Enterprise PACS: Where Do the Opportunities and Challenges Lie?

 Deploying PACS capabilities beyond a radiology department or facility provides the opportunity of extending the reach of diagnostic imaging to the entire spectrum of clinical medicine. The benefits to healthcare practitioners are immense—increased diagnostic certainty and the capability to provide efficient and effective treatment.

Radiology services in the United States are typically provided in three venues: academic medical facilities; private practice diagnostic imaging centers; and community hospitals. A multi-site facility that covers thousands of lives will face different challenges to extending a PACS throughout its enterprise than will a diagnostic imaging center or community hospital practice. However, each of these types of operations must meet the demands of multiple specialties to have access to radiological images and information.

Academic practice meets challenges

Jeff Schaefer, director of diagnostic and therapeutic services at University Medical Center (UMC) in Tucson, Ariz., has slogged his way through the PACS trenches for a number of years. The 355-bed non-profit, acute-care hospital is part of the Arizona Health Sciences Center and is adjacent to the University of Arizona Colleges of Medicine, Nursing, Pharmacy, and Public Health. Although spun off as a private organization, the facility maintains a strong relationship with the university.

Besides the hospital, UMC operates two hospital-based physician offices, a cancer center, and is affiliated with an orthopedic practice in Tucson; one hospital-based physician office in Green Valley, Ariz.; a medical transplant physician office in Phoenix (for pre- and post-transplant patients); and is opening a diagnostic imaging center in its home city. In addition, the UMC radiology department is part of the Arizona Telemedicine Program, which provides consultative healthcare services to the state’s rural and Native American reservation residents.

The facility performs approximately 190,000 imaging procedures on an annual basis, with a modality mix of digital x-ray, mammography, CT, MRI, ultrasound, fluoroscopy, and nuclear medicine studies. This results in about 4 terabytes (TB) per year of digital image storage for the institution, according to Schaefer. UMC has 26 attending radiologists and 24 radiology residents.

PACS capabilities are deployed throughout the UMC enterprise, Schaefer says, with diagnostic-level workstations and monitors in the operating rooms and emergency department as well as the radiology reading area. Off-site access is controlled through secure network connections.

When UMC first began widespread implementation of PACS access, there was some initial adoption reluctance on the part of clinicians who had grown comfortable with a film-based culture.

“Over time, they’ve grown to recognize how much faster it is to retrieve image studies via the PACS,” Schaefer noted.

The facility is in the midst of a transition to a new PACS product to meet increased demands by its users for diagnostic images and information. Along the way, Schaefer has acquired some hard-won knowledge of the issues facing an enterprise-wide PACS deployment.

“One of the biggest challenges we’ve had over the past few years has been the issue of storage management,” he says. “With the changes in diagnostic modalities to higher volumes of images as well as bringing onboard new digital modalities, I was faced with asking for more and more money each year just to maintain the archive.”

To address this situation, UMC has elected to transfer its archive management to an application service provider (ASP) model. According to Schaefer, this frees the facility from having to construct and deploy an archive disaster management solution, provide archive maintenance, or hire personnel to manage and service the system.

“With an ASP-based archive, we’re better able to focus on providing service at the point of clinical care, which is our primary goal as a healthcare system,” he noted.

For those facilities seeking to expand their current PACS beyond radiology, or an institution looking to bring an enterprise PACS on board, Schaefer recommends that they pay close attention to security and access beyond the walls of the hospital.

“One of the challenges we faced is that we wanted to be as secure as possible, but we didn’t want to hinder patient care,” he says. “You have to walk a fine line between securing your PACS network and providing as much access as possible to physicians. You should plan on spending a fair amount of time documenting and testing your strategy to achieve this goal.”

Community hospital maximizes resources

Greene Memorial Hospital in Xenia, Ohio, is a mid-size community hospital, licensed for 210 beds but typically staffed for 80 beds. They are targeting 78,000 imaging procedures performed in their hospital this year, plus an outpatient imaging center and four satellite facilities in medical office buildings.

The hospital provides a broad mix of imaging services, including digital x-ray, CT, MRI, SPECT/CT, breast-specific gamma imaging, ultrasound, mammography, fluoroscopy, DXA, and is considering bringing mobile PET/CT on board. Mary Ann Hargrove, director of radiology at the facility, is justly proud of the imaging service lines Greene Memorial is able to offer residents of Xenia and its surrounding area.

“When we set out to bring an enterprise PACS into our facility, we first realized that we would have to upgrade our modalities in order to utilize the benefits of PACS,” she says.

According to Roxanne Quinlan, imaging services coordinator at Greene Memorial, this meant replacing a variety of systems.

“We replaced our film-based x-ray units with CR, upgraded to three new ultrasound units, replaced our C-arms and portable x-ray, purchased a new CT, and acquired a SPECT/CT system,” she says.

The equipment acquisitions took place over a two-year period while Hargrove and her colleagues planned Greene Memorial’s PACS installation. Due to budget constraints, the facility’s administration asked her team to handle all aspects of the PACS project.

“Our facility has limited resources and we planned, implemented, and deployed the PACS on our own,” she says. “We did not hire a PACS consultant. We did it from the ground up by ourselves.”

Hargrove accomplished this task by educating herself on best practices, as well as pitfalls and potholes, for PACS implementation via extensive research, informational interviews with professional colleagues at other institutions, and attendance at educational sessions such as those provided at the American Healthcare Radiology Administrators (AHRA) annual conference.

They went live with their enterprise PACS in October last year. Hargrove says that the radiologists began reading from the system at 8 a.m. and by noon that same day her staff had stopped printing film. She prepared the facility’s referring physicians for the all-digital roll-out by enabling them to work with a web-based system starting in Spring 2006. 

“We got them interested and excited about digital, but kept printing film for a window of time,” she says.

The web system is available to referring clinicians who create an account with Greene Memorial, Quinlan says. Patients who request copies of x-rays or other test result images are now given a copy of the report and images on a CD that is provided at no cost.

Greene Memorial has its PACS interfaced with an EMR from a smaller vendor with a radiology module that Hargrove’s staff uses, replacing its use of a RIS and allowing enterprise-wide access to diagnostic images and information.

Hargrove reports that not only did they work through this project on their own, but they’ve had no major problems and have saved money with the new system. Although the team planned for contingencies in its PACS budget, they did not have to use the funds, so they are currently under budget projections for the implementation. In addition, the efficiencies created by the deployment have allowed Hargrove to downsize the staffing levels in her department when two full-time equivalent (FTE) employees left due to attrition.

Hargrove says that the project could not have gone a smoothly as it did were it not for the excellent relationship that radiology department formed with the hospital’s IT group.

“Having a strong relationship with the information systems management and staff is very important,” she says. “You have to be able to communicate with one another and share each other’s expertise. We would not have had as successful a project as we did were it not for their help and support through every step of the process.”

Private practice puts it all together

Radiology Ltd. is one of the largest physician-owned group practices in Tucson, and has been providing diagnostic imaging services to the community for more than 70 years. The group has 48 radiologists affiliated with it and employs more than 425 technical, clerical, and administrative personnel.

They are also one of the largest providers of diagnostic imaging services in southern Arizona, according to Eric Nied, director of information technology.

“We currently perform close to 700,000 imaging procedures annually,” he says. “We’re storing between 8 to 10 TB per year of digital images and information.”

The group offers a complete service line of diagnostic modalities including digital fluoroscopy, digital x-ray, CT, MRI, PET/CT, ultrasound, nuclear medicine and interventional services, digital mammography, DXA, and a 3D image processing laboratory at 11 locations in the city.

In addition to outpatient services, Radiology Ltd. provides a wide range of imaging services to Tucson Medical Center (the largest hospital in southern Arizona), St. Joseph’s Hospital, UMC, and Northwest Hospital. According to Nied, the practice imports and exports images through its PACS from these facilities.

The group was the first to provide PACS services to the community, via a teleradiology network, and its IT infrastructure has evolved as the practice has added more modalities and services. Its referring clinician base is able to access images and reports through a secure network connection into the PACS.

Nied has been through a pair of PACS deployments and learned first-hand about some of its pitfalls.

“One of our biggest challenges a few years ago was getting servers and workstations with enough computing horsepower to run the applications our radiologists use,” he says. “For awhile we were building our own custom server workstations to meet our needs. We’re just now getting back to replacing these home-built machines with commercial models, in order to meet service requirements.”

The PACS runs on a 100 megabit fiber ring that is connected to each of Radiology, Ltd.’s facilities, so network throughput has not yet been an issue for Nied, even with image volume in the practice’s workload.

The group maintains its own image management through both network-attached storage (NAS) and storage-area networks (SANs) that can provide real-time fail-over service as part of the practice’s disaster recovery plan.

Nied learned early on that the addition of any new service line or modality to the practice would have a direct impact on archive capabilities, so the IT group is part of the team that helps develop new offerings. This allows it to plan for the front-end deployment of the new service through the PACS as well as assuring a seamless archival strategy on the back end.

For facilities looking to deploy an enterprise PACS, Nied recommends looking to a vendor that can offer a one-stop shop for its system needs.

“You should research the companies out there that have the all-inclusive package: a RIS, PACS, HL7 engine, practice management, and billing offering,” he says. “That kind of system, where you’re not putting together too many disparate systems, is probably the better path to take.”

Future PACS paradise

As PACS access moves beyond the radiology department and into the enterprise, it’s only natural that other image-generating specialties will want to take advantage of these systems. Currently, there are cardiac-specific PACS, orthopedic-specific PACS, radiation therapy-specific PACS, and a few pathology-specific PACS on the market.

Other specialties, such as endoscopy, ophthalmology, and microscopy, create visible light (VL) images and also will want to be part of a future enterprise PACS. Integrating these specialties will provide system-wide access to their diagnostic reports and images, allowing healthcare practitioners to further expand their diagnostic capabilities.

Obviously, from an enterprise standpoint, it makes little sense to have a collection of independent PACS keeping medical images within each department—which requires a back-up and disaster recovery for each individual specialty. An enterprise image-management strategy will be required to centralize the archiving of this data, both for economy of scale and electronic health record capabilities.

John Koller, a healthcare information technology consultant and president of Larkspur, Colo.-based KAI Consulting, notes that such an enterprise-level image archive has the potential to significantly lower the cost of ownership of a PACS.

“The long-term life-cycle costs associated with managing these images can be significantly lower by creating an enterprise archive, if you look at what it costs to migrate from PACS vendor to PACS vendor,” he says. “Historically, when you go into your first PACS, it’s a learning opportunity. You end up buying it, you get into the vendor, and then once you figure out what you really want and go out and buy it, you have to go through a lengthy and expensive migration of your data from the original PACS to the new system. Some of these can take months or years and cost ten of thousands or hundreds of thousands of dollars or more.

“By building a common, standards-based image archive, what you’ve done is started to virtualize the PACS front end. This enables a user to deploy a department-level PACS and plug and unplug it without having to migrate images that have been accumulated over a long period of time. This allows any new PACS to come in and start accessing the images using standard formats such as DICOM to query and retrieve the images and information that is a hospital asset.”

In addition, an enterprise PACS that provides image management for all specialties will need to have a single platform architecture, to allow efficient systems administration, according to Herman Oosterwijk, president of Dallas-based PACS education training and education firm OTech. He also recommends that such a system be strictly standards-based to ensure interoperability with existing, as well as future, healthcare IT products.

“If you’re looking for an enterprise-level PACS that can bring together all imaging specialties through one system, you’ll want to have it built on a single architecture and provide one user interface [with tools for various specialties]; otherwise support and management will be very difficult to do,” he says.