THE P IN PACS
...PACS is about more than Pictures
In The Beginning
Back in 1980, medical imaging departments attributed most of their problems to their dependence on film. As a result, early PACS were designed as replacement technology for film. Hence the name, Picture Archiving and Communications System.
Almost 25 years ago film was much more expensive and many figured they could pay for PACS based on film savings. "Going film-less" became the mantra for both vendors and the market.
Fast Forward 25 Years
We finally have the technology to replace film:
- Interfaces to connect modalities
- High-speed networks for moving massive amounts of image data
- Fail-safe servers for 99.9% availability and reliability
- A variety of standards-based compression schemes (including J-PEG 2000) to improve performance and reduce hardware costs
- Reasonably priced, "off-the-shelf" storage solutions
- High resolution displays that rival the image presentation quality of film
All of this has made it possible to replace the film-based process with an electronic process.
Lessons Learned
Based on our experience, we've made some surprising realizations. The first is that the economics of the medical imaging business have changed.
In response to the perceived threat of PACS, film companies have been dropping their prices over the last 25 years. Using today's film prices, materials and labor savings alone will not break-even or produce an operational profit. In fact, operational deficits with PACS can run six figures year after year.
Over the past few years, it has dawned on us that film is not the only important piece of information in the film jacket. The other "P" in PACS is for paper. For example:
- Patient/exam history
- Print of the order or requisition
- Any and all clinical notes
- Release forms
- Technologist worksheets/reports
- Radiologist reports
This paper supports the internal workflow of the department that the traditional Radiology Information System (RIS) does not reach. It might also represent the workflow that the PACS will not reach unless the system is properly designed.
In order for the PACS to be successful, the radiology department needs to eliminate all of the study-related documents (1) because there will be no one to move it, nowhere to store it, and no way to find it when the Jacket goes away. That means replacing the paper exchanged between the Emergency Department and Radiology to note preliminary impressions, and the occasional discrepancy or incidental finding. That means eliminating the hardcopy of the requisition, simply because the radiologists use its bar code to open the dictation file. If you stop and think about it, this means eliminating a lot of paper forms you have invented for good reasons and have gotten very used to using.
Lessons Learned Summary
Assuming current film prices, PACS is a zero gain initiative, at best costs equal savings. The goal of PACS should be to "go jacketless" rather than "film-less". And that means developing a new workflow that successfully eliminates the use of paper [1] to announce the readiness of a patient or study, [2] to communicate clinical information to the radiologist, [3] to communicate results to the referring physician.
In the process of determining this new paper-less workflow, it was also discovered that the technologists will have to play a larger role in preparing the study for interpretation. The technologists and not the system administrator will have to take responsibility for study QC. The Technologist must determine if all the clinical information needed by the radiologist for interpretation is present and accurate and attached to the electronic study.
Current Meaning of PACS
The epiphany that there is more to PACS than film has lead to a new goal: the delivery of clinical information (images and reports) in the most expeditious and cost-effective manner throughout the health care enterprise.
The term PACS has become an anachronism, pictures are no longer the only focus. The market has matured to become more centered on information management.
Aren't you glad you didn't spend $4 million two years ago only to realize you now need to automate the other half of what's in the film jacket?
State of the Art PACS
The ideal PACS today is more than just a PACS. It must manage all forms of data prior to interpretation, enable the creation of multi-media reports and distribute the reports quickly at a cost-effective price. This ideal information system is comprised of:
- PACS as we knew it
- RIS as we know it
- Technologist workstations with PACS and RIS features
- Voice-to-text and multi-media reporting
- Workflow engine that directs operations
- An enterprise oriented data repository and distribution system
New Paradigm, Same Old Name
The next time you are talking to someone about PACS, be sure to find out which PACS they are talking about.
And as you review this web site, know that the PACS I'm talking about is the new PACS, not the old.
