Industry thought-leaders speak out on how PACS continues to progress to better serve clinicians.

Less than a decade ago, a picture archiving computer system (PACS) was considered a luxury only the largest hospitals and imaging groups could afford. Today, thanks to numerous technological innovations, patient expectations, savvier radiologists, and a change in the politics of health care, a PACS is the standard.

Axis Imaging News recently spoke to Tim Kulbago, Merge Healthcare?s Senior Vice President of Product Technology; Michael Green, president and CEO of Agfa HealthCare North America; and Allan Noordvyk, Director of Radiology Product Management Medical Imaging Group, McKesson. All are industry leaders in the PACS market and shared their unique insights and visions about where the technology has been, where it?s going, and what radiologists and administrators can expect in the present at RSNA 2009.

Axis Imaging News: How have PACS systems changed over the last decade? Have these changes been driven solely by the marketplace or are they a result of technological innovations or a combination of both?

Michael Green

Michael Green: The two go hand-in-hand. Advances in technology such as server side rendering and zero footprint clients enable the widespread availability of enterprise visualization that is emerging as a key driver in health care today.

Tim Kulbago: If you look over the last decade, there have been a couple of changes. First, there?s been a wholesale adoption of standards. ?Proprietary technology? is employed only in the absence of a standard. Clearly, the spearhead for imaging has been the continued evolution of DICOM. From a visualization perspective, the demands for radiologist efficiency have increased. For example, there?s been a lot of demand for integration of CAD and reporting. From a technology perspective, mainstream technology has caught up with the demands of radiology. That?s allowed price and risk to come down. Modern PACS systems use off-the-shelf technology.

Allan Noordvyk: PACS is considered a mission-critical component for patient care and service delivery; hospitals cannot afford for the system to be down. Hospitals are replacing the single use/departmental solutions that do not improve efficiencies or position them for future success (and health care dollars). Products and improvement must focus on workflow and productivity enhancements, not just adding a button or isolated feature. Real improvements help hospitals improve their operations, service delivery, patient care outcomes, and operational goals. There?s a sense of urgency in the market?hospitals that haven?t planned for the future may get left behind. Buying another scanner is not a solution for long-term success?investing in IT is. And image management is at the core.

Axis Imaging News: PACS is now pretty standard in most large hospital settings. What about community hospitals and imaging centers? What?s the biggest barrier to adopting a PACS system these days?

Tim Kulbago

Green: For the community hospitals and imaging centers, it isn?t a matter of ?if? they should go to PACS, but ?when.? While on the surface these smaller facilities? needs seem simple, the radiologists and referring physicians need the same full features found in any university hospital system for reading and result distribution. In some ways, it is even harder to complete the digital transformation since these facilities don?t typically have the same IT support structures found in larger institutions. Agfa addressed this challenge with our Fast Forward to Digital solution. This solution features a complete hardware, software, and services package required for these smaller sites, designed to allow these customers to leverage the experience of more than 1,400 installations globally.

Kulbago: PACS is the standard in most community hospitals and imaging centers. Where it isn?t the standard is in rural hospitals and very small imaging centers. For the low-volume market, implementation of a PACS solution is mainly a cost issue. Another barrier is interoperability. PACS systems are going to have to be able to ?play? with each other, especially in the context of addressing legacy systems and new business partnerships. So technology challenges still exist.

Noordvyk: In reality, few facilities have not adopted PACS. [The issue is that] facilities are re-evaluating their PACS decision. Does their existing PACS position them for future success, government funds, etc? They?re looking for replacement solutions that deliver on the promise (and take them into the 21st century).

Axis Imaging News: What are customers demanding these days regarding PACS? Are you seeing that radiologists are becoming savvier about digital imaging and technology in general?

Allan Noordvyk

Noordvyk: Radiologists and administrators are looking for solutions that enable them to acquire, distribute, and archive medical images and diagnostic reports across the enterprise. Integrating images from multiple modalities with clinical patient data, streamlining the department?s workflow, and contributing to improved radiologist efficiency. Additionally, they need systems that provide referring physicians with patient images as part of a comprehensive medical record. The status quo is not a viable business plan?they?re looking for vendors that get them closer to their goals and objectives and deliver on expectations.

Kulbago: The main thing radiologists want is that a new system is like the one they used before. [As a group,] radiologists are becoming savvier. They?re asking much more pointed questions. The second demand is the capability to integrate a PACS with other ?stuff.? For instance, radiologists doing CAD want a really good CAD option. Those doing mammography or ultrasound need to use a special application. Integration of these specialty solutions into the PACS continues to be a focus for many PACS vendors. Third, radiologists and imaging organizations want to be able to distribute information efficiently. Fourth, on the business side, they want to know how they can cost-effectively operationalize a PACS system. They?re asking: Can I lease it? Is the service contract optional? Can I get a 1-year contract instead of a 3-year one? There?s a lot more fiscal conservatism going on in PACS procurement today.

Axis Imaging News: What about subspecialty PACS? Particularly in mammography and cardiology is there a growing demand for an affordable specialized PACS system from these radiologists? How are you meeting this challenge? What?s critical for these subspecialties?

Kulbago: I see [the market moving] deep into radiology subspecialties. For instance, a radiologist might be doing prostate MR and wants a CAD solution. I see radiologists fragmenting?not in a bad way?but into [more defined] subspecialties. However, it?s critical for PACS providers to avoid locking into somebody?s subspecialty issues. The key is to remain flexible. No single PACS vendor is going to be able to offer everything in one package.

Noordvyk: Solutions that allow for the more efficient reading of digital mammography, nuclear medicine, CT, and MR studies, and don?t require specialized dedicated workstations to do so make technologists and radiologists more efficient. And allow for faster case reading times, scan to read times, and (depending on the current site workflow) potentially increased scanner utilization.

Green: Dedicated display stations and miniPACS were the norm, but now customers have broader expectations to accept limited solutions that isolate medical records. Health care providers are looking to vendors like Agfa who can meet all of their imaging needs and provide a broad access to health care information across a multitude of image and information sources.

Axis Imaging News: We hear a lot about thin-client, Web-based, and even zero-client PACS systems?what are the key benefits of each? Who needs what most?

Green: Thick was the trick but now, thin is in! The markets are trending to zero footprint clients. Clinical users require access to medical images from a variety of locations and image sources across the enterprise, but often can?t install viewing software where they are. At the same time, image sizes are increasing exponentially and Web applications are radically changing how people access information. Agfa?s IMPAX XERO technology delivers a medical image viewer for ubiquitous access to imaging information independent of location and platform limitations. Only an Internet browser and a simple network connection are needed; no client software installation is required.

Kulbago: [The main question is] who needs what most? The thin-client solution is a PACS solution delivered in a standards-based way. In the thin client environment, something gets installed on the system. Something has to get installed on the workstation to allow it to work. To me, a Web-based solution means technology that can run over the Internet without dedicated networking solutions like VPN technology. In today?s market, a zero-client solution is not yet available to meet the demands of radiologists who do high-volume reading. This may exist in the future. However, Merge has created something called Fusion Web to address the much more challenging area of imaging distribution outside of radiology. It?s one of the coolest things we?ve done, and it provides interactive medical imaging on any Web browser without any additional software being required.

Noordvyk: McKesson pioneered the concept of the zero-download PACS client with our eJacket interface for referring physicians. The two main benefits of zero-download are immediate access to patient information from a new device and cross-platform support. Both are of increasing importance as recent generation iPhones, Blackberries, and other PDAs become commonplace in the hands of health care workers and thus mobile access to images on modest, non-Windows platforms is increasingly in demand. If it?s done correctly, zero-download clients can also be zero-training clients. However, the technology currently available for zero-download clients remains insufficient for high-performance sophisticated image manipulation and the underlying required network and data management strategies. Thus, for radiologists classic downloadable Web clients are still required.

Axis Imaging News: How will PACS/RIS systems play a key role in the new electronic health records and information exchange landscape? Are the government?s new requirements going to change the ?rules? that radiologists have been operating under using PACS/RIS? Or are they already ahead of the curve?

Green: Medical imaging is a critical part of the health care debate going on in Washington today. Already, the draft definition of meaningful use is looking at health information and result exchange. As we know, in order for health care providers to take full advantage of ARRA incentives, the entity is required to have in place a ?certified EHR? and achieve ?meaningful use.? Those health care providers that are not compliant by 2015 risk penalties associated with not having a certified EHR in place. Two requirements that specifically will impact medical imaging are the current ARRA requirement for medical device interoperability and multimedia support. True interoperability between systems requires standards like DICOM and HL7 as well as the IHE technical framework. For a certified EHR to include multimedia support, providers must either interface multiple sources of images and multimedia data or implement a central medical imaging repository, such as IMPAX Data Center, that consolidates all of the disparate multimedia information prior to EHR integration.

Axis Imaging News: What are the latest trends? How is PACS continuing to enhance workflow and efficiencies for radiologists? What is still needed?
And what can we expect to see from you at RSNA?

Noordvyk: Health care providers/radiology service providers are finding the limitations in the PACS they purchased years ago hinder their success now, have not lived up to the promises and their expectations, and are restricting their ability to plan for future success. Users are often still forced to use 19th-century workflow and technology but in an increasingly more complex and demanding 21st-century environment. What you?ll be seeing from McKesson is optimizing workflow and productivity in the breast center. By minimizing the duplication of effort caused by disparate systems and removing redundant hardware, the potential for errors is reduced. The automation of tasks provides maximum efficiency for the radiologists and other clinical personnel while providing better, safer patient care. McKesson offers a professional services portfolio that [has] consulting services that make a direct and positive impact on the customer?s balance sheet by accelerating the adoption and optimization of the system. Through strategic, well-defined, and targeted services, customers will generate more value, thereby creating greater customer loyalty. We help the customer get the most from their storage infrastructure by taking advantage of technology and hardware that scales from small archives to large regional solutions. Additionally, we recognize that the market is looking for lower footprint archives that both reduce hardware costs and are more energy efficient.

Kulbago: No-client imaging is the biggest trend. Merge is making a controlled foray into mobile communications and how it interacts with imaging with our newest iPhone application. We showed a market prototype with the core technology at last year?s RSNA and the feedback was overwhelmingly favorable. It?s amazing how creative people can become when they imagine technology?s possibilities. Our solution, the new ?eFilm for iPhone,? will launch at RSNA. It is not designed for diagnosis; rather it is intended for image review using a mobile device. We?ll anticipate a very positive response. We?ll also be showcasing our integrated billing application.

Green: Agfa HealthCare?s new IMPAX Xchange is a solution that delivers secure, reliable transfer and localization of patient studies between health care institutions. Using Web 2.0 technologies, this solution addresses the problems associated with using CDs and DVDs for data transfer. IMPAX Xchange works with a legacy PACS to preserve IT investments. It works by building a health information network between disparate systems to exchange and share all types of DICOM medical imaging data. IMPAX Xchange eliminates expensive peer to peer VPN and similar connections. Web 2.0 technology means no software downloads are required at any site. The user interface is an intuitive Web page that doesn?t require skilled personal to import or request images.

C.A. Wolski is a contributing writer for Axis Imaging News.