So, you’re finally shopping for that picture archiving and communications system you’ve always wanted. And as you’re undoubtedly finding out, planning for PACS is an undertaking that’s almost as ambitious as installing one. You can’t just trot over to Radio Shack. Where do you start?
First, decide what you need and what you don’t. Then make a business blueprint. Ask questions, lots of them. And it wouldn’t hurt to find out what not to do from people who have already done it.
The very first question to ask yourself is this: Does my organization really need a PACS? We’re kind of [pick one] too big/too small/don’t have the budget for that sort of thing.
“Everybody is going to wind up needing PACS, because it’s going to be a standard of care for radiology in the next five years,” says Paul Unkel, director of Inturis for Radiology at Philips Medical Systems North America (Bothell, Wash.). He cites a second, equally compelling reason: “Radiologists going into residencies these days are not interested in going into an analog environment. If you want to be competitive, you have to be doing things electronically.”
So much for fence sitting. But how much is being modern and competitive going to set you back? Unkel estimates that a PACS for an outpatient imaging center costs $400,000 to $500,000; for a 150 to 250-bed facility, $1 million; 250 to 350 beds, $2 million; 350-plus beds, $3.5 to $5 million “for full turnkey solutions that include hardware, software, everything.”
For service and support, says Unkel, expect to pay an additional “8 to 12 percent for a typical 9-to-5 service with break/fix activity. You need to cover break/fix 9-to-5, and be able to have a 24×7 telephone for support.”
The installation and transition process for a smaller facility may take 120 to 150 days, says Unkel. A university hospital may take 5 months to a year, “depending on how they want to roll it out, and how quickly they want to put the PACS all the way out to the referral physicians. They have tremendous numbers of specialty areas, and all of them have to be converted.”
Where to start
For anyone planning for PACS, a must visit is Peter Veader’s Web site, Image Management and PACS (users.erols.com/veader), where he generously shares his hard-won knowledge. Veader is the radiology manager for Inova Alexandria Hospital in Alexandria, Va. He says: “All PACS implementations should start with a business plan ? segmented into smaller, separate plans for cost justification, resource utilization, technology assessment and integration, product evaluation for purchasing, and an implementation plan.” (See more of Veader’s advice in the sidebar, “The ABCs of PACS Planning” page 84.)
Gary Reed, president of Integration Resources, Inc., a PACS consulting firm in Lebanon, N.J., says that after putting a plan on paper, “the hard work begins. We look for performance guarantees, such as how long does it take to transmit a CT study with 290 images from the CT scanner to the archive? How long does it take from a diagnostic workstation to pull that image over? PACS are supposed to do things. It isn’t just equipment.
“When selecting a vendor and going to contract, you absolutely must have a set of not only technical specifications, but functional and performance specifications,” Reed continues. “It’s not a matter of a vendor saying it is DICOM compliant or submitting the DICOM conformance statement. That is really meaningless.” He says to make the vendor “explain and guarantee how data will be exchanged, for example, with a modality work list from the RIS to a modality to the workstation or archive. And the vendor should not only guarantee how that happens, but how long it will take.”
Nuclear medicine DICOM, in particular, can be a headache to integrate. PACS customers should ask vendors for results of nuclear medicine connectivity tests performed with other equipment. Many PACS owners complain that some vendors use proprietary DICOM in their products, making them difficult to interface with other vendors’ devices.
Alan Rowberg, M.D., a PACS consultant with Rowberg and Associates, Inc. of Seattle and an affiliate associate professor of radiology at the University of Washington, recalls one beseiged PACS that couldn’t even interface with itself. It seems the vendor’s programmers had written conflicting code to manage the application entity titles that identified its DICOM devices. “No one could get the system to work, including the vendor who was providing all parts of the system, because it had been programmed to be incompatible.”
In devising your PACS plan of action, be ruthless. Ask vendors hard questions about compatibility and upgrades. Calculate image volume and analyze departmental workflow. Find out what the clinicians and referring physicians require with regard to technologies and image transmission speed. Design several PACS models, including phased implementations and configurations that include future requirements. Do thorough cost analyses. Assess and document your enterprise and departmental LAN and WAN infrastructure requirements.
What kind of infrastructure will you need? Jon Lehman, CEO of Inphact Inc. (Nashville, Tenn.), a PACS/RIS application service provider (ASP), says that if you have a 100-megabit network in place to start, “that’s probably fine. If you’re going to do a networked [ASP] model, you’re looking at having some kind of WAN connection in there, probably a minimum of a T1. If you’re looking at a traditional [on-site] model, you’re going to have to have some kind of data center-like area where you can put the bigger storage boxes and other pieces.”
What about security? That actually requires a combination of solutions, among them firewalls, encryption, password access, closure of software back doors, and connections that time out when activity stops. If you’re using the Internet with your PACS, Rowberg suggests including virtual private network (VPN) boxes.
“You can put one on each end of a public communication link and not worry about your computer communications getting tapped and released in an illegal way. If you have two hospitals that have PACS connected with an insecure link, all they have to do is plug in the two boxes and configure them, and that link becomes secure. These boxes talk to themselves on a hardware basis and encrypt all the data that are going across. VPN doesn’t slow things down, and you don’t have to program it.”
What if you want a PACS, but you can’t implement one immediately for some reason – budget constraints, for example, or a HIS that must be upgraded first. An interim solution may be an application service provider.
Donald Peters, M.D., is the medical director of radiology at The Everett Clinic, an outpatient facility in Everett, Wash., that logged 120,000 radiology exams last year. “A few years ago it became evident that PACS was the way to go,” he says. “Unfortunately, we didn’t have a radiology information system.”
The clinic’s RIS installation is still a year away, he says, because “the main hospital information system here needs a major upgrade before we interface to it. I thought a good way to start would be to start distributing images to the physicians outside the radiology department, to actually try and get the physicians comfortable over a period of time, rather than trying to do it all at once.”
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He achieved his PACS-like environment with the iSite solution from Stentor Inc. (South San Francisco). All the clinic’s hardware and software are on-site, except for the disaster recovery unit. Thirteen orthopedic surgeons and radiologists are using the pay-per-exam system. Peters says, “Orthopedics can be one of the harder departments to get to go filmless, so what we’ve done there is install a Kodak CR system [from Kodak Health Imaging, Rochester, N.Y.]. We had an opportunity, because we were designing a whole new department. All the images go to the iSite server. We don’t actually have a PAC system, so what we do is print the orthopedic films late in the evening, after they’ve seen the exam. We’ve basically been able to wean them off of having a real film in hand when they’re looking at today’s images.”
Inphact sells similar solutions, and Lehman describes his typical customers as 50- to 300-bed facilities “that have a limited capital budget, with a smaller IT department or an IT department that has other priorities, somebody who wants to implement faster.” He says he can get them up and running in 3 to 4 months, compared with the 4 to 12 months required for a traditional PACS deployment, because “the central data center has already done a lot of the integration work with different PACS vendors, so it becomes a very different process in terms of implementing a site.”
An ASP arrangement for a fully digital department costs about half the price of an on-site enterprise PACS. “You don’t need RIS servers, archive or Web servers on site,” says Lehman. “You don’t need additional IT people. You just need to be able to acquire the images and do the interpretation on site.”
Multi-site installations
A PACS shared with one or more other facilities – particularly physically separated facilities that previously maintained separate records – presents a special set of challenges.
Just ask eMed Technologies, a PACS and teleradiology solutions company in Lexington, Mass. Peter Bak and Dave Mahoney, eMed’s V.P.s of product development and sales, respectively, advise telerad customers to choose a vendor with WAN expertise and plan radiologist workflow diligently. In an on-demand PACS over WAN, studies can be pulled from a centralized archive, but how will the radiologists’ reading “stack” be defined? If studies are to be pushed to various radiologists, the group must consider who will get what, and where. Also, say Bak and Mahoney, decide who owns the data. Consider when and where they reside, and how data from individual facilities are segmented.
An example of a multi-site PACS done right is at Austin Radiological Association (ARA in Austin, Texas). ARA just finished installing a state-of-the-art Synapse PACS from Fujifilm Medical Systems U.S.A. (Stamford, Conn.). It links some 100 devices using an OC-3 optical network connecting 14 outpatient imaging centers and a teleradiology tenant, the three-hospital Seton Healthcare System. The system interfaces MRI, CT, ultrasound, nuclear medicine, and X-ray. ARA has 52 radiologists who perform some 375,000 exams per year.
The conventional wisdom among PACS cognoscenti is that HIS and RIS should be installed before PACS. That’s exactly what ARA did. However, says ARA’s president, Greg Karnaze, M.D., “Our RIS vendor was a little reluctant to work cooperatively” with the PACS vendor. PACS buyers, he says, “need to be very careful when they’re selecting their radiology information system vendors. Be sure you understand the services that that vendor provides, and how well they play with others.”
It’s also important to ask RIS vendors whether they offer document imaging. ARA was very disappointed to learn, post-installation, that theirs didn’t. “Our RIS vendor currently does not have a way to scan documents and have them be part of the radiology information system data,” says Karnaze. “We have patients who come in with a piece of paper that’s the order for their exam, or an insurance card, or a form they have to fill out to see if they have any medical conditions that would be problematic for the exam they’re having. Historically, we would put those in the X-ray jacket and file them away with the films. Now, since there won’t be an X-ray jacket, we’re having to grapple with how to handle that data.”
Things nobody told you, but they should’ve
Planning for PACS has as much to do with dodging traps as mapping actions. PACS potholes take many forms, all of which are avoidable. The best place to go for advice is the pros.
Talking to them is a little like that old Indian fable about the blind men describing an elephant. One feels the tail and says the elephant is like a rope; another feels the trunk and says it’s like a snake; the one who feels its knee reports it’s like a tree. In much the same way, everyone who designs, installs or uses a PACS has a unique and valid take on what makes the beast work – or not.
Veader says, “It is easy to view the latest installation of any vendor, because it is always the most impressive. Not many locations are going to admit to making the million-dollar mistake. One way to select site visit locations is to ask the participating vendors where the competition has installations. Make the phone call to these sites to balance out the ‘perfect’ sites.”
What if you already have a PACS and now want to upgrade it? Eric Mahler, marketing manager of Inturis for Radiology at Philips, says to forget about keeping older workstations built on conflicting platforms if you’re revamping your operating system. “The current standard is Windows. If [your old workstations] were on a Unix or Mac basis and you try to migrate that to NT, you won’t have the full functionality of a Windows-based system.”
Personality clashes can sink PACS as easily as hardware incompatibility, cautions Rowberg. While some department chairmen have enough clout to order everyone to read on the PACS, he says, “there are others who say everyone can do whatever they want. Those hospitals have terrible growing pains, because it’s very expensive to maintain both a film-based and a PAC system in parallel. You don’t know ahead of time which physician is going to be reading a case, so you end up having to take the CR images and print them out, so they’re available just in case Dr. X does the reading. That sabotages efficiency.”
Reed says the biggest mistakes he’s seen involved PACS installed without redundant back-up archiving. “There’s a big difference between back-up, disaster recovery and continuation of business,” he says, adding that these are confusing concepts for an industry that hasn’t traditionally used computers. Make sure you know the differences, and are adequately covered for all of them.
When designing your system, Lehman says it’s important to avoid being underconfigured from the get-go. Facilities “generally don’t plan out far enough for capacity. They end up getting stuck two or three years into it, like, ‘Oops, we filled up the archive.’ And they’re going to have to upgrade that. And they typically don’t understand the additional FTEs [facilities, terminals and equipment] required to keep up and maintain that system. You don’t just plug these things in and they work magically without problems.”
