For some institutions, it can take years and more than a million dollars to buy a new PACS and migrate every bit and byte of archived data to the new system. Is it worth it? For CIO Robert Diamond, PACS is not only worth the money; it is simply the cost of doing business in modern radiology
For the past 7 years, Robert Diamond, vice president and chief information officer of Orange Regional Medical Center, Middletown, NY, had been nursing an old PACS with its tape and spinning disk archives, and he knew it was time for a change. A modern PACS would increase Orange Regional’s efficiency with a paperless, all-digital workflow, voice recognition, and seamless integration with 3D rendering software. It also would give his radiologists customized hanging protocols, and the hospital’s referring physicians would have faster, convenient web services.
Diamond’s belief is that PACS is essential for radiology today. “If you do more than 50,000 studies per year, or whatever that number is for you, you can see the return on investment for PACS,” he said. “When you go to the next level, however, and you’re at your second-generation PACS, it’s the cost of doing business.”
The price of a modern PACS and its associated upgrades is as variable as the vendors and institutions that need them. The bare bones software with a 1 terabyte server might cost as little as a few hundred thousand dollars, but that does not include archive servers, the service contract, new workstations, plus migrating all of the old data from the legacy PACS and a host of other related expenses and options. Although upgrading a PACS might be the cost of doing business in radiology, certain strategies can help to decrease those costs. In fact, there may be some significant savings today, as well as for the future.
Costs to Consider
Orange Regional performs about 250,000 radiology studies per year from eight off-site locations and two hospitals. After due diligence, Diamond eventually selected Dynamic Imaging, Allendale, NJ, and its IntergradWeb PACS for his facilities. “It’s a fairly sophisticated environment,” Diamond said. “From a radiology standpoint, it’s a fully integrated desktop, inclusive of the RIS, the PACS, and the speech recognition. We also have full central scheduling for radiology and our outpatient departments.”
For Diamond and Orange Regional, the cost was about $1.2 million, inclusive of the PACS software, new servers, and on-site training. Prices widely vary, depending on the brand, features, and institutions. In general, facilities should keep in mind several PACS upgrade expenses, including:
- the price of the vendor’s PACS software and future software updates;
- new larger servers for the active archive;
- new larger servers or other storage system for older, less frequently used archives;
- new workstations and/or monitors;
- upgrading networking systems and increased bandwidth;
- service contracts for the new PACS;
- continuing the service contract for the legacy PACS during migration;
- potential downtime due to training/installation; and
- migration expenses.
Migration: Time, Money, and DICOM
Aside from the actual PACS software with supporting servers, perhaps the most significant cost of changing PACS vendors is the transfer of archives from the legacy PACS to the new one. For some outpatient centers, migration expenses could be minimal due to moderate patient volume or because it is a relatively new facility with a young (2- to 3-year-old) archive. For these imaging centers, PACS vendors typically include migration fees in the overall package price. However, for hospital archives that have many years and multiterabytes of data, the cost can be more than $400,000. The high price tag of PACS migration is for basically two reasons: time and DICOM.
In theory, DICOM is an international standard that was created so that different digital imaging and data information systems (ie, PACS, MRI, CT) could communicate and exchange data easily. Every PACS company utilizes DICOM to send image data to other vendors; however, the fact is that each vendor’s database structure remains proprietary. Consequently, images and parts of the archive could migrate without a problem, but usually, textual information about patients and examinations, pointers to the associated image data files, and other data fields are imported incorrectly.
Verifying and correcting multiple fields in multiterabytes of newly transferred data can be time and labor intensive—and, hence, expensive. Special automated migration software might catch many of the errors, but the process also is verified by a highly paid technician. Consequently, the larger the archive, the longer it takes, and the more expensive the migration costs. If the data is stored on an older type of media, such as tape archives, that also increases the time and cost. In Orange Regional’s case, Diamond estimates that it will take about 2 years and several hundred thousand dollars to transfer the archive.
PACS Migration Strategies
Several strategies can be employed during PACS migration. First, facilities can use an in-house IT person to handle an automated query/retrieve program that slowly imports the archives over months or several years. Of course, the downside is that the migration will distract one’s trusted IT personnel from important daily or overnight IT tasks and maintenance.
Thomas M. Fabian, MD, medical director for Advanced Imaging of Port Charlotte, Fla, chose the in-house method when he migrated a year of archived data to a SmartPACS system from Infinitt North America Inc, Phillipsburg, NJ. Fabian used one of his practice managers for the migration. Asked about the cost, he said, “If you had to figure it out, he probably spent 4 to 6 hours per day, checking and double-checking and verifying the correct migration of all those patients.” When Fabian further calculated for his practice manager’s hourly salary, he estimated that it cost several hundred dollars per day for the in-house migration. “Not huge,” he said, “but still money out of pocket.”
It should be noted that some PACS vendors may invalidate the product’s warranty if data is migrated with an unauthorized technician. Therefore, it is important to check the contract’s fine print regarding migration.
Because PACS migration can be so technically cumbersome, especially for large, older archives, many IT professionals prefer outsourcing strategies. For example:
- Contract with the legacy PACS vendor to transfer the data. This method will not be inexpensive, as there is little incentive for the legacy vendor to make a deal, other than the potential for future business or ancillary business.
- Negotiate archive migration costs into the new PACS contract. With this strategy, the new vendor will undoubtedly make every effort to please the imaging center and its radiologists. However, it might be difficult to discern how much is being paid for the actual migration. Vendors might offer a package price that includes not only data migration, but also the software, servers, training, licenses, and other essential costs.
- Hire a third-party vendor specializing in PACS migration. Relatively few of these companies exist, and the price for their services will differ. Generally, third-party vendors charge by the amount of data to be transferred.
The time that it takes a third-party vendor to transfer, correct, and validate the migrated data also depends on the type of media (tape, film, or spinning disk), the type of network being used by the client, the compatibility between the legacy and new systems, and the migration vendor’s unique migration software. For smaller archives, the task may be completed in a few weeks. For larger archives like Orange Regional’s, it can take years. (For a case study using a third-party vendor, read the November 2005 issue of Medical Imaging.1)
Diamond eventually decided to use a third-party vendor to migrate Orange Regional’s legacy archives and contracted with TeraMedica Inc, Milwaukee. He expects the process to be finished in about 2 years.
Reducing Future Migration Costs
In addition to migrating Orange Regional’s archives, Diamond is considering TeraMedica for a service that will store its archive data in a DICOM structure that is independent of any proprietary PACS software.
“When images are acquired from the modalities, TeraMedica ends up being the filer of these images into a connectable infrastructure and then stores those images into a different repository,” Diamond explained. “So, the next time you buy a PACS, there’s no migration of data required.” Instead, TeraMedica’s nonproprietary DICOM database will be pulled into the new PACS, regardless of the vendor.
Diamond conceded that this service will cost more than a traditional PACS storage system, but he said that it will be worth it in the long run. “It might cost you a couple of hundred thousand dollars as an investment in servers and software, but it’s still a fairly cost-effective investment today,” he said. “And tomorrow, the payback is huge. These images keep getting larger and larger, and radiology is the fastest-growing service in health care.”
Don’t Forget the Old PACS
Although a new PACS might be a facility’s new best friend, one must still respect—and pay for—the old PACS and its service contract, at least during migration.
“Keep in mind that while the old PACS is feeding you data, you must maintain some portion of the support,” Diamond said. “Typically, you need to maintain the core, which would be the DICOM servers, the archive, and the tape archive.” For Orange Regional, Diamond said he will pay an additional $100,000 per year for 2 to 3 years to maintain his legacy PACS until the migration is complete.
Asked whether his legacy PACS will have any trade-in value after the migration, Diamond laughed. “Servers depreciate quicker than boats,” he said. “Typically, the vendors are sunsetting those products, so they have no value. This is an albatross. It’s something that we must keep going, but we wish we didn’t have to. It’s the cost of doing business.”
Migrate Everything? Not Necessarily
Another way to decrease the cost of PACS migration is to limit the years being migrated. HIPAA requires health care providers to maintain patient records for 7 years for adults and up to age 21 for children, but it may not be cost-efficient to import all 7 years of data into the new PACS.
Jim Sheperd, MD, medical director of imaging and chief of radiology at Olympic Medical Center, Port Angeles, Wash, had migrated his facility’s legacy archive data to a PACS from DR Systems Inc, San Diego. Olympic Medical had been dissatisfied with its legacy PACS, which it used for about a year. As a result, only about 60,000 studies were imported from the old PACS. The rest of the archive was still on film and initially slated to be totally digitized and imported into the new PACS. But then, Sheperd changed his mind.
“I did a quick 3-month check and saw how many times we were looking for comparisons and how far back they went,” Sheperd explained. “It was really painful, but I had everyone save their requisitions and write down what we were doing. We were able to go through that and make the decision that it was not cost-effective for the amount of time it would take us to digitize everything and have it online.”
Instead, Sheperd implemented a pre-fetch scanning solution that uses two digitizers from DR Systems—when necessary.
Similarly, some facilities might find it more cost-efficient to migrate only 2 or 3 years of data rather than import the entire legacy archive. Studies that are older than the desired time frame can be queried/retrieved as needed. Naturally, the cost of maintaining the service contract for the legacy PACS core must be balanced against the costs of a full migration and the efficiency of having every study in one PACS.
Training and Downtime
After the software and server installation, vendors typically provide on-site training for radiologists and technical staff. The training cost for a new PACS usually is included in the vendor’s package price—often with 24/7 telephone technical support.
Imaging professionals who are familiar with older systems usually pick up the new PACS with minimal training time. In addition to on-site training, some PACS vendors provide IT administrators with off-site training.
Don Wilson, IT manager for six outpatient imaging centers at Tristan Associates, Harrisburg, Pa, received 3 days of off-site training from its new PACS vendor, AMICAS Inc, Boston. With the new training and his previous experiences in PACS migration, Wilson and his IT support staff accomplished the migration over the past 2 years without hiring any extra staff.
The migration process rarely gets in the way of throughput. PACS migration primarily occurs overnight when in-house IT personnel have the servers and PACS network mostly to themselves. Third-party migration vendors also work off-site and during off-hours.
Finally, when it is time to go live with the new system, vendors run several tests with personnel. The day before full implementation of the new PACS, Orange Regional went live with both the legacy and Dynamic Imaging systems running at the same time.
“We had a segmented radiologist who went live on the new system to validate workflow, functionality, and that the new PACS was acting and working correctly,” Diamond said. The day went smoothly, and Orange Regional has been exclusively working on the new PACS ever since.
The Good News: Savings
At a cost of up to $1.5 million, it is no wonder that CEOs think twice before sending the old legacy PACS to the proverbial PACS farm. However, as Diamond pointed out, an efficient, full-featured PACS is the cost of doing business—and it can save money, too.
Nowhere is that more apparent than at Comanche County Memorial Hospital in Lawton, Okla. When George Schutz, MD, the medical director of imaging services, returned to Lawton after 11 years of practicing radiology in Colorado, he found an outdated PACS that made it difficult to attract radiologists to Comanche’s 300-bed hospital.
“The PACS was just storing images as it did originally,” Schutz said. “There was no worklist, there was no work driver, and everything was paper driven. You couldn’t read from multiple sites—it was completely inefficient.”
After getting approval from his board for an upgrade, Schutz chose eRAD Inc, Greenville, SC, because of its ability to be installed on any PC, anywhere. As a result, Schutz has attracted four more radiologists, who can work on-site, from home, or, in one case, part time from New York City. Plus, because some of his new partners work from off-site locations, Schutz pays them less than full-time salaries. “In terms of radiologists’ salaries, that saved about $250,000 to $300,000,” he said.
The PC-accessible PACS from eRAD also saved Schutz from buying any new radiology workstations. Instead, Comanche uses regular hospital PCs to read studies.
Diamond and all of the experts included here said that they have obtained significant efficiency savings by upgrading PACS. Most found solid savings by becoming completely paperless and generally filmless. Accordingly, one of the first bonuses from their new PACS has been thinner files and fewer full-time file room personnel. Also, fewer runners are coming from and going to physician’s offices, as most reports are now delivered via the Web.
Schutz said that he has reduced his file room staff by 50% and saved Comanche $70,000. In more expensive job markets, that savings could be even greater. Also, the extra file room space can be repurposed. For Schutz, it has been converted into a transcription room. Later, after the migration is complete, Schutz said he will add eRAD’s voice recognition software and then transfer or reduce half of his transcription staff as well.
Diamond also is finding benefits in increased efficiency. “In the past, we didn’t have business continuity. Now we do,” he said. “Each of our major sites has its own archive, and if the network goes down, they can still be productive and read off the local archive. … Honestly, a PACS at this point is a commodity. It’s the cost of doing business.”
Tor Valenza is a staff writer for Axis Imaging News. For more information, contact .
- Cater D. Making the migration. Medical Imaging. 2005;20(11):26–27. Available at: www.medicalimagingmag.com/issues/articles/2005-11_08.asp. Accessed May 3, 2007.