Roadmap to cloud-based PACS

By Cristen Bolan

 “Will the next generation of PACS be sitting on a cloud?” asked James Philbin, PhD, Co-Director, Center for Biomedics and Imaging, Johns Hopkins, School of Medicine, in an article he wrote in 2011 for the Journal of Digital Imaging.1

A year later, Johns Hopkins is in fact implementing cloud technology to house its own medical data and “to allow other institutions to use the cloud to share medical images,”2 said Philbin, who went on to declare, “We think the cloud is the future of medical imaging.”2

Johns Hopkins may have acted at just the right time, as major trends and policy changes will significantly impact medical imaging and accelerate adoption of cloud-computing in radiology. Not only are volumes of diagnostic imaging data tripling in size annually, but the importance of imaging as part of the medical record has also gained industry recognition. Recently, meaningful use (MU) requirements added imaging to the list of optional criteria.

Driving forces

The cloud computing market for medical imaging in the United States (U.S.), valued at an estimated $56.5 million in 2010, is expected to grow at a compounded annual rate (CAGR) of 27% through 2018.3 As diagnostic imaging extends across medical specialties, imaging data will account for 35% of all medical data by 2015, up 7 percentage points from 28% in 2010.3

There is clearly a need to simplify image sharing across healthcare organizations. All of these factors point to cloud computing. Adopting a cloud-based picture archiving and communication system (PACS) can benefit radiology by removing upfront software licensing fees, mitigating maintenance costs, overcoming departmental silos, improving collaboration and data sharing with referring physicians, and enabling upgrades with minimal downtime.

The cloud can furthermore provide enhanced security because more expertise can be put into securing the server. Once data migration to the cloud is completed, it may be the last migration ever needed.2

In addition, the cumbersome process of CD production, involving multiple viewers and potential for file corruption, viruses, and image loss, as well as the associated courier costs, can be all but eliminated.

With the latest iteration in MU policy, the need to streamline PACS with electronic health records (EHR) has come of age. In April, the Center for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for HIT added medical imaging to the Stage 2 criteria for MU. Imaging is now one of 10 possible objectives doctors can put on their list of 5 objectives aimed at demonstrating MU. Specifically, >40% of all scans and tests ordered by eligible providers (EPs) or hospitals are accessible through certified EHR technology. Since 90% of radiologists are classified as EPs, and eligible for the $44,000 per physician by complying with MU criteria before 2015, many are scrambling to participate in the Medicare EHR program. If $1.5 billion in available incentive payments4 wasn’t enough of a carrot, heavy payment reductions for failure to meet the criteria is the stick to get radiologists going.

Where does cloud computing play a role in all of this?

For those EPs who don’t already have an EHR, the biggest obstacle is sticker shock – the initial cost of installing an EHR is high. Client-server systems can cost $40,000 or more just to set up, and then licensing fees, maintenance costs, updates, and patches must be added.5 But in a cloud-based PACS or EHR, since there is no hardware installation or software licenses, the cost of implementation is significantly less. Practices pay a monthly fee, like a utility bill, as part of an arrangement called software as a service (SaaS).6 For a small- to mid-size radiology group, a cloud-based platform may be more appealing than a client-server system.

Cloud models

In a cloud-based system, data are stored on external servers and can be accessed via the Web, requiring only a computer with an Internet connection, whereas the client-server systems store data in house, requiring a server, hardware, and software in the physician’s office. Although in-house servers have traditionally been the norm, practices are increasingly switching to the cloud for a number of reasons.

The benefits of cloud computing include cost and energy savings, rapid deployment, and customer empowerment. According to the working definition by the U.S. Commerce Department’s National Institute of Standards and Technology (NIST), cloud computing is designed to enable “ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources (eg, networks, servers, storage, applications and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction.” Simply put, cloud technology allows users to access applications from any computer with Internet access.

The 5 essential cloud-computing models that NIST7 lists are:

• on-demand self-service

• broad network access

• resource pooling

• rapid elasticity or expansion

• measured service

When a radiology department or group adopts a cloud solution, it is essential that it match one of these models as closely as possible to the NIST list to reap the benefits the cloud offers image and data exchange.

3 key cloud scenarios

There are a few different cloud solution scenarios: public, private, and hybrid. Each has its advantages, but privacy issues often dictate which type is most suitable for a specific industry, and how quickly an industry adopts the technology.

In the public cloud scenario, an organization migrates its existing IT structure to a public cloud. The characteristics of this category include a low-level of sensitive data, and users often represent early adopters of the technology.8

The second wave of cloud adopters use the hybrid model, which combines private and public cloud platforms. Typically, 75% of data is considered sensitive and is migrated to the private cloud, and the remaining 25% with less sensitive applications is sent to the public cloud to provide “surge” support.

Finally, departments with sensitive information will build their own private cloud or interdepartmental private cloud. These represent the late adopters of cloud platforms.

In all three scenarios, data transfer involves uninterrupted migration.8

Cloud-based PACS

The PACS in the cloud is actually the “zero client” or “zero footprint client” model, which is a Web-based PACS. The cloud-based PACS integrates diagnostic viewing, addressing the radiologists’ need to make diagnoses at any time from anywhere.

The sharing and communication approach is appealing with its inherent vendor neutrality for data storage. This allows hospitals to easily send data from the old PACS vendor to the new PACS vendor without worrying about compatibility.3

A widely popular model is SaaS, or the pay-per-use model, in which healthcare organizations pay only when they use the solution. Although subscription fees do not necessarily include maintenance or operating costs, SaaS lowers the high cost of software license fees.

Carestream Healthcare recently launched Vue cloud solutions for medical imaging, a managed cloud services platform for PACS with a pay-per-use structure. Carestream’s managed cloud services for PACS delivers a zero footprint viewer that requires no download to enable a quick review and exchange of clinical notes on virtually any device, such as the iPad, without patient data residing on the hardware. Radiologists can securely access image data, and use reporting tools, including dictation or voice recognition, as well as advanced 3-dimensional postprocessing and automatic volume registration comparison. Its patient-centric design enables access to disparate PACS on local systems, regardless of location. With the vendor-neutrality capability to take over a legacy solution, it also mitigates the need for costly migration and enables radiologists to view prior exams seamlessly and quickly.

Similarly, MIMcloud by MIM Software is designed to provide a secure, low-cost way to manage, retrieve, and archive DICOM images while sharing with colleagues. MIMpacs functions as a central DICOM repository for imaging, registration, and contour data, with automatic redundancy and backup. 

Dell offers Dell InSite One with an archiving-as-a-service capability, which is a cloud-based medical archive. By consolidating and moving long-term medical archiving to the cloud, hospitals can simplify their infrastructure and reduce storage and retention costs.

Depending on your facility, a hybrid model may be just what the doctor ordered—the best of the both worlds. “You need both the private PACS and a cloud-based PACS if you work with specialists from other systems, and it’s easier to collaborate through a secure cloud-based viewer,” said Joel E. Barthelemy, Founder and Managing Director of GlobalMed, which recently acquired EMDTransfer. Emergency Medical Data Transfer’s solution supports an internal private cloud to exchange image and data within a hospital network. It also provides a public cloud, ViewAnywhere Image Access, where physicians can conduct remote clinical consultations, and then transfer the images to another medical facility using TransferBridge. The cloud-server can be used to post comments and write notes instantly.

CoActiv offers its vendor-neutral, cloud-based EXAM-VAULT archive where images are stored locally, and offsite on CoActiv’s cloud archive for fast access to authorized users. “The dual-archive architecture offers us speed and affordability, not to mention disaster protection and 100% uptime, while bringing us an important step closer to meaningful use,” said Howard Lee, MD, president, Northeast Radiology, Brewster, NY.

Another cloud-based image archive was recently launched as part the existing Synapse platform by FUJIFILM Medical Systems U.S.A., Inc. The company’s new cloud-based image storage service, Permivault, is a service designed for health and medical data management and supports radiologists requiring file-based storage.

The RIS fix

In other scenarios, radiological information systems (RIS) may be the missing link to connecting all of the disparate systems. Cloud-based RIS offerings can provide an additional option to bring down the total cost of ownership while still allowing a specialty department like radiology to use a best-of-breed solution.

Siemens Healthcare recently introduced a new cloud-based option for its RIS, which is called syngoWorkflow. The radiology department at The Chester County Hospital and Health System, West Chester, PA, has been hosting Siemens’ enterprise clinical/financial health IT solutions, and has now implemented the syngo Workflow cloud solution.

syngo Workflow allows the customer easier access to one of the best RIS’s without the headaches and difficulties of having to set up and manage the expensive and complicated backend hardware. In addition, the customer gains superior stability and uptime with syngo Workflow cloud solution’s inherent high availability,” said Paul Russell Morris Jr., MSHA, Radiology Information Systems Administrator, The Chester County Hospital and Health System.

Morris added, “The platform will provide a stable, cost-effective, long-term solution to our radiology information system needs.”

A cloud-based RIS/PACS SaaS model by 7 Medical Systems provides a low-cost model with a low barrier to implementation, which is particularly helpful for cost-effectively centralizing data across multiple sites.

“We had 3 locations using disparate systems. We chose 7 Medical Systems because they offered an all-in-one integrated, cloud-based RIS, PACS, and revenue cycle solution,” said Aatif Rahman, administrator of Chicago Ridge Imaging, Oak Lawn, IL. “They also helped us migrate data from 3 systems into one. Now these locations are centralized and operate out of the same system from scheduling to billing. Not only were we able to automate workflows among all locations, we reduced overall costs, improved our billing accuracy, and shortened the billing cycle.”

He added, “We are encouraged by the prospect that the solution will enable us to comply with meaningful use requirements.”

Additionally, RIS can enable radiologists to meet MU requirements by operating as a modular EHR. Fujifilm’s Synapse® RIS Version 6.1 recently received modular EHR certification for radiologists. Solutions receiving modular EHR certification meet multiple criteria, whereas complete EHR certification meets all 33 ONC criteria. “Having our Synapse RIS receive modular certification is a tangible step towards receiving complete certification,” said Jim Morgan, Fujifilm’s Vice President of Medical Informatics. “This means that our radiology clients can address their meaningful use requirements that ensure an improved workflow and allow them to more quickly qualify for the incentives set forth by the ONC.”

Bird’s eye view

There are several advantages to the cloud-based architecture, and, as Philbin predicted, it looks like the future of medical imaging. With the recent inclusion of imaging as an optional meaningful use objective, radiology groups and departments are expected to turn toward cloud-based PACS, EHR, as well as RIS platforms as a low-barrier to implementation, highly scalable, and cost-effective option for optimizing the use of imaging in the clinical environment.


  1. Philbin J, Prior F, Nagy P. Will the next generation of PACS be sitting on a cloud? J Digit Imaging. 2011;24:179-83.
  2. Cloud Computing in Medicine. HIT Exchange Media. Accessed May 2, 2012.
  3. The US cloud computing market for medical imaging. January 5, 2012. GlobalData.
  4. Meaningful use for radiologists. Accessed April 19, 2012.
  5. 5 Advantages of a cloud-based EHR for small practices. Power your practice. Accessed April 17, 2012.
  6. 5 Advantages of a cloud-based EHR for small practices. Power your practice. Accessed April 17, 2012.
  7. Final Version of NIST Cloud Computing Definition Published. IST Tech Bet. NIST. Updated October 25, 2011. Accessed April 12, 2012.
  8. Alford, TA, Morton, G. The economics of cloud computing: Addressing the benefits of infrastructure in the cloud. Booz, Allen, and Hamilton. Updated October 26, 2009. Accessed January 3, 2012.
  9. Dell InSite One Medical Imaging Enterprise Archive Reaches a New Pinnacle. Dell. May 23, 2011. Accessed April 12, 2012.
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Roadmap to cloud-based PACS.  Appl Radiol. 

May 30, 2012

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