PACS Grows Up

November 1, 2007
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As imaging technology matures into its second generation, the industry begins to feel the shift forward

Lynn Witherspoon, M.D., has an unusual background for a CIO. A physician whose clinical specialty was nuclear medicine, Witherspoon first became interested in imaging and image data-management issues while practicing within what is now the Ochsner Health System in New Orleans. As a result, Witherspoon became involved in a project 11 years ago that brought what he calls a "quasi-PACS" system for X-rays to what was then the Ochsner Clinic, and is now the flagship hospital of the seven-hospital Ochsner Health System. This system created digital output of images from X-rays (no CT or MR), and allowed radiologists to print out those images onto film. But without digital storage, the radiographic images were still stored on film.

This early experience put in place some of the infrastructure needed when the health system grew into a seven-hospital, 35-clinic integrated health system following Hurricane Katrina in 2005. The organization had already extensively automated clinical documentation, and had "evolved" its EMR platform forward, says Witherspoon, who has been CIO for nearly 11 years. The implementation of PACS seven years ago changed the EMR world dramatically, Witherspoon reports, compelling the expansion of high-bandwidth capability, which meant the installation of a high-availability, broadband ethernet fiber network that Bell South (now AT&T) had built in Southeast Louisiana. "We needed the bandwidth to be able to transmit images in a reasonable period of time," Witherspoon explains.

With its unusual history of having already had a "proto-PACS"-type system that already generated (though did not store) digital images for the physicians, "Our referring doctors had a long culture of reviewing their patients' X-rays," Witherspoon notes. As a result, there already existed pressure for the Ochsner system to use PACS to make diagnostic images more readily available to referring and ordering physicians. And, in turn, the rollout of the EMR system and the diffusion of electronic records to physicians across the community added to the forward momentum at Ochsner. As for integration, Witherspoon reports that, "As the patient chart became electronic, the X-ray jacket was still film, now scattered around the place, and there was a large disconnect. PACS," he says, "allowed us to put a Web portal in the EMR. So now they'll open a folder on a patient record in the EMR, and they can open the PACS." (Ochsner is using a PACS system from Mortsel, Belgium-based Agfa.)

The path forward to PACS-EMR integration hit a fairly big bump, however, when the attempt over the past couple of years to partner with a large core clinical IS vendor to create an enterprise-wide image management capability failed. Still, Witherspoon says he and his colleagues learned a great deal from doing that project, "and we turned back to Agfa to reconnect all the pieces." At press time, Witherspoon and his colleagues were in the process of building out that enterprise-wide image management system, which is fully interfaced with the organization's core EMR. And Ochsner Health System's saga, though varying in certain details, mirrors the long-and-winding-road types of experiences many hospital-based organizations are currently having across the United States, as well as internationally.

Nationwide, a surge in development

Indeed, hospitals and health systems across the United States. and worldwide are facing similar challenges as they push towards the full integration of PACS systems with their core clinical computing systems. Among the key trends and developments pushing comprehensive image management forward are the following:

  • a rapid acceleration in the implementation of EMR systems nationwide and worldwide;

  • increased sophistication in terms of the capabilities and functions of PACS systems;

  • lower prices for PACS systems than a few years ago, due to vendor market competition;

  • an explosion in the size and number of diagnostic imaging studies because of the economics of digitization of the diagnostic imaging process;

  • the emergence of PACS and PACS-like systems for non-radiology disciplines, including cardiology, surgery/OR, orthopedics, oncology, ophthalmology, gastroenterology, dermatology, and pathology, and the subsequent need to integrate those systems into broader clinical information systems;

  • because of the explosion in the size and volume of diagnostic imaging studies, a concomitant explosion in the need for additional image and data storage among hospitals and health systems;

  • higher expectations on the part of radiologists, referring and ordering physicians, clinical departments, and other stakeholders, with regard to the availability and share-ability of images and data enterprise-wide.

All of this, of course, means a sense of urgency on the part of many patient care organizations to systematize what could otherwise balloon into a jumble of images and data.

"The topic of integration with EMRs is really becoming the next big thing," confirms Scott Grier, a director at Abrio Healthcare Solutions, Nashville. "I think that we technology geeks have accomplished the majority of things in PACS," says the Sarasota, Fla.-based Grier, who has decades of experience in PACS selection and implementation consulting. "It's a question now of how we use it."

In fact, Grier says, the availability of digital images is rapidly becoming part of the assumed cost of business for all but the smallest and poorest of hospital organizations nationwide.

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