Today’s Radiology PACS – Shiny But Not New

It may seem a little late for commenting on observations from RSNA 2013, but then nothing has changed in the Radiology PACS market since then, so I think observations from three months ago are still valid.  Come to think of it, nothing really significant seems to have changed in Radiology PACS for several years now.  Pesky little things like bug fixes get attention each year, and functions that should have been standard years ago have finally shown up, but there have been very few major changes in system architecture.  Some semblance of Disaster Recovery has always been there, but a true Business Continuity configuration is still a reach for many of the PACS vendors.

Lots of radiology PACS on the market today are old.

havana3Interesting to see some of the PACS vendors developing a clinical display application based on server-side rendering and a zero (or at least near-zero) client. Why is the diagnostic application suite still a beefy client that requires delivery of the full lossless dataset to the remote display platform?  While the EMR user can access and view data on their Windows or Mac laptop, mobile tablet or phone, why is the radiologist still limited to a glorified PC?  Clinical image distribution and display has historically played second fiddle to the diagnostic application suite.  Why this sudden shift in focus from diagnostic to clinical?   Could it be that image enabling the EMR is the “new thing”, or simply the easier and less expensive engineering effort?  In the absence of meaningful change in system architecture and diagnostic display technology, perhaps the thinking is that a shiny new clinical viewer will serve as a differentiator among a handful of radiology PACS solutions that are otherwise old, and effectively the same core systems they were nearly ten years ago.

From my perspective, it seems that today’s Radiology PACS market is a zero sum game.  While some vendors with old technology are clearly losing market share, vendors with even “decent, old PACS” tend to lose as many existing customers as they gain new customers each year.  At 95+% market penetration, it’s a replacement market, where vendors attempt to take market share from each other.  Price pressure takes its toll on system sales revenue, so the real money is in service contracts.  But once again, if there is no net increase in customer base from year to year, that revenue stream is not growing. Only so much R&D funding is available each year, and apparently there is not enough revenue to fund “the next big thing” for Radiology PACS.   When revenues are flat or falling, profits also fall unless costs are reduced.  In addition to cutting R&D, that typically means vendors cut costs by eliminating staff through layoffs, or euphemistically “rightsizing”, “reorganizing”, spinning off or shutting down under-performing parts of their businesses.  When the Radiology PACS market went cold, the size of Radiology PACS companies shrunk.

In addition to standing pat with their existing technology, the Radiology PACS vendors have fallen behind in enhancing their solutions with those features and functions that radiologists and radiology departments need today to provide good patient care and stay competitive in their market. By and large, today’s Radiology PACS solutions do not support advance Breast Imaging packages to cover Full Field  Digital Mammography and Breast Tomosynthesis, as well as the ability to display multi-modality breast imaging presentations.  They do not include advanced diagnostic Nuclear Medicine packages to cover all the variations on mixed modality image fusion.  There is no advanced worklist functionality that can escalate studies on the read list to meet TAT requirements, no ED preliminary findings and discrepancy reporting, no call functionality and follow-up.  3D is basic if available at all, and remote access is typically poor. Today’s Radiology PACS frequently have no business analytics or data mining that would enable the department to discover and monitor the drivers of their business.

All of these highly desirable, if not necessary, features and functions are third party plugs-ins developed by smaller, more nimble and innovative vendors.  In too many cases, however, the interfaces required to plug these tools into the core Radiology PACS are not yet developed for a specific combination of vendor solutions.  It’s as though cooperating with the third party vendors to expand the core PACS through the addition of these plug-ins would be seen as an open admission that the PACS vendor has fallen behind.

Based on last year’s RSNA observations, it’s time for the PACS vendors to admit their system deficiencies, and start working on the solutions.  If keeping up with current requirements through in-house development is not feasible, then the PACS vendor must embrace the concept of third party plug-ins and get on with the development of the interfaces.  They should think of this strategy as a business necessity.  The VNA is steadily pulling image management from the department PACS.  Advanced clinical viewers that address both DICOM and non-DICOM objects will easily outperform those new PACS clinical viewers.  If a PACS vendor can’t keep up with all of the new radiology department application requirements, it will be a struggle to sell any new systems a few years from now, and that is the beginning of the end for the installed base.

Havana2As I departed Chicago last December, one strong image came to mind.  Pick any upscale neighborhood in Havana and you’re likely to see shiny cars parked at the curb.  The interesting thing is, none of these are new cars, they’re shiny old cars.  Some have new wheels, but they’re still old cars.  Today’s Radiology PACS conjured up images of Havana streets…shiny cars that are not really new, with underlying layers of faded paint covered in super-high-gloss wax.