A User's Perspective: Examining How PACS Performs

The focus is always on more: more speed, more power, more images. But the output from today's mighty modalities must be managed. In less than two decades, PACS systems transformed from conceptual ideas to essential tools in the world of imaging.

As one respondent to the second annual Medical Imaging magazine PACS Usage Survey put it, "The RIS/PACS runs our business. Our patient volume has increased, referring physicians are happy, and our costs have decreased. The overall workflow of the RIS/PACS is exactly what we needed."

A colleague concurs: "Turnaround is a fraction of what it was with the film/chemistry-based system. Our physicians and staff could not function nearly as efficiently without PACS."

More than 200 imaging professionals participated in the online survey, sharing details about their experiences with PACS—from what they were using to what was on their wish list and everything in between.

Who Are You?

Of those who answered the two dozen or so questions, an overwhelming majority of them (93%) were working at facilities that already possessed a PACS solution. This is an increase since last year's survey, when 11% of respondents' facilities did not have a PACS solution in place.

And respondents indicate that plans are under way to close that gap even further. Those who are currently working without a PACS system are moving quickly to put one in place.

How many vendors were evaluated before purchasing your PACS?

Hospital / Medical Center / Multi-Hospital System	Percentage
More than 7	6%
6	3%
5	19%
4	30%
3	28%
2	10%
1	4%

According to the representatives of large facilities who responded to this query, 46% are planning on making a PACS purchase in less than 6 months; 12% will do so in 6 months to 1 year; 23% will take the leap in 1 to 3 years; and 12% will do so in 3 to 5 years.

When looking at those locations where the technology has been implemented, a full three quarters were self-described as "Hospital/Medical Center/Multi-Hospital System." A distant second was "Freestanding Imaging Center" (15%), followed by "Group Practice" at 8%. Other possibilities, such as independent teleradiology providers, rounded out the tally.

What features of the PACS solution were important to your facility in making its PACS purchase?

Feature	Percentage
Price	78%
Functionality	71%
Compatibility with RIS and other systems	64%
User friendliness	62%
Remote access	55%
Web-based	54%
Scalability	50%
Customizability	48%
Document scanning	34%
Disaster-recovery system	33%
Time on the market	31%
Structured reporting	25%
Open system	1%
Radiologist preference	1%
Service	1%
Other	15%
(including 100% online all studies, 3D integration, datamigration, KIAS ranking, referring physician portal, and speed)

As is often the case in business, the smaller organizations appear to be more eager to adopt new technologies than their sizable counterparts. The majority of freestanding imaging centers (29%) and group practices (31%) indicated that a PACS system had been in place for more than 5 years.

By contrast, only 25% of hospitals or health systems fell into that category, but 37% have had a PACS in place for between 1 and 3 years. It should be noted that an equal number of group practices have had a PACS in place for only 1 to 3 years.

Exactly how many imaging exams or procedures were completed annually at each facility was totaled according to the type of organization. Considering volume, large medical centers and hospital systems seemed to fall into distinct tiers. More than one third (35%) of those in this category reported handling between 50,000 and 150,000 studies each year. The ends of the spectrum are virtually equal, with 16% of respondents performing less than 25,000 and 17% performing more than 250,000.

Perhaps the most interesting were the two distinct categories reported by the 31 freestanding imaging centers that participated. While the bulk of respondents are performing fewer studies than their incorporated associates—19% are in the 50,001-100,000 category, with 58% performing less than 50,000 studies—a full 10% are pushing through more than a quarter million exams each year.

How would you rate your facility's overall satisfaction with its PACS?
(On a scale of 1 to 5, with 5 indicating very satisfied)

Level of Satisfaction	Percentage
1	3%
2	5%
3	19%
4	33%
5	40%

Purchasing Decisions

When selecting a vendor, facilities have their work cut out for them. From well-established brands to energetic upstarts— more than 20 vendors were rated in this survey—but even that is only a fraction of the 78 manufacturers in the latest Medical Imaging Buyer's Guide who are vying for a stake in the PACS marketplace.

GE Healthcare's Centricity heads the list, and NovaPACS, from NovaRad, makes its debut in the ranks, with 10% of respondents naming it as the product of choice. Rounding out the top spots are familiar brands: McKesson Horizon Medical Imaging (10%), Philips iSite (10%), and Siemens Sienet, Syngo Imaging, or MagicView (9%).

Overall, imaging professionals are happy with their PACS. More than 70% ranked their satisfaction as a "5"—for very satisfied—or a "4." Pleased clients made a number of observations, including:

• [We] could not be better satisfied; we have had two upgrades since installation [and] both radiologists and referring physicians are satisfied.
• Excellent product, responsive to customer needs, scalable, economically friendly, fully loaded with features, excellent uptime.
• Solid platform, very scalable, deep archive moves 750,000 to 1 million images per day.
• We are archiving at a rate of nearly 1 million exams per year and growing. The overall system has scaled and performed beautifully. The Web-based architecture and network accessible archive design have been very durable and performed very well.
• The PACS workflow solution has allowed our department to become fully staffed and nearly 100% efficiency. We were able to recruit radiologists due to flexibility of reading site and schedule, eg, hospital, home office, or remote office, which is seamless.

Not everyone is delighted with their systems, and the dissatisfaction was evident in the comments section of the survey. Their remarks provide valuable insight for those who are shopping for a PACS.

• Adequate to very good for plain films [and] ultrasound, [but] less so for nuclear medicine. Lousy for CT—very poor scrolling through image stacks.
• Not as scalable as desired. Poor company understanding of the needs of an imaging center versus those of a hospital. Lack of follow-through on promised upgrades, data migration, service responsiveness; upgrade quotes that don't mirror those promised by rep.
• Platform is way behind in terms of technology. It is a workhorse ... our end users, however, could care less: [they] want the functionality that it cannot provide.
• Seems like a never-ending, bottomless money pit.

Making the Sale

The lion's share of respondents (72%) indicated they jumped into PACS headfirst—with only 28% utilizing any sort of mini-PACS system as an interim step. Still, the sentiments held by those unhappily tethered to their current system bring with them sound advice: screen manufacturers diligently.

Medical Imaging asked about the role respondents played in the purchasing decision. Not surprisingly, radiology administrators, directors, and managers made up the majority with 31%. Also actively involved are radiologists (13%), PACS/RIS administrators (9%), chiefs of radiology (8%), and PACS administrators (7%).

Exactly how they participated varied by individual:

• All the way from research to selection through infrastructure design and implementation.
• Compared [PACS/RIS systems] at the RSNA for two consecutive years.
• Researched all options and did a cost analysis of all that met our needs; doctors gave final approval.
• [Responsible for] making the specification, evaluating the vendor proposals, and selecting the most suitable one.
• Was involved with the planning, RFP process, installation, training—and now—support of the PACS.

To help narrow the field of competitors to a manageable number, imaging professionals took into account a number of different factors. Topping the list of important features was price (78%), which was a recurring theme in the open comments sections of many ballots:

• Price, growth, service, evolution are most important.
• This field is changing too fast and [with] our yearly budget cycle, [it] is hard to keep up.
• If you bought anyone else, you spent too much and didn't get anywhere near as much as you could have.

Readers also ranked functionality (71%), compatibility with RIS and other systems (64%), user friendliness (62%), remote access (55%), Web-based capabilities (54%), and overall scalability (50%) among the most essential qualities for a PACS to possess.

Equally important to purchasers were the characteristics of the vendors themselves. As one radiology administrator commented, "PACS does require a totally different evaluation and expectation framework than typical radiology equipment; it was challenging to make the right decision on a vendor."

What PACS solution does your facility use?

Note: Total percentage reflects not every respondent answered every question

Solution	Percentage
GE Healthcare's Centricity	19%
NovaRa NovaPACS	10%
McKesson Horizon Medical Imaging	10%
Philips iSite	10%
Siemens sienet, Syngo Imaging, or MagicView	9%
Agla Impax	6%
FUJI Synapse	5%
Merge Fusion PACS	4%
AMICAS	3%
DR Systems Dominator	3%
CoActiv Exam PACS	2%
CPSI ImageLink	2%
Vita Imaging (Department of Veterans Affairs)	2%
EasyVision from Philips Med (by Sectra)	1%
Emageon Ultravisual	2%
Kodak Carestream	2%
Acuo Technologies	1%
BRIT Systems	1%
Erad	1%
SmartPacs	1%
Other	6%
(including Catella, Dynamic Imagin's IntegradWeb, eRAD PACS, TeraMedica, Aspyra's Medview, Thinking Systems, Ramsoft's PowerReader, OpenMed PACS, and Evolved digital Solutions' RadWeb)

Failing to obtain an ideal match can create difficult circumstances. One site noted that "we now have a PACS/RIS team of four FTEs to support the system and most of their time is spent addressing issues that should be resolved by now. We believe the product was released before it was ready and that support and consistency in service are sorely lacking." Another contributor pulls no punches: "I wouldn't buy a toaster from these guys."

Which aspects about the vendor matter most? It was a virtual tie between RIS integration abilities (65%) and the company's having installations at similar facilities (63%).

After working through the multitude of possible options, most organization whittled it down to a select few. The most common occurrence was thinning the competition to between two and four contenders.

Straight from the Source

Being able to travel to nearby facilities and see the solution in play at a comparable location is an extremely valuable option for those in the evaluation stages of the purchasing process, according to those who participated in the survey. In fact, 77% of the 209 respondents indicated they attended on-site visits to their PACS vendor's other customers before purchasing the system.

In 1 to 3 years,how many service calls has your facility needed since installing its PACs?

Calls	Percentage
None	11%
1-5	31%
6-10	17%
11-20	8%
More than 20	33%

In addition to providing direct access to the technology, respondents thought one of the most beneficial aspects of site visits was access to other professionals who regularly put the system through its paces. Their specific benefits vary:

• Learned about integration, implementation, and service-view product in operation under similar work environment.
• Information gathered directly from users was key to helping drive our selection process.
• [It allows for] customer response to exact questions and the end-user input.
• We only wanted to see sites that had the same HIS that we did. That allowed us to ask questions that directly affected us.
• [We] gained knowledge for smooth implementation and negotiation points for purchase.
• Seeing overall operation of the system, identifying strengths and weaknesses of system.
• Showed the working side of the product as compared to what was being marketed.
• There's no substitute for observing a system in operation, at a real clinical setting.

For those facilities without extensive prior exposure to PACS technology and its associated programs, site visits offer a painless way to acclimate. As one survey-taker put it, the site visit "helped me with mostly understanding the change in workflow that comes with PACS programs. Also with understanding of the terminology and lingo that is associated with PACS."

Further down the list of important characteristics—after site visits—were service plan and technical support (56%), previous experience (51%), and number of years providing PACS (49%).

The training offered by a manufacturer is also critical, with almost half (48%) of respondents indicating they looked specifically for this skill set when seeking a vendor.

From 1-day sessions to weeks of on-site follow-up, training supplied by the vendor runs the gamut, making a definite impression on users. And one thing came across: the time invested by manufacturers can significantly impact whether a PACS system is a help—or a hindrance.

Individual comments noted the important role training plays in not only helping users know how to manipulate the system and make the most of its functionality, but also aiding administrators and managers in identifying the specific impacts the new product will have on workflow and intradepartmental relationships.

Whether they got it or not, most agreed that proper training is "critically important in making the transition to PACS." A health care administrator stated it simply: "without adequate training any PACS will be worthless."

Service Is King

A number of respondents also indicated, through comments, that they wanted training to extend into servicing the system. One example: "Although our system works well and we experience very few service issues, we feel as though we could be better trained by the vendor. Instead of telling us how to fix problems, they just do it for us and don't want to be bothered with explaining."

The frequency of and reason for service calls was the last major section addressed in the PACS Usage Survey. Divided by the amount of time they'd been using their PACS, respondents were asked to rank the number of service calls; 42% of organizations went through the first 6 months without placing a call. That mark dropped to 16% for a PACS 6 months to 1 year old. For locations with the solution online for between 1 and 3 years, 11% had never called in for service: that figure was 17% at the 3- to 5-year mark, and 6% for those boasting more than 5 years' experience with PACS.

Participants were also asked to provide specific details on the types of problems the facility had experienced with the system. Comments included:

The good

• Excellent customer service; zero downtime since installation; ROI for entire project was 9 months.
• We purchased 99.99% uptime with continuous online monitoring of all systems. If something fails or starts to fail, the part is identified and replaced before a problem is caused. All critical parts are redundant.
• There were a number of situations handled by telephone calls and others fixed remotely as the issues came up, but nothing requiring on-site visits.

The bad

• Our service calls have been mainly for hardware problems, such as a couple bad hard drives, bad ups, CD burner problem.
• You name it, it probably [happened]: everything from PACS freezing to going down to an individual workstation mouse not working properly.
• Vendor has bad attitude regarding customer service, poor follow-up, not responsive to site specific problems.

And the ugly

• [Problems] too numerous to describe, system does not perform consistently.
• Server-related issues, upgrades cause issues, RIS program doesn't recognize PACS system.
• Lack of follow-up and upkeep of server; unable to transmit images consistently; finger pointing [and] being defensive instead of owning the problem and finding a fix.

In the end, most users agreed that once a PACS solution is in place, they prefer it to the "old way" of film and file rooms—even when taking into account the imperfections involved with the online options. As one respondent noted, the "PACS transition was painful, but necessary to move forward in today's health care environment."

Dana Hinesly is a contributing writer for  Medical Imaging. For more information, contact .

Did your facility begin with a mini-PACS?

	Percentage
Yes	28%
No	72%

Does your facility have a PACS?

	Percentage
Yes	93%
No	7%

Modalities that your facility offers
(Freestanding Imaging Center)

MR	87%
CT	81%
Ultrasound	74%
X-Ray	68%
Bone Density/DEXA	65%
Mammography/Women's Health	58%
Nuclear Medicine	48%
PET/CT	32%
Interventional Radiology	29%
SPECT	26%
PET	19%
Multimodality	13%
Flouroscopy	6%
fMRI	3%
SPECT/CT	3%
PEM	3%

Modalities that your facility offers
(Group Practice)

CT	88%
Ultrasound	88%
X-Ray	82%
MRI	82%
Bone Density/DEXA	71%
Mammography/Women's Health	65%
Nuclear Medicine	59%
SPECT	53%
Interventional Radiology	47%
PET/CT	35%
PET	29%
Multimodality	29%
Radiation Oncology/Therapy	18%
SPECT/CT	12%
Vein therapy	6%

Modalities that your facility offers
(Hospital/Medical Center/Multi-Hospital System)

X-Ray	98%
CT	96%
Ultrasound	95%
MRI	93%
Nuclear Medicine	90%
Mammography/Women's Health	83%
Bone Density/DEXA	80%
Internvetional RAdiology	72%
SPECT	51%
PET/CT	48%
Multimodality	43%
Radiation Oncology/Therapy	42%
PET	34%
SPECT/CT	19%
cardiac cath	2%
Gamma knife	1%
FLUORO	1%
Cath Lab	1%
CR, RF	1%
Echocardiography	1%
RF	1%
Vascular ultrasound	1%

Does your facility have a PACS? YES!

Clinical setting at your place of employment	Percentage
Freestanding Imaging Center	15%
Group Practice	8%
Hospital/Medical Center/Multi-Hospital System	75%
Other (including teleradiology provider)	3%

If no PACS, when does your facility plan to purchase a PACS?

Hospital/Medical Center/ Multi-Hospital System	Percentage
More than 5 years	8%
3-5 years	12%
1-3 years	23%
6 months to a year	12%
Less than 6 months	46%

How many vendors were evaluated before purchasing your PACS?

Freestanding Imaging Center	Percentage
More than 7	14%
5	10%
4	28%
3	34%
2	14%

Group Practice	Percentage
More than 7	20%
5	13%
4	7%
3	13%
2	13%
1	7%

Other (including teleradiology)	Percentage
4	50%
6	25%
3	25%

How many service calls has your facility needed since installing its PACS?

Had PACS for less than 6 months	Percentage
None	42%
1-5	33%
6-10	25%

Had PACS for 6 months to 1 year	Percentage
None	16%
1-5	32%
6-10	21%
More than 20	32%

Had PACS for 3-5 years	Percentage
None	17%
1-5	19%
6-10	12%
More than 20	52%

Had PACS for more than 5 years	Percentage
None	6%
1-5	4%
6-10	12%
11-20	6%
More than 20	52%

What aspects about the vendor were important to your facility in making its PACS purchase?

Feature	Percentage
RIS integration abilities	65%
Installations at facility similar to yours	63%
Service plan and technical support	56%
Previous experience	51%
NUbmer of years providing PACS	49%
Training	48%
Number of current US installations	38%
On-site demo capability	29%
Same vendor as other systems (RIS, HIS etc)	18%
OEM Partnerships	17%
Downtime reimbursement	13%
Vendor's geogrpahical location	11%
Other	6%
(including satisfaction guarantee, AP provider, company vision, and market presence)