Radiology’s transition to filmless operation has gone much more slowly than expected. Among the reasons for this delay are the expense of conversion, the inertia that characterizes some departments, and uncertainty about the stability of the technology involved. Many health systems also lack the infrastructure needed to support a picture archiving and communications system (PACS) effort throughout the enterprise. Even in facilities where these barriers have been overcome, a lack of published economic analyses of filmless operation has been a handicap to those considering transition.

Filmless operation can be defined as having 90% of images interpreted and stored without the use of film; complete filmlessness will not be possible until advanced networks make it unnecessary to print film for patients to take outside the institution, for use in courtrooms, or for physicians who now lack access to digital images. Fewer than an estimated 10% of facilities will reach 90% filmless operation within this decade, but by 2012, 20% of institutions will have reached this goal. Only 6 years later, 60% of departments will be filmless, and only a few will still be using film by 2026.

As with most technologies, the costs of filmless operation decrease as its adoption widens, fueling still broader dissemination of filmless systems. The cost in this case, however, is decreasing far more rapidly. In 1998-adjusted dollars, for example, a 40-workstation PACS having a 5-year archive, purchased in 1992, would have cost $8 million. Today, it can be acquired for less than $3 million, and its cost is likely to decrease a further 30% within the coming 4 years. PACS computer hardware, networks, archives, and workstations have all become less expensive (and, in most cases, faster). There is also more competition among PACS providers, and broader implementation has made it less necessary to recoup software development expenses from early customers.

Currently, more than 98% of PACS purchases are made with conventional financing. In the future, however, trends will favor alternative (risk-sharing) financing. Leasing arrangements may have a number of advantages for many institutions. PACS also could be paid for as a utility option based on a department’s number of studies, number of megabytes, and/or number of image retrievals; this type of arrangement will become much more popular.

Other trends favor a shift in the responsibility for (and control of) PACS from the radiology department to the information technology department. PACS images will be incorporated into the electronic medical record. Computed radiography (CR) and other specialty radiology workstations will also be optimized for speed and image enhancement.

To date, far too little attention has been paid to the importance of reading-room design. In the future, this will be recognized as a major factor in the productivity (and, potentially, in the accuracy) of radiologists. As a result, more attention will be paid to lighting, acoustics, ventilation, and other factors that can enhance or detract from radiologists’ performance.

Tomorrow’s reading room will be an intelligent workplace of the type already described in the published literature as improving conditions for pilots and air-traffic controllers. Design will emphasize indirect, incandescent lighting; room dividers; acoustic optimization; chairs and tables that are more comfortable; individual temperature controls; and better integration of telephone, email, and dictation functions within the workstation.

The reading room will also become less tethered in location because radiologists will be freed of the constraints of remaining near a film library. Radiologists will tend to work in smaller groups (with individual spaces divided by partitions) or alone (in separate offices). Radiologists will more commonly be located closer to clinical areas. This will promote greater interaction with clinicians while allowing them to retain the ability to read any and all studies. In particular, reading areas are likely to be near or within emergency departments, intensive care units, and orthopedic departments.

While the groups in which radiologists sit to work will become smaller, their group practices will continue to become larger. Night and weekend coverage using teleradiology will increase, with the routing of images to appropriate subspecialists becoming more commonplace. This is likely to slow or reverse the current trend toward the practice of general radiology by encouraging subspecialization.


The US Department of Defense is now implementing a virtual radiology environment in the southern central region of the United States. In this environment, a management system monitors available radiologists and their subspecialties while it tracks, at the same time, the volume and types of unread studies. The system then distributes cases to multiple facilities within the Department of Defense network, according to need and radiologist availability, while it continues to monitor their completion status. The goals of such a system are to make the most of a radiologist’s time and to obtain the best possible turnaround time for image interpretation by matching studies that need to be read with the individuals best able to read them. In the future, this system may be used to send cases outside the network as needed.

Such unexpected workload problems are also likely to become less common as more institutions take advantage of PACS-based improvements in work flow. PACS and CR are often thought of merely as tools to provide an electronic substitute for film; workstations replace alternators, with images routed to the workstation in the same way that they were hung on the alternator, and CR images are processed to look like film. All this implies that digital images are approximations of film, but this is not the case.

Instead, the digital environment provides both diagnostic advantages and efficiency improvements to those who take advantage of its capabilities. Computer-aided diagnosis will progress relatively slowly for the next few years, with two exceptions: computer-assisted nodule detection for spiral/multislice CT scanners and digital mammography (where computer-aided diagnosis will become commonplace).

Changes in efficiency will be more striking. PACS actually provides the opportunity to reinvent the way in which an imaging department functions. It can eliminate most of the manual work-flow steps required in a conventional department through

? the issuance of electronic image requests;

? the use of automated, intelligent scheduling;

? the ability of digital imaging modalities to update the hospital information system (HIS) and radiology information system (RIS) when a study has been completed; and

? the flow of patient information directly into PACS.

The future of radiology is what we make it. The use of PACS as a tool to achieve filmless radiology will undoubtedly also reengineer the practice of radiology. Used improperly, PACS will shift control and responsibility for imaging away from radiology. It will also diminish the roles of the radiologist and technologist in patient care; this, in turn, will decrease the quality of patient care.

Used properly, however, PACS may be used to address some of the major challenges presented to radiology today. These include the need to be efficient, to cover multiple locations, and to provide around-the-clock coverage with a high level of expertise. In addition, PACS will allow radiologists to provide added value to their patients and colleagues while serving the ultimate purpose of PACS: improving patient care.

Eliot L. Siegel, MD, is director of imaging, Veterans Administration Maryland Health Care System, Baltimore, and associate professor, University of Maryland School of Medicine, Baltimore. This article has been excerpted from Future of Filmless Imaging, which he presented at the Fourth Annual CR and PACS Conference on March 3-7, in San Antonio.