The move to filmless is like an ocean wave. It starts way offshore, builds in intensity, and can hit the shore with a gentle soothing touch or, like a tsunami, wreak havoc on all in its way. It is not a matter of whether the wave will hit the beach, but of when, and what sort of effect it will have. Bottom line, it is time even for independent imaging centers to learn how to surf. Treading water just will not do.

Implementing a picture archiving and communications system (PACS) is not only about replacing film, but how the technology can improve an organization, its services, and its financial picture. Going filmless provides a prime opportunity to reassess and revitalize the way a center does business.

The independent imaging center faces less complexity than a large health care organization in the PACS decision process but usually will have fewer resources to apply to the process of assessment, acquisition, and implementation. What follows is a review of the key concerns, beginning with cost and benefit.

The actual purchase price of a PACS can be fully amortized from savings on film purchases alone. However, there are other less tangible but significant financial benefits.

Tables 1 and 2 (page 56) represent assumptions made about film usage and costs at a typical independent imaging center client with MRI, CT, ultrasound, and radiography. They exclude tangible costs for film handling, storage, couriers, and investments in computed radiography (CR) and DICOM connectivity. The $1.25 per sheet figure represents a weighted average cost, as film prices can range from approximately $0.89 per sheet to $1.90 per sheet of 14- x 17-inch film.

Table 1. Imaging center film costs per day.

There are several factors that determine the degree of film use reduction, but an achievable reduction following the initial 6 months is 50%. By applying a film reduction rate of just 50% to the figures above and allowing for an average investment of $225,000 for PACS software and hardware, the simple pay-back period is about 3 years ($225K divided by half of $150,625). Readers can apply their own data to this methodology to arrive at the potential for film savings. If CR and DICOM device investments are included, it is advisable to use 60% of your CR investment for PACS because CR has some productivity ROI inherent to its own technology.

In the example above, the imaging center was spending an average of $12,550 per month on film. After PACS, it spent about $6,275 per month less. One option is to consider letting the PACS system pay for itself by leasing the system. Table 3 (page 56) represents a couple of typical lease arrangements in today's market, based on the $225,000 PACS technology investment described above.

Because referring physicians' use of the system is the key to reducing film costs, it is important to start the clinician education process early and to show users how it will be to their benefit. Clinician resistance to going filmless is the main reason PACS sites achieve only a 50% film reduction after implementation.

Must-have Options

It is essential that the independent imaging center incorporate a document scanner at one or more locations in the PACS system. This allows paper documents such as referring physician's orders to be scanned into the PACS and viewed along with the images. This enables the radiologist to have the entire contents of the film jacket at their remote location.

Table 2. Annual film costs.

A web server will allow radiologists, referring MDs, transcriptionists, and other personnel to access the system remotely. In addition, if the system architecture is totally web-based, in other words, if even your office reading station uses a web interface, deploying the system throughout your organization becomes very easy.

When working from a remote location via a web server/browser combination, even with a broadband Internet connection and data compression, it will still take several minutes to download a complete study. For this reason, it is recommended that the system be able to download multiple studies in background mode while reading other cases.

Another important factor in the freestanding independent imaging center is  Modality Worklist Manager (MWLM), a work-flow integration profile specified by the Integrating the Healthcare Enterprise Initiative (IHE). Many newer diagnostic devices, RIS, and PACS systems are compatible with modality worklist integration. With MWLM, a capable diagnostic device can retrieve the patient and study information from the PACS without manual intervention. This will free up the technician's time to spend with the patient and help reduce typographical errors.

To RIS, or Not to RIS?

A look at PACS would not be complete without mention of the radiology information systems and HL-7. PACS is normally part of a suite of software applications and is even more dynamic when properly integrated with a RIS that aids the imaging center's administrative and operational functions.

HL-7 is an industry standard information exchange protocol for transferring data between applications. If properly configured, it works across differing platforms and even physical locations. HL-7 is an Electronic Data Interchange protocol for exchanging test-based information between two systems and DICOM is a specification for a standard file type that contains images and data. These two standards enable the interfacing of data management systems with image management systems. For instance, if you have a UNIX-based RIS server in Oakland, Calif, and a Windows-based PACS server across the bay in San Francisco, HL-7 enables the exchange of information between the two.

This is an example of what work flow might be like with a bidirectional HL-7 interface between PACS and RIS:

Table 3. Two sample lease arrangements for a $225,000 PACS system: the higher-priced option offers a $1 buyout after 72 months and the lower-priced option offers a 15% (of $225,000) purchase price at end of lease.

• Patient and examination information entered by the receptionist is relayed to the PACS server by the RIS.
• Relevant prior examinations are prefetched from the archive for comparison the night before the patient is scheduled for a follow-up examination. This becomes even more significant with increasing image data sets, such as 800-image CT examinations.
• When the patient arrives at a worklist-enabled modality, the technologist selects the scheduled examination from the modality worklist, avoiding the redundant retyping of information. This automation eliminates costly typing errors that may cause examinations to be filed under the wrong identification.
• After the examination is completed, the modality sends images to the server.
• The completed examination, including all images and documents along with relevant prior examinations, is available for interpretation by the radiologist. The examinations may be routed to remote locations if the radiologist normally performs diagnostic interpretation from a distance.
• The radiologist dictates the interpretation directly into his or her workstation. The digital audio file is routed to the RIS or directly to a transcriptionist.
• The transcribed report is entered into the RIS and forwarded to the PACS or directly stored on the PACS.
• Examination images are sent to the archive for permanent storage.
• Referring physicians can log in and view studies, including all images and completed reports
• Examinations are associated with the appropriate referring MDs based on information received from the RIS. By interfacing the PACS with RIS/HIS, data entry time is reduced, errors eliminated, and a single source for access to patient and examination data is provided.

The standards of HL-7 and DICOM enable the effective interface between information systems and the PACS and connected modalities.These make it possible for a center to choose what is believed to be the best of breed for both information and image management. If a change of vendors is desired in the future, the imaging center may change one, instead of both, systems.

Many vendors today offer an integrated PACS/RIS package, in which case centers need not implement an interface. But if an imaging center has a PACS/RIS integration proprietary to a particular vendor, it will be "locked in" to that vendor unless it is willing to scrap its entire investment to make a change.

Practice Management Tool

PACS is a cost-effective asset for the independent imaging center. It can have a fairly short pay-back period and can be central to the ability of a practice to thrive in an ever-demanding business environment. The contribution PACS can make to improving practice management may be an even bigger benefit than reducing film costs.

There can be hidden costs and costly mistakes if a detailed and professional plan for installation, training, and implementation is not in place and adhered to. It is important that the PACS be DICOM-compliant to the lowest levels of software in case data migration is required in the future.

Once PACS is up and running and the practice stops printing films (except on demand), it becomes a mission critical system and its functionality affects the entire practice. It is crucial that support personnel are reachable and available quickly.

Finally, the most feature-rich PACS system available is of little use if it is not highly intuitive and easy to use by all involved, and a high price does not necessarily ensure success.

Ted Huss (mirted@inreach.com) is a principal in an information technology consulting company based in Northern California.

John Vlahos (john@vlahosassociates.com) is a principal in an information technology consulting company based in Northern California.