PACS: Dead, Dying or Re-born?

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The great American humorist Mark Twain once quipped, “Reports of my death have been greatly exaggerated.” If digital image management technology had a voice (and ergonomists would likely agree that it should), it also might pronounce its longevity.

Some naysayers have scribbled an obituary for PACS, claiming good riddance to a radiology-centric, efficiency-obsessed system riddled with baffling buttons. Others refuse to bid adieu, and underscore the central significance of imaging in healthcare.

To better understand if PACS is on the edge of obsolescence or if a new and improved model is about to emerge, Health Imaging spoke with three thought leaders about digital image management.

PACS 3.0: Meaningful innovation for meaningful use

Paul J. Chang, MD, Professor of Radiology, Vice Chair, Radiology Informatics; Medical Director, Pathology Informatics; Medical Director, Enterprise Imaging, The University of Chicago Medicine

“We’ve had two PACS deaths already,” says Chang, adding that the third generation is an expected and welcome evolution of digital image management.

First-generation PACS seemed excruciatingly painful in retrospect. The sole emphasis was on translating film to digital in an environment that lacked networks, technology, archives and more. This radiology-centric, thick-client model has ceased to exist.

“The battle cry of PACS 2.0 was workflow,” says Chang. Radiology had solved the film-to-digital transition and began to leverage digital image management systems to improve workflow. PACS entered the age of the -ologies and employed an enterprise-centric model. Web-based systems, thin clients and EMR integration were the hallmarks of PACS 2.0.

“We’re seeing the end of this cycle and the beginning of PACS 3.0. The fundamental difference is the drivers in radiology have changed dramatically.” As PACS 1.0 and 2.0 were developed and disseminated, reimbursement was a given. Radiology could focus on maximizing its investments through maximum efficiency and throughput.

Although PACS may not be dead, fee-for-service is on its last legs. In new reimbursement models, radiology’s value will hinge on its capability to manage imaging, rather than reading studies.

“In a capitated model, radiology is a cost sink not a revenue generator. This requires us to change our view. Anything we talk about when we design the next-generation PACS has to directly result in measurable improvements in the value proposition, with value defined as quality, efficiency and safety simultaneously.”     

To navigate this disruption, radiology needs to understand that its stakeholders extend beyond referring physicians, patients and local hospital administrators and now include entities beyond the firewall. New stakeholders include third-party payers, who are aligned with radiology in accountable care organizations, as well as government agencies that require analytical data.

In addition, patients have morphed into healthcare consumers who demand value. “If a radiology provider can’t demonstrate its differential value and provide the best service, the patient can go elsewhere.”

Many in radiology, says Chang, aren’t ready for these changes and need PACS to address these new realities. Third-generation systems will require an archive neutral approach that leverages the cloud and emphasizes interoperability. Chang foresees radiologists working in highly distributed, federated environments that will require interaction among multiple vendor neutral archives.

“It’s easy to send current images and priors, but it isn’t enough. We also need clinical context.” PACS will need to interact with the EMR and other information systems to provide data, such as lab values and pathology results.  

The third element of PACS 3.0 is robust business intelligence and analytics. Reimbursement will depend on meaningful services that add value. Traditional data, such as turnaround time, are insufficient, says Chang. Correlation between imaging and clinical outcomes will be a key metric. This requires an unprecedented level of integration with the EMR.

“This is a huge challenge and opportunity,” Chang concludes, before offering a few words of wisdom for RSNA attendees. “If you want to see where the zeitgeist is truly moving, visit the small vendors.”

The next intersection: Imaging informatics & ethics

Keith J. Dreyer, DO, PhD, Vice Chairman of Radiology at Massachusetts General Hospital (MGH); Associate Professor of Radiology at Harvard Medical School, Boston