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RSNA 2013: Meaningful Changes

December 10, 2013
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The 2013 RSNA is now history. This year there were meaningful changes that IT must pay attention to.

Last week marked my thirty-seventh consecutive Radiological Society of North America (RSNA) annual meeting (!  Not only does each meeting go by in the blink of an eye, but so have the years!  It is hard to believe that I have been attending these meetings since before PACS even existed!  Imagine a meeting with no flat panel displays, and display panels filled with film!

This year, I have to say was truly a meaningful year in light of ARRA/Meaningful Use.  I have been anticipating changes ever since the enactment of the law and this year seems to be the first year that exhibitors really emphasized its impact! 

This week as I pour through my notes and materials from the show, I thought it would be helpful to reflect on some of my key observations.  Here are my initial takeaways from the meeting:

The Cart and the Horse: Over the past few years much emphasis has been placed on the emergence of the Vendor Neutral Archive (VNA).  As a radiology meeting, emphasis has primarily been on the extension of a radiology archive to other imaging services, such as cardiology for economies of scale and reduction in the number of archives a site has to manage. 

Last year, at least one vendor (Client Outlook - began to suggest that it might be appropriate to lead with a universal display as a precursor to the VNA.  The premise was that one could implement the viewer and realize immediate benefits from enterprise viewing, such as through a link to an EMR.  The display could always pull from multiple archives and eventually grow into a VNA as archives are consolidated. 

This year, several vendors are placing greater emphasis on the importance of a Universal Viewer (UV) over the VNA.  There continues to be controversy surrounding the type of viewer, and the benefit a VNA brings to the table in conjunction with a UV (more on that in a moment).  The simple fact is that momentum is building to suggest that the viewer may have more benefit to the enterprise than the VNA necessarily has by itself.  Hence, the cart in front of the horse.

Homogenized vs. Raw Milk: Just as in the dairy industry where the homogenization process increased the ability of dairies to deliver a viable product, the imaging industry is controversial with respect to the “homogenization” of images.  VNA vendors have not done an effective job at selling the added advantage of a VNA in terms of providing a repository of images that is more readily accessible by enterprise-scale viewing devices.  In the case of DICOM images, there are public and private tags.  Private tags were created to enable vendors to support the DOCOM standard, yet still handle unique processing and viewing requirements in a proprietary way.  The ability to perform dynamic tag morphing helps prepare DICOM data for access by universal viewers.  Similarly, it is great to think that the IHE standard’s Cross Document Sharing (XDS) protocols would do the same for other file formats.  Unfortunately, we are very early in the adoption rate of XDS – hence, it is great to say that you are an XDS Consumer, but there has to be something to consume! 

As with many things in life, the UV and VNA are complimentary, and the combination of the two makes a more compelling case.  If one is in an environment where the expectation is there will be many different data formats, a VNA can be very helpful in structuring the image information for display.

The Patient vs. the Physician: As a meeting oriented to radiologists, one would expect to see a lot of emphasis on diagnostic displays, and some emphasis on the radiologist’s customer, the referring physician.  I have long contended that radiology has not well understood the intent of the ARRA/MU objectives, in that the Stage 2 inclusion of imaging objectives are aimed at patient communication.  I am pleased to see that several vendors now appear to be catching on and paying attention to this requirement! 

To name just a few, Carestream (, TeraRecon (, Infinitt (, Fujifilm (, and Vital Images ( all showed forms of a patient oriented portal.  Most of these portals provide the patient with an ability to register and request appointments, receive messages, and access diagnostic results.  Most employ some form of viewer technology to enable the patient to see their images.  These devices are all in line with ARRA/MU objectives, and point the way to an improvement in patient access, and I salute these companies for recognizing the value of this capability. 

PACS Decomposed: In past years I have reported on a trend toward PACS components.  The advent of VNA’s, client-server advanced visualization, alternative workflow applications, and universal viewers have all placed pressure on the classical radiology information system (RIS)-picture archive and communications (PACS) configuration.  In the past, these initiatives have seemed like logical extensions of a RIS-PACS.  But with this year’s show, it is ever more evident that the classical RIS-PACS as we have known it is essentially gone.  As imaging services beyond radiology go digital, an enterprise perspective to image storage and accessibility makes economic sense.  That basically leaves acquisition, and diagnostic interpretation left to RIS-PACS.  With alternative workflow solutions like Primordial ( and Medicalis (, along with increased emphasis on the EMR for order and patient management, the role of a dedicated RIS is being redefined.  The combination of these alternative workflow solutions and additional capability built into a PACS diagnostic workstation means that the thought of a truly “decomposed” RIS-PACS is closer to reality.  This provides users with a wider variety of alternatives and greater customization of applications, and vendors with the challenge of a more intraoperative and competitive environment.  Only time will tell if the benefits outweigh the interoperability challenges, but one thing is certain – the age of a single-vendor RIS-PACS is over!

These are a few of my early observations.  As the dust settles and I have time to reflect, I am sure I will come up with additional thoughts.  Enjoy the holidays and look forward to new challenges in 2014!

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