Dr. Shrestha is the Vice President of Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA, and the Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.
Let’s start with a bit of a history lesson around the DICOM standard — the Digital Imaging and Communications in Medicine standard — that essentially led the way to picture archiving and communications systems (PACS), from its academic conception all those years ago. It was back in early 1983 (Pianykh, 2008) that the ACR-NEMA (American College of Radiologists and the National Electrical Manufacturers Association) Digital Imaging and Communication Standards Committee was founded. After 2 years of work, the first version of the standard, ACR-NEMA 300-1985 (also called ACR-NEMA Version 1.0) was distributed at the 1985 Radiological Society of North America (RSNA) annual meeting and published by NEMA. In 1988, ACR-NEMA 300-1988 (or ACR-NEMA Version 2.0) was published. In 1993, DICOM version 3.0 (also known as DICOM 3) was released, and is the current standard. Although the standard itself has not changed, 23 supplements have been added to address technological changes and needs arising since the original standard was prepared. These supplements extend the functionality of DICOM to many types of digital imaging communications.
Just the quick review of the brief history of the DICOM standard above indicates one thing — PACS has been around now for a while. We saw a large-scale mass adoption of PACS nationally in the early 2000’s. Today, in 2012, it is impossible to argue against the logic of implementing PACS, and we have seen how in the last decade, PACS implementations have reached almost every nook and corner of imaging centers and hospitals nationwide.
PACS have matured tremendously, as have the implementation processes. A walk around any radiology trade show bedazzles anyone with the sheer number of imaging vendors touting one system or another, with added features, functions, tools and widgets. The reality, however, is that radiology workflows as well as the healthcare organizations have matured, too, over the years. Many who embraced the digital era in radiology with PACS years ago are going through various stages of maturity. There is a move towards redefining the demands of what PACS should deliver. Provider organizations often struggle with one or more aspects of their current PACS system, and for one reason or another often seek to move on to another vendor. Indeed, today, the largest growing segment of the PACS market is the replacement PACS market (Division, 2010).
But what does it mean today to switch PACS vendors? In this day and age of meaningful use, wide-spread electronic health record deployments, and competing needs in not just the imaging department, but across the provider space, there is a growing redefinition of what enterprise imaging really is, and an evolving approach to trying to fill the variety of often complex needs of the radiologists. It is not enough today to simply have a PACS system that archives studies effectively, and displays them efficiently for interpretation or review. Our clinical workflows in radiology are more mature and complex than ever before. Furthermore, our expectations for system performance, uptime, vendor responsiveness and the spectrum of workflow-centric tools are varied and many — and growing. It is no wonder then that every 7 to 10 years, provider organizations raise the white flag with their existing PACS vendors and look to replace their systems with something better.
Replacing a PACS is easier said than done, and this is clearly a decision that no one should take lightly. Challenges include many, from real workflow concerns for technologists and radiologists to database migration issues, such as patient reconciliation, interface issues and hurdles with proprietary file formats and the actual data migration itself, which could turn out to be a nightmare.
Implementing a PACS is a major commitment, and the analogies to marriage are many. So bear with us as we lay a few out to you. Much like any good marriage, the key is of course to first marry the right individual (in this case, the right PACS vendor)! But despite the best intentions, one often gets to the divorce court. Well-constructed prenups are a great idea (detailed service-level agreements, with defined expectations and penalties, along with detailed what-if scenarios and obsolescence protection), but if the unfortunate need to split comes up, make sure the kids don’t hurt too much (protect the data first, ensure the workflow continues to be smooth in the transition for all involved). It’s also highly recommended to go through focused rounds of serious discussions with your current vendor (marriage counseling?). Most PACS vendors are at a mature stage and are at varying stages of adoption of best practices, so a little (or a big) push may actually yield favorable results.
But if splitsville comes calling, ensure you hit the dating circuit well ahead of time — you will need as much time as you can get to plan well and plan thoroughly. You will need experienced and focused team members to see beyond the glossy brochures of the next vendor, in this increasingly genericized imaging market. Ensure you have a lean, focus-oriented yet well represented steering committee leading the charge and handling all aspects of change management.
Work with the right team of clinical, IT, finance, supply-chain, business and legal experts to ensure you leave no stone unturned. You may need a third party to assist in the data migration process. Ensure that you have a strong QA methodology in place to ensure the accuracy of the migration, and the mapping of a number of possibly idiosyncratic yet critical fields such as annotations, measurements, tables and pointers. Build well-thought-through contingency plans. Evaluate the evolving role of ancillary systems, such as the radiology information system (RIS), dictation system, advanced visualization, and image-postprocessing (eg, computer-aided detection (CAD), lesion management software, etc. The tide today is turning towards a more patient-centric workspace that is much less siloed and much more workflow centric and tied tightly upstream to the electronic medical records (EMR) (CPOE, decision support, enterprise access).
It is highly recommended to use this as an opportunity to reevaluate your current and future imaging needs, both within the radiology department and across the healthcare enterprise. An actual PACS replacement is not the only way to do this, but this is as good an opportunity as any to put a strategic focus on rearchitecting the infrastructure, embracing a more vendor-agnostic content storage paradigm (that includes DICOM, as well as non-DICOM content such as waveforms, movies, sound, stills, etc.) that accounts for specific workflow needs beyond radiology.
In this era of meaningful use and patient-centered care, an enterprise imaging strategy that accounts for current and future digital imaging needs across specialty areas, enabling easy image and content sharing, and ease of workflow will be highly regarded.
Guide to replacement PACS, version 2012. Appl Radiol.