Since the earliest days in the evolution of picture archiving and communications systems (PACS), vendors have designed their solutions for large-enterprise hospitals, and that is where the lion’s share of sales were made: big systems with big price tags.

The problem is that imaging centers are not hospitals. From one-modality/one-site shops to multisite regional operations, they come in many shapes and sizes. Few, if any, have the same PACS needs as those of a hospital enterprise.

Even so, imaging centers that—5 years ago—considered PACS an expensive luxury are now treating it as a necessity nearly on the same level of importance as their modality equipment.

Three PACS experts from opposite sides of the United States provide a revealing look at the unique and unhospital-like PACS needs of imaging centers:

    Luke Bernier
  • Luke Bernier, director of business systems for Borg Imaging in Rochester, NY. Borg Imaging is an independent radiology group with eight facilities,145 employees, and a fully integrated RIS/PACS offering a wide variety of all-digital modalities, including 3-D tools.
  • Mike Boyer, chief technologist for MRI/CT and PACS administrator with Medical Imaging Northwest in Puyallup, Wash. Medical Imaging Northwest has two freestanding facilities in the Puyallup region. Its radiologists access the PACS from hospitals and several outpatient centers associated with other facilities. As with many imaging center operations, Medical Imaging Northwest is partly digital in one facility and all-digital in the other.
  • Jon Copeland, CIO
  • Jon Copeland, CIO of Inland Imaging in Spokane, Wash. Inland Imaging is unusual in that—in addition to its own outpatient center, which encompasses 250,000 examinations each year—it offers the use of its PACS to other regional imaging centers, hospitals, and small users such as orthopedic specialists who have MR systems. These “time-sharers” on the PACS add another 350,000 examinations per year to Inland’s network and storage, effectively making Inland Imaging both an imaging center and an ASP (application service provider) with 6,000 users.

When asked how their PACS needs differ from those of hospitals, these three imaging centers show clear agreement.


The universal difference between hospitals and imaging centers lies in how results are distributed to radiologists and referring physicians.

Hospitals have a captive audience. Most studies are accessed from within the building on workstations and monitors already connected to the network, and they have little or no reason to allow users to dictate how results are delivered.

Imaging centers, on the other hand, deliver results and studies to a diverse and geographically spread-out group of radiologists and referring physicians.

The radiologists may do the reads from satellite offices within the internal network, or they may work from a local hospital, especially if subspecialty expertise is needed. All three of our interviewees agreed that a well-designed, robust network makes delivery to established reading sites fairly straightforward. A less-than-robust network can stop a busy radiology practice in its tracks.

What is not so straightforward is the task of delivering images to a large group of referring physicians whose personal comfort levels and own IT infrastructure may demand anything from traditional film to CDs to online access to the PACs itself.

“Hospitals can dictate the mode of delivery to physicians, but we have to compete for physicians’ referral business,” says Bernier. “We have to make accommodations to guarantee that physicians in the referring community get what they want. If we meet their needs, they’ll use our service. We are not the decision maker for the mode of delivery.”

Both Bernier and Boyer say that having physicians directly access their PACS online is by far the most cost- and time-efficient method of delivering studies, but getting physicians connected to the network can be a challenge.

Bernier says that sometimes just getting through the clinician’s own security firewall takes additional tech support. He copes with it by sending a team of six IT people out to referring physicians to train them and work through the connectivity challenges. These in-house IT experts have become a de facto part of Borg’s marketing efforts.

“We love to allow physicians into our PACs and go to great lengths to encourage them to use it,” he says. “Our IT team is kept fairly busy setting up accounts and arranging access. We also provide CDs via courier if needed.”

Boyer agrees. “You need good people who can help physicians dial in,” he says. “A lot of referring physicians even have problems viewing images on CDs. They might want to access the new technologies, but they can’t get their systems to do it.”

Inland Imaging attacks the access problem head-on with a six-person help desk and 15 to 20 dedicated IT staff members who work with users to train, get past firewall issues, and traverse networks. “We’re almost a networking company,” Copeland says.


Another issue imaging centers cope with is the differing bandwidth capabilities of people who need to access their PACS. As imaging files become bigger and use of 3-D rendering more common, anything less than a 5- or 10-megabit network will cause long download times and often result in frustration for users.

For Copeland, this is a particular concern. Copeland says that while Inland’s 6,000-user PACS works extremely well, they do have some issues with users who do not have access to high-speed network bandwidth.

“Between our major centers, we’re running 100-megabit backbones,” he says. “But we also have rural hospitals and physicians accessing our PACs. Many rural hospitals have only a single T1 line. They can do the imaging and send the data to us over the T1, but in most cases, it just means a few minutes of download time for a large study, so we’re getting along fine with it, but it’s an issue.”

According to Bernier, bandwidth is critical. “Some of the more progressive physicians are approaching us and asking for PACS access,” he says. “We’re saying ‘absolutely’ and we can even embed a hot link in their EM, but they need to have the bandwidth, too. You need a 5- or 10-megabit pipe to see a 250-slice study in a 30-second download. We’ve found that 30 seconds is acceptable to most physicians, but we already have some that want shorter download times. Others, who are used to a 2-week window for film delivery, don’t see the benefit of more rapid results.”


Bernier says that when it comes to archiving images, hospitals usually need more storage because they have more modalities, but they still have it much easier than imaging centers.

“Ninety-nine percent of everything hospitals do is internal to their four walls,” he says. “Imaging centers have to cope with transfers to and from remote sites as well as backup storage sites from multiple locations.”

Bernier says Borg Imaging started out with an archive system that had four tera-bytes of storage and used DVD for backup media. They found that the recovery rate was too slow for their needs compared to a spinning disk system, and after just 3 years, they replaced it with an enterprise class storage system that more than equals that of most hospitals. They have a four-terabyte live archive where they store more than 1 year’s worth of cases on a spinning disk. The PACS also sends the same file copies to a 12-terabyte long-term storage archive. A third off-site tape backup holds 48 terabytes in a robotic cartridge system for disaster recovery. The Borg system also has redundant workflow managers (subsystems that manage network traffic) in case they lose network access to any one site.

Bernier says most imaging centers could get away with less storage and redundancy, depending on their risk exposure.

“It’s a business decision,” he says. “You have to decide what the pain factor will be if your network goes down for an hour or two. For our center, that pain factor—the financial loss—would be too high. We wanted the reliability of enterprise class redundancy.”

Boyer says that Medical Imaging Northwest recently upgraded to what he calls a “second generation” PACS, which consists of two duplicated systems structured so that if one goes down, they can access the other one. Archiving is done on two networked hard drives providing eight or nine terabytes of storage with a tape backup. “It’s a lot more flexible and productive than the old system,” he says.

Copeland says Inland Imaging has about 26 terabytes of storage, all backed up with a vendor ASP disaster recovery service. They archive around 600,000 examinations a year, 250,000 of which are Inland Imaging’s own studies.


While representatives from all three imaging centers said they have considered online scheduling, none have made a commitment to it.

“I know some facilities that have it,” says Boyer, “but they don’t always allow online access. Each modality has different ways of scheduling. Online scheduling can mess it up because [referrer] don’t understand how the radiology department works. They may not know the best type of examination for what they do, or how long procedures take, and then we’re into multiple phone calls. I just don’t think any system can be that intuitive. It might work for CT, but nuclear medicine, no way.”

Bernier says that Borg Imaging plans to add online schedule requests. Users will be able to see schedule blocks and request a booking, and then the center will confirm the appointment. “If a slot is available, if they meet requirements, and there are no contraindication,” he says. “It’s been a tough sell to our administrative directors. It’s hard to give up control of our schedule book. You need an extremely trusting relationship with the referrer.”


Borg Imaging, Inland Imaging, and Medical Imaging Northwest all represent one side of the spectrum of imaging centers: large-scale organizations with enterprise-like PACS systems and full-time IT staff.

Clearly, they have succeeded in working through the issues of making PACS work for their needs. But what about all the imaging centers that do not require an enterprise-scale PACS or have the ability to support on-staff IT expertise?

One solution that is beginning to emerge for smaller imaging centers is a module approach. This type of solution allows imaging centers to buy and install a PACS, one piece at a time, gaining knowledge and comfort level as they go, as well as making their financial investment in stages.

For these imaging centers, choosing a PACS vendor who can provide an installation project manager is very important. Basic technical support is not enough to bring the center through the myriad of choices and networking/IT issues that inevitably arise.

Once the PACs is installed, ongoing IT support from an outside vendor and storage service through a qualified ASP may also be good options that will help a center continue to be competitive as the imaging world increasingly goes all-digital, our sources suggest.

If an imaging center is considering both a PACS and RIS, Boyer recommends installing the RIS first. “It’s a lot easier to start with a RIS,” he says. “Make sure your backbone is secure and solid and go from there. If your RIS isn’t solid, it’s going to cause a lot of frustration.”

Boyer says imaging centers have no choice but to eventually get a PACS. “People are still not comfortable with it and they don’t want to spend the money, and it’s hurting their imaging business,” he says. “These days, nothing is worse than loading 30 films in a view box.”

Money-Saving PACS Tips

  • Go Modular. Modular systems allow you to build a PACS one element at a time. Just be sure the modules are designed to fit together and have a plan for the total system before you make your first purchase.
  • Investigate Fiber Optics. With most fiber optics, the cost to scale up from five megabits to 10 megabits all the way up to one gigabit is not a linear progression. The cost per megabit drops as you go up.
  • Dump Film. The faster you can go filmless, the better off you are. Invest in driving acceptance of nonfilm options.
  • Consider Sharing. With networking technology and appropriate security/privacy safeguards, there is no reason why even competing imaging centers cannot share the cost of a PACS.
  • Up-front Investment Pays Off. There are no cheap substitutes for a good database, storage media, or workstation. The same holds true for a fast network.

Tamara Greenleaf is a contributing writer for Decisions in Axis Imaging News.