PACS/RIS is ready for a revolution

By Nancy Ryerson
DOTmed Business News
February 2013 – PACS/RIS Industry Sector Report

*This article contains quotes from CoActiv management and customers.*

Can PACS bring departments and health care systems together as its own future remains unclear?

After nearly 20 years on the market, PACS may be experiencing a quarter-life crisis. The technology is expected to reach 90 percent penetration by 2014, according to a recent report from Frost & Sullivan. Most facilities are on their second or third replacement PACS. Over the  next few years, PACS replacements are expected to contribute only modest gains; the industry will grow from $1.1 billion in 2011 to $1.4 billion in 2018, the Frost & Sullivan report says.

And PACS has moved away from home. As web-based PACS, vendor-neutral archiving and cloud storage become increasingly commonplace, PACS is no longer constrained to physical sites. It’s also evolved from just serving radiology to being a part of cardiology, mammography  and, soon, pathology departments.

PACS customers have grown up, too.

“The PACS industry has gone through its development and maturation,” says Philip Manly, president of Connect Imaging, a PACS vendor. “People who are buying PACS understand what they need. They don’t need to be told what it means and what it does. They understand much  more what they want, which means they can be much better shoppers.”

The PACS industry’s next direction is up for debate. Health care reform and tightened budgets drive the market, and meanwhile, changing technology may alter the industry for good. While PACS and RIS currently have close ties, some experts predict PACS may ditch traditional RIS with its archiving and communication features to make room for a “best-of-breed” approach to working with images. The next generation of PACS may look nothing like the current one.

Making PACS meaningful

One factor driving the PACS replacement market is stage 2 meaningful use. The second part of the government’s health IT incentive program, which will go into effect in 2014, includes radiology-related “menu items” that hospitals can select to be a part of their MU efforts.

“The PACS market is not going to really grow,” says Steve Tolle, senior vice president of solutions at Merge Healthcare. “You’ll just see 1 to 2 percent growth, really around workstation consolidation. The real innovation is going to happen around interoperability and how do you actually do everything that the government is contemplating under meaningful use.”

One option requires providers to be able to access radiology images from within the electronic medical record. “Legacy” PACS that are more than five years old may not be compatible with modern EMRs, encouraging some facilities to update.

“Integration with various EHR was important for us,” says CoActiv customer Steve Kelley, CEO of Ellenville Regional Hospital about his choice in PACS. “We are using the HMS EHR product and it’s integrated exceedingly well. We’re able to go right into the EHR, click on it and send it right off.”

While PACS vendors have been sure to become meaningful use certified, some report little interest from customers regarding the initiatives.

“To be honest, we’re not hearing that much about it,” says Chris Henri, chief technology officer for Intelerad, a radiology solutions provider, offering solutions for PACS, RIS, workflow, disaster recovery and referring physician portals. “At the most recent RSNA, I don’t think it even came up once. It’s like people are assuming that the products are already certified. But I don’t think anyone is underestimating the challenge of making it work.”

All together now: the VNA solution

Another industry driver is the need for consolidation between departments and facilities. As radiology produces higher and higher volumes of images and hospitals are increasingly incorporated into larger systems, facilities must determine what to do with all of that information. For 27 percent of hospitals in a KLAS study from July 2012, that enterprise imaging  solution will include a vendor-neutral archive, one of the fastest growing sectors of the PACS  industry.

Frost & Sullivan projects that the VNA industry will be worth $210 million by 2018, approximately double what it is now.

Although today’s PACS tend to be “vendor neutral,” PACS from different vendors or even from the same vendor often have subtle differences in data headers that made other PACS unable to read images.

“There are a lot of nuances in different PACS vendors’ interpretation of the standard, and as a result we have variations in compatibility,” says health IT consultant Michael Gray, who blogs regularly on the benefits of VNA. “One of VNA’s very important major functions is to reconcile the idiosyncrasies between different solutions.”

Definitions of what a VNA is and what it should do vary, with some proponents saying it should be called something different entirely, such as “PACS neutral archive.” But a VNA by any other name would need to have the same key feature: communicating between disparate clinical systems to store and manage images as well as other documents and files.

In addition to image consolidation, VNA can also help facilities purge data they no longer need or safely store images that are still necessary.

“For example, pediatric data typically must be kept until the patient is in their mid- to late-20s, while adult data might only need to be kept for five, seven or 10 years,” says Greg Strowig, VP of client services at VNA vendor TeraMedica. “Our VNA has clinical intelligence to determine which studies are no longer needed and which must be retained longer.”

TeraMedica is one dedicated VNA vendor. Agfa and Merge are popular PACS players in the VNA market, according to a KLAS study.

PACS and RIS continue to blend

The traditional role of a RIS (radiology information system) is to perform administrative functions such as patient tracking, workflow management, result entry and billing. Not much has changed for RIS over the last few years.

“For the most part, the providers are used to it and it does the job it’s supposed to do,” says Nadim Daher, advanced medical technologies principal analyst at Frost & Sullivan. “However, some providers still today, which is almost unbelievable, haven’t succeeded in making their RIS work alongside their PACS. So replacement with PACS has led to replacement of their RIS.”

Today, more and more facilities use integrated PACS/RIS systems rather than standalone RIS.  Vendors such as Viztek provide an image-centric RIS that brings studies to radiologists without the need for data entry, useful for facilities with smaller staffs.

“Studies are read based on how they’re performed instead of how they’re specifically ordered in a Medicare billing code, for example,” says Steve Deaton, director of business development for Viztek.

For larger facilities, RIS-driven workflows are common, as they allow radiologists to view a variety of information simultaneously rather than needing to switch workstations. RIS can also be integrated into the EMR to provide a fuller picture of the patient in question.

“We use RIS (EMR) driven workflow which for me has been a sea change from PACS driven workflow,” says radiologist Daic Channin of Guthrie Clinic in Pennsylvania. “The medical record and the RIS have so much information about the patient and their context that it only makes sense to drive the imaging workflow from that system.”

RIS technology is also helping facilities break through the last bastions of paperwork and create a truly paperless office. Agfa, for example, offers a work list in its RIS sign that can be used on an iPad or other tablet for the forms technologists and patients must sign.

“’Paperless’ has been the buzzword for 10 years, but it’s been almost impossible to do that when the patient has to sign things,” says Tara Vail, head of Agfa’s U.S. RIS/PACS division.  “This really allows facilities to go paperless.”

RIS has also begun to join the national trend toward cumulative dose tracking. Last year, Carestream’s RIS introduced the storage and tracking of radiation dose information.

“In the future we will be able to allow physicists at user sites to enter formulas that can be used to calculate dose and ultimately will enable tracking cumulative dose for each patient,” says Cristine Kao, Carestream’s global marketing manager, health care IT solutions.

For PACS, cloud cover remains spotty

To borrow a line from Joni Mitchell, customers have had a chance to look at the “cloud” from both sides, now. Vendors say customers now have a better understanding of what the cloud, a remote storage and viewing option delivered over the Internet, can offer. However, “cloud PACS,” in which PACS applications are hosted in the cloud, have not gained as much traction as what was once predicted. In 2012, cloud-based PACS accounted for only 0.6 percent of PACS, even less than the forecasted 1.3 percent.

“I know it’s the push, but when the rubber hits the road, I don’t think it’s feasible to get rid of on-site forever,” says Tyler Harris, vice president of clinical solutions at PACS vendor Novarad.  “We still have an on-site archive, even with the cloud-based archive. That way, they’re pulling their images from the local server, and then they have the cloud-based features for off-site archiving and some of the critical archives.”

That holds true especially for rural facilities or facilities in countries with less reliable Internet access.

“Many of our accounts are ones in rural areas and they do not find yet that they have complete reliability on their Internet connections,” says Connect Imaging’s Manly. “So when set up something for an account, we have a localized server that can provide all of their needs. That way if they lose Internet, which apparently they do periodically, they have everything they need.”

For now, most customers use the cloud for what is known as “deep archive”: images and related information that was gathered more than six months ago. Cloud storage is also popular for disaster recovery plans, a concern that received greater attention following last October’s Superstorm Sandy, vendors say.

“We can take DICOM exams from any PACS, from any premise, and put them in a Tier-IV data center, which means it’s going to be highly secure, private and impervious to most natural  disasters and power failures,” says Frank Baker, VP of sales and business development at CoActiv, which offers a disaster recovery cloud called EXAM-VAULT. “And for a relatively small  fee, you now have a copy of every single exam in a safe harbor.”

Beyond “deep archive,” cloud vendors hope to encourage customers to use cloud service for managing images and information online.

“That’s where a very big challenge is right now, of persuading customers that cloud vendors can be your storage and archive provider, rather than just replacing your truck-based model where a truck comes every week and takes your records someplace,” says Daher of Frost & Sullivan. He says cloud archiving is in its early adopter phase, while cloud-based PACS are in an even earlier phase. Daher predicts that growth for cloud usage will be “linear, not exponential.”

The “best-of-breed” approach

As for the next incarnation of PACS, some experts feel that just as VNA can potentially take the “A” out of PACS, each element of PACS can be separated out and made into a modular solution, with separate vendors for diagnostic imaging and workflow as well as for archiving.

“You bring in your first choice for each component and make it work as an integrated system once in place,” says Daher of Frost & Sullivan.

While this “best-of-breed” approach is currently in its early adoption phase, some radiologists are looking forward to its potential benefits for improving the viewing and manipulation element of PACS.

“I hope that as VNA and back-end functionality become commodities that PACS vendors can then return to focus on images and the radiologist, a focus I believe they have lost,” says Channin of Guthrie Clinic.

Regardless of whether that possible PACS future takes root, smooth communication between radiology departments and hospital systems will continue to be a top priority. Meaningful Use stage 3, for example, will likely require information to be exchanged between unassociated systems, like the Mayo Clinic and the Cleveland Clinic, Henri “Rik” Primo, director of strategic relationships, Siemens Healthcare SYNGO Americas says. Cross enterprise document sharing will become important if those initiatives are put into place.

Whatever the approach, it’s clear that PACS have moved far beyond simple digitalization of radiology information to become a key element of a patient’s total health.

“After so many years of evolution, PACS does most of what the radiologists want it to do,” says Deborah Reed marketing manager for Infinitt. “Now there’s more emphasis on the referring physicians, and the service PACS provides them.”

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