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Image is Everything

March 27, 2007
by Mark Hagland
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No longer solely the domain of radiologists, imaging is taking hold throughout the hospital.

Q: When is the management of radiologic images no longer about the radiologists?

A: When a combination of technology advances, alterations in medical practice, the evolution of enterprise-wide clinical computing, and changes in the hospital strategic planning landscape redefines the question -- in other words, now.

In fact, industry experts agree, the whole notion of how and why hospitals and health systems should implement picture archiving and communications systems (PACS) is undergoing fundamental change these days, as they become one element in a far broader, more complex, and more strategic, buy/build/upgrade planning process.

Just take the example of 450-bed Regional Medical Center at Memphis, popularly known as "The Med" That hospital is currently going through a total PACS system replacement, which should go live by late spring.

"From my standpoint, second-generation PACS systems are a marketing tool for the hospital,"says James Leonard, the hospital's CIO. Leonard, who heads up a fully outsourced IT department that is staffed by Long Beach, Calif.-based First Consulting Group, says that while first-generation PACS systems were tools for radiologists, the second-generation systems being implemented now are, strategically speaking, for the referring physicians. "What you're trying to do is to put together a PACS system that's easier for a referring physician to use and view, so that he or she sends you more radiology studies than to the competition down the street. So it's all about ease of use for referring physicians."

Of course, such altered calculations mean that CIOs necessarily must engage clinician leaders in broader discussions around implementation -- not only among radiologists, but among all clinicians. The focus must be not only around images and data for radiology, but increasingly for cardiology as well (as cardiology PACS solutions come online) -- and soon for pathology. Down the road a bit, they will need to be for gastroenterology, dermatology and other clinical areas as well, say experts.

In this context, Leonard says bluntly, "If you buy a PACS system today for the radiologists, you're making a $2.5 million mistake. I want those neurologists and orthopods sending their studies to me, because they like the way my system works for them, versus the PACS across the street."Differentiating a hospital as superior in service and capabilities is the goal, he says, and it's a conversation CEOs and clinician leaders will understand.

Nationwide, a realization

The kinds of conclusions that The Med's Jim Leonard has come to are now being reached by CIOs nationwide, as they face multiple challenges, including:

  • integrating images and data from cardiology and other disciplines with the radiology images and data;

  • integrating the image-based systems with core electronic medical record (EMR) and hospital information systems;

  • coping with the explosion in radiologic images that is putting a strain on storage architectures nationwide;

  • expanding the availability of images and data to physicians everywhere; and

  • dealing with the need to upgrade or replace systems altogether, as hospitals move towards second-generation PACS systems.

Indeed, now is a time of intensive PACS implementation and upgrading, note those tracking industry trends. According to Mike Davis, executive vice president of HIMSS Analytics, Chicago, his group's latest research indicates that about 50 percent of hospitals nationwide have at least some of the components of PACS systems, while around 70 percent of 300-plus-bed hospitals have some version of PACS. In other words, in contrast to even five years ago, PACS capability has become the norm rather than the exception in the hospital world.

There is good and bad news in these statistics, industry analysts say. On the one hand, core PACS technology is rapidly becoming commoditized. On the other hand, the wait for the expertise to install hospital-based PACS systems and integrate them with EMRs is becoming longer.

Vincent Norlock, a Whitefish Bay, Wis.-based consultant with First Consulting Group and a specialist in PACS issues, says, "Smaller vendors in the PACS sphere are growing so quickly, some by 40 percent or more a year, that some of their installations are going beyond the three-to-four-month timeframe for their people even to show up."Tim zoph

A separate but ultimately more significant challenge for information executives, Norlock says, is the need for CIOs to plan strategically for the costs of implementing, maintaining, upgrading, and replacing these expensive systems. (Although individual situations vary widely, implementations are averaging about $1 million for smaller hospitals and $2-2.5 million for larger hospitals, he says.)

"At some point, you'll have to come to grips with the very large amounts of money needed to maintain these systems,"Norlock emphasizes. "The longer you wait to assess that scope and communicate it effectively out, the more weakened your credibility and perceived effectiveness will be."In other words, CIOs must develop strategic plans that CEOs and boards will understand and can endorse.

In fact, as they plan strategically, CIOs should think about the long-term efficiency gains that are a key part of the PACS promise, says consultant Scott Grier, president of Grier & Associates, an independent consultancy based in Sarasota, Fla.

"People think that ROI (return on investment) always has to have a dollar sign in front of it, but it's really the efficiency of the hospital that we want to affect,"he says. Calculating the advantages of being able to shorten average length of stay (when unnecessary surgeries are averted because of timely, PACS-facilitated diagnosis, for example), and of speeding patients through the care process (and thus shortening individual lengths of stay) are among the areas where CIOs will prove their investments' value.

CIOs moving quickly to adapt

Given the rapid advance of technologies, hospital and health system CIOs are finding their work cut out for them. Take, for example, 744-bed Northwestern Memorial Hospital, a leading academic medical center located in downtown Chicago. Vice President and CIO Timothy Zoph confirms that the hospital has 74 terabytes of data in its PACS system (which encompasses cardiology as well as radiology), and a phenomenal 155.8 million total images in its system overall.

Not surprisingly, Zoph says, the rapid volume increase has compelled a great deal of planning for the hospital, including the recent revamping of its storage capabilities. More broadly, Zoph says that one of the biggest issues facing CIOs of large teaching hospitals is "almost an anchoring issue. In other areas of image management"outside radiology, he points out, "there are already specialized localized systems in place. So how do you move from (a constellation of) such systems to a broader environment? You have to bring a set of localized image management technologies, that were evolved outside a broader view of the architecture, into a broader context,"and incorporate workflow issues into every aspect of planning.

In other words, Zoph says, the challenge lies in analyzing radiology, cardiology, pathology, and other disciplines' workflows, and determining the extent to which each discipline can be allowed different operating arrangements. "I think the answer lies in understanding the unique workflow needs of these various image-intensive areas, and identifying those things that are unique, while embracing the elements that are common,"and making all the elements work together, he concludes.

Changing physician practice patterns already brought about by working with PACS systems is having a major impact on CIOs' strategies. Prior to the implementation of the first generation of PACS systems, of course, radiologists as a practical matter controlled radiologic images by virtue of their being on film and stored in paper jackets. But as PACS went widely live in the 1990s, referring physicians realized they had virtually equal access to the now-digital images, and began making clinical decisions in real time, even as radiologists wrote their diagnostic reports.

As a result, referring physicians and emergency physicians now regularly make a range of clinical decisions before radiologists complete their reports, relegating the radiologist to more of a consultant role, more focused on complex and unusual clinical cases. All of this has brought workflow issues to the forefront in implementing and architecting PACS solutions in hospitals and health systems.

"PACS was originally seen as a radiologist solution,"Grier explains. "And in the beginning, the two driving forces were speed, so the radiologist could read the image faster; and prevention of loss of images. Now, however, radiologists are just another component in the subcontracted-out process around images."

The whole notion of a separate, siloed archive of digital images that can remain un-interfaced with other silos of images and data is rapidly becoming anachronistic, he argues. At the same time, with other medical disciplines such as cardiology (and soon pathology) having PACS-like configurations developed for them, and with the volume of diagnostic images continuing to explode in volume, "The challenge for the savvy CIO is to look 15-20 years down the road, so he doesn't get himself boxed in or firewalled someplace with software or hardware he can't manage."

Offerings immature

Working through issues that satisfy the needs of both referring physicians and radiologists, while moving towards an enterprise-wide image and data management system is complicated by the immaturity of the vendor market at this point, say some CIOs.

"The costs"of building separate PACS silos for radiology, cardiology, and soon, pathology and perhaps gastroenterology and dermatology, "are duplicative, but the applications aren't where they need to be, and therein lies the problem,"says Stephen Clark, Ph.D., CIO of 400-bed University of Colorado Hospital in Aurora, Colo. We've seen the market begin to coalesce in adopting standards in data architecture, but the tool sets are still very different. And there's nobody that provides a single solution across all your images. It doesn't exist. The closest is people who provide a common set of tools across radiology and cardiology."

The reality is that hospital leaders will still have to cobble together different solutions for different disciplines (radiology, cardiology, etc.) and then work to create interoperability among those images and data solutions and with core EMR systems -- and to create workable storage architectures for all those systems, Clark says. That's what he and his colleagues at the University of Colorado Hospital have done.Darrell leonhardt

One key element in moving forward in such a challenging environment is "to have the department chairman or key clinician leader on board and working with you,"says Darrell Leonhardt, CIO at Arkansas Children's Hospital, a 292-bed academic pediatric facility in the state's capital, Little Rock. Leonhardt says he was extremely fortunate to have his hospital's radiology department chair as a strong champion who attended board meetings and finance committee meetings, and helped craft the first-time PACS implementation proposal. In addition, he says, Arkansas Children's Hospital has a pediatrician CEO, one who "has a great grasp of what technology can do for him."

With the right leadership and championing, PACS implementations can be win-wins for everyone, many agree.Michael shrift

Michael Shrift, M.D., the chief medical information officer and vice president of information technology at 12-hospital, 2,400-bed Centura Health in Denver, says, "Our steering groups have always seen radiology and imaging as a part of the workflow of the hospital. It was just in the past very difficult to integrate images into that workflow."

As his system works to fully integrate its PACS and core EMR systems, "it's important to have broad inclusion of all stakeholders, and to have clarity about scope."

Author Information: Mark Hagland is a contributing editor based in Chicago.

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