prints will also go to referring physicians who ask for hard-copy images. “We will move our plain film through CR onto the PACS,” Halls says, “and we will have all plain film into the PACS by mid 2003.”

In another use of CR, Cayuga Medical Center will put single-plate CR readers in radiography rooms so that technologists need not leave patients alone while they verify image quality. “We would like the technologist to stay in the room with the patient; this is better patient care. The technologist can see immediately if there is a need to retake an image, and we can also improve turnaround time on the images with the technologist in the room,” Halls says.


For many reasons (including speed of image transmission and availability of images, elimination of film loss and of film purchase and storage costs, radiologist efficiency, reading flexibility, better patient care, and improved service to referring physicians), community hospitals are finding that they need a PACS. Low-cost technology from a vendor like AMICAS now lets smaller hospitals have the option of an affordable PACS.

There may also be a more important reason that small community hospitals need a PACS. Electronic transmission is the way that images are handled routinely in today’s radiology departments. Both radiologists and referring physicians now expect images to arrive electronically. A small hospital may need a PACS to remain a functional piece in the larger medical community, for imaging today is being relied on much more than it was even 5 years ago. Vitacco says, “We especially want to cater to surgeons, cardiologists, and orthopedists who want quick access to images. We are surrounded by hospitalssome much largerand it is very competitive here. What we try to do is provide the best service in Chicago. Our turnaround time on images and reports has to be dramatically less.” That is one thing that their PACS will help them accomplish.

George Wiley is a contributing editor for Decisions in Axis Imaging News.