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Navigating
Mini-PACS Options
Set Sail With Confidence
(Radiology Today Magazine,
July 19th, 2004) |
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As PACS technology marches toward full integration,
an emerging trend toward implementing enterprisewide
PACS for many different modalities and facility
types has some observers calling into question the
future of the highly popular mini-PACS configuration.
That trend, however, fuels the hesitation many smaller
and medium-sized facilities feel over going digital.
These facilities, including many smaller hospital
radiology departments, reading groups, and stand-alone
imaging centers, face a crucial decision that will
affect their business for years to come: Should
they install a traditional mini-PACS to handle precisely
what they need right now and wrestle with larger
integration issues down the road? Or should they
take on the cost and complexity of an enterprise
PACS with a full range of features that currently
amounts to overkill but may better serve long-term
needs?
Configuring
Mini-PACS
Part of many users’ confusion stems from the
spreading use of the term mini-PACS to include a
number of applications beyond its original definition,
notes Rik Primo, director of strategic relations
for the Siemens image management division. Originally,
mini-PACS were small systems dedicated to one or
two highly specific modalities—particularly
ultrasound—that allowed radiology departments
to implement the digital technology
alongside film but in a completely separate workflow.
That basic application soon expanded as imaging
departments began to digitize existing films to
send them over a network for reading at various
remote locations, often the radiologist’s
home or to another radiologist for overread studies.
The third configuration, which seems on the verge
of becoming a de facto definition of mini-PACS,
enables imaging departments with a limited number
of modalities (eg, one CT and one MRI) and only
two or three workstations to go completely filmless
but still network interactively, whether using a
Web server or another Internet connection.
Affordable
Expansion
Finally, says Primo, mini-PACS remain many users’
first choice for implementing enterprisewide PACS
in controllable (and affordable) stages. “They’ll
first install a couple of workstations connected
to a couple of digital modalities … to gain
experience. They’ll learn to work with a RIS,
couple that [with] the PACS, start archiving images,
and [eventually] deploy a full-fledged ‘maxi-PACS’
by extending the original system to the rest of
the modalities and implementing electronic image
distribution to the entire hospital and network,”
he explains.
It’s this last apparently infinitely extendable
configuration that for many imaging centers seems
to embody simultaneously both the carrot and the
stick. This concept of a minimalist-enterprise PACS
holds the potential for wide-ranging functionality
and the promise of easy, swift integration of future
applications and network nodes; at the same time,
it often seems to mean an immediate steep capital
outlay coupled with the need to quickly reorganize
workflow and retrain virtually veryone.
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Planning
Well Ahead for Mini-PACS Expansion
Advanced Medical Imaging of Fort Lauderdale
(AMI), Florida, epitomizes how many
smaller users make their move into PACS
technology. The stand-alone imaging
center, which opened in January, now
serves roughly 100 area physicians and
patients from nearby cruise lines. The
current system handles studies for one
radiologist using one on-site workstation
and supports a range of tests with multiple
modalities, including MRI, CT, fluoroscopy,
and conventional radiography. All the
modalities are incorporated into the
Siemens Outpatient Practice Management
System’s RIS.
This month, AMI plans to integrate a
bone densitometer as well as scheduling
and billing for the new machinery. Within
the next five years, Robert R. Brown,
MD, says he also plans to add ultrasound
and at least one additional remote office.
PACS Administrator David Itkin projects
that by year-end, the system will handle
some 2,500 MRIs and 4,000 CTs annually.
The AMI installation uses the Siemens
MagicView VE40 PACS with a Plasmon Enterprise
D- Series Jukebox containing 2 terabytes
of storage as 100 disks (200 sides).
PACS/RIS integration and modular scalability
was the key selling point for Brown.
He says the MagicView was chosen as
much for its RIS as PACS capabilities.
“If I had thought this was going
to be it, it would just be an expensive
piece of software. But [the MagicView]
certainly allows growth [and] it was
affordable. It’s easy to add to
the PACS or the RIS so you can have
multiple offices [with] one central
control.”
Even in its present minimal configuration,
the system supports remote viewing via
Siemens’ MagicWeb interface. An
active link at AMI’s Web site
enables referring physicians to access
patient studies online and allows Brown
to both receive outside consultations
and perform readings at home or on the
road. “Adding a new office location
will be almost as easy as expanding
within existing space,” says Brown.
Just as important to Brown as the technical
details was the ease of dealing with
a single vendor. “[It] simplified
practice start-up. For somebody who’s
starting out, it’s kind of daunting
to deal with different companies for
different machines,” he says.
The center also uses a Siemens Somatom
MDCT and Symphony Tesla MRI, and, based
on previous experience with the company,
Brown says, “To have everything
[from] Siemens meant … having
the security that the one company would
be able to help me if I did encounter
problems. The integration of the machinery
and software systems has been much easier
with this one vendor.”
—
JKB
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Optimizing
the Digital Environment in the Heart
& Vascular Center of Bradenton
Small- and medium-sized imaging
facilities often hope to ease into PACS
by going digital one modality at a time.
In contrast, the Heart & Vascular
Center of Bradenton (HVCB), Florida,
specifically sought the independent
consulting and integration firm PCCG
(PC Consultant Group), Inc. to help
them move directly from analog to digital
as swiftly and seamlessly as possible.
HVCB comprises four cardiologists, including
one interventionalist, performing approximately
5,000 outpatient studies annually.
“We’re what you could
call a small practice, but we have a
large volume,” notes Donovan Copeman,
RDMS, director of ultrasound. “I
came from a digital lab, and after a
couple of years, I had to tell [the
doctors], ‘I can’t work
[effectively] in analog.’”
Initially, the physicians were reluctant
to move to PACS, partly because of the
expected expense; they prefer spending
money on employees rather than equipment.
That’s one reason Copeman chose
to work with PCCG: “[I found many]
of the bigger companies can’t
customize to your needs, whether you’re
small or big.” Instead, Copeman
says, he particularly appreciated PCCG’s
responsiveness to his group’s
individual requirements. “[They]
matched product to volume perfectly.
With the right product, even a small
practice can go digital without a quarter-million-dollar
cost.”
The PCCG installation uses a Web-based
dedicated PACS server to integrate two
Hewlett-Packard Agilent 5500s, each
with two workstations. With 1 terabyte
of storage, Copeman finds the system’s
vast capacity as valuable as its speed
because it’s enabled the group
to completely eliminate “a huge
volume” of other media, with associated
hardware and costs. He estimates that
“it should be six years before
we have to dump the hard disk”—even
better, the system allows automatic
archiving to DVD “as we move through
the month … all [our] studies
are already backed up. If a patient
wants a copy of their [exam] now, we
just shoot one and hand them a CD almost
before they leave. And if we want to
look at any study, we can just pull
it up on the server —no retrieving
tape or rewinding.”
Remote reading capabilities from virtually
any location also helped convince the
physicians to take the plunge into full
digital. Plans include adding electronic
medical record capabilities within the
next few months and eventually implementing
RIS. “People feel like they’re
not big enough to go digital, but that’s
[a mistake]. Whether you’re doing
40 studies a month or 10,000 a year,
[working with the right company] can
help,” says Copeman.
—
JKB
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Defining
Differences
The most basic mini-PACS installation, vendors
and buyers agree, encompasses a single or
very limited number of modalities (most often
CT, MRI, and ultrasound, but sometimes also
echocardiology and nuclear medicine). The
mini-PACS generally handles a small exam volume
at a handful of workstations, requires a small
amount of local storage, and usually (but
not always) lacks interactivity with other
network systems. Small of course is a relative
term to the buyer; many believe the term mini
refers to a fixed price point. “Most
of the time, when we make the first contact,
the customer’s first [question] is,
‘What’s it going to cost for me
to get PACS?’” says Carter Posner,
president of and consultant with PCCG (PC
Consultant Group), Inc., a PACS integrator
and consulting firm.
PCCG helps buyers understand what’s
most applicable for them by categorizing PACS
solutions not only on the basis of space storage
requirements and exam volume but also according
to the type of facility, number of radiologists,
and where they prefer to read, says PCCG vice
president and consultant Christie Hentschl.
With those needs determined, eventual plans
for Web communications, teleradiology, and/or
RIS/HIS (health information system) integration
can be anticipated more realistically.
Table 1 (right) outlines PCCG’s general
size guidelines for mini- and enterprise-PACS
hardware and software needs.
In general, the main differences between a
mini-PACS and its hospitalwide cousin are
size and RIS/HIS capabilities. An enterprise
PACS requires a RIS element to integrate patient
data and administration tracking, and usually
HIS support as well. The typical stand-alone
mini- PACS configuration uses the same rule-based
DICOM routing automation for receiving, archiving,
and distributing exams as an enterprise PACS.
Both automatically direct and track images
among modalities and locations, including
diagnostic viewing stations and short-, mid-,
and long-term storage servers.
While some define mini-PACS as a configuration
that relies on manual archiving and image
control in which the administrator typically
assigns images to a reading station and moves
images into long-term archives as needed,
Posner cautions that a true “mini-PACS
should not be confused with homegrown, selfimposed
PACS solutions” that simply use a workstation
to receive, send, and back up DICOM files
manually.
| Table
- 1: Mini-PACS vs Enterprise |
| If
you read this many exams annually... |
| 0
to 5,000 |
| 5,000
to 10,000 |
| 10,000
to 20,000 |
| 10,000
to 20,000 |
| 30,000
to 60,000 |
| 60,000
to 100,000 |
| 100,000
to 150,000 |
| 150,000
to 200,000 |
| 200,000
to 250,000 |
| 300,000-plus |
New
Solutions
Today, even a single-site, single-modality
mini-PACS doesn’t necessarily completely
exclude a RIS component. “Customers
just aren’t aware that many mini-PACS
solutions already have some imbedded RIS features,”
says Hentschl. “That means you can get
a mini-PACS [to take] you through the whole
imaging process—from doing the actual
scan through the report, dictation, and distribution
process, which normally the RIS would take
care of.”
Of course, you may want to departmentalize
some of your information on an institutional
level, adds Posner, for which a mini-PACS
installation is clearly best tailored. That
doesn’t lessen the need for intercommunications,
whether via the Web or an internal network.
“Let’s say you have five
facilities,” Hentschl says. “You
want to be able to isolate exams by tech,
by radiologist, [or] by facility. But a radiologist
reading for five hospitals, no matter what
the size, should be able to see any patient
record from any facility and any patient report
from any modality.”
Market
Trends and User Needs
The PACS market in general is increasingly
geared toward providing “the total solution,
with the PACS and the RIS preintegrated,”
Hentschl says, “[and] imaging departments
are afraid to buy just the component they
need now and try to integrate it in the future.”
While buying on the enterprise level to ensure
future support is a functional choice for
larger facilities that can afford it, smaller
facilities with correspondingly smaller budgets
shouldn’t worry excessively.
Focus instead on full DICOM and Health Level
7 (HL7) compliance that will ease integration
issues when they arise. Doing so, Hentschl
advises, prevents small- and medium-sized
users from “tying themselves to a less
than best-of-breed PACS they really don’t
care for [because] they feel they’re
buying into the future RIS.”
Many smaller and midsized imaging center administrators
are swayed by the recent wave of mergers among
several RIS and PACS companies, adds Posner.
“If you go to just one manufacturer,
you’re missing a good overview of what
the [total] market can offer you.”
Failing to do this necessary research can
create real problems for many smaller buyers,
warns Primo. Because PACS is a relatively
small market, based on local or regional healthcare
needs, vendors sometimes just “disappear,”
whether they’re absorbed by other companies
or simply go broke. “If you are going
into a mini- PACS without really having a
plan [except to] worry about expansion later,
well, when later comes, you’ll really
have something to worry about,” he says.
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Solid
Foundation
Larry Cornell, president of the PACS integration
and service company MTSDelft USA, informatics division,
concurs. “Most OEMs [original equipment manufacturers]
will want to sell their whole system, but I think
users, even when they walk in talking about ‘scalability,’
don’t always realize they can in fact buy
components and grow at their own pace.” Scalable
means you should be able to add storage, clinical
and diagnostic workstations, and communication capabilities
incrementally according to what you need and can
afford, not according to the vendor’s plan.
Whatever vendor(s) you select, look for systems
that adhere to the highestlevel IHE (Integrating
the Healthcare Enterprise) guidelines governing
DICOM and HL7 interexchange compliance. DICOM compatible
is a meaningless marketing term; demand full DICOM
compliance for all services you’ll require.
While scalability is the major buzzword among large,
all-inclusive companies, if you purchase a mini-PACS
from one company expecting to expand it with equipment
from another firm, it’s critical to ensure
your data can be migrated to the new standard. Or,
better, says Primo, “be certain right from
the beginning that your mini is based on open standards
so that subsequent communication between systems
is seamless.” That proviso applies not only
when adding PACS workstations and modalities but
also when networking your original mini-PACS with
RIS and HIS.
“The idea of going from
small to large should be based on what you can afford
this year and what savings can be gained by going
to PACS,” says Cornell. “For example,
at Medina [Ohio] General Hospital, we sold the mini-PACS
to the radiology department, but now cardiology
is going to use [that] storage device instead of
buying a separate one. They’re looking at
an enterprisewide solution [with] SAN [Storage Area
Network] technology [and] everything stored online.
One server will be radiology, another server will
be cardiology, another server could be electronic
medical records [EMRs], one will be laboratory,
and so on.”
If you concentrate on backbone connectivity and
hardware infrastructure, he says, “it’s
almost like building a house from the foundation
up and enlarging it as you can afford to. You may
start out with a smaller infrastructure with smaller
applications [initially] defined as mini- PACS,
but you’re really looking at the endgame of
total EMR for all areas … in an integrated
workflow.”
Buying
for the Future
Most experts believe the trend away from stand-alone
mini-PACS and toward network integration is likely
to accelerate. That reinforces the importance for
smaller imaging facilities to analyze business as
well as medical goals and strategies before taking
the mini-PACS plunge. “The reason to start
small,” says Cornell, “is to capture
your most important assets, taking full advantage
of the modalities you have and putting them into
digital format.”
Today’s shortage of radiologists offers great
opportunity to take on additional reading, he adds.
“You may have a radiologist at one site …
able to access images from many other centers, or
from home, so the efficiency of radiologists at
one location increases dramatically. The ability
to read virtually anywhere [and virtually 24 hours
a day] becomes a very functional option.”
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— J. K. Bucsko is a freelance healthcare
and technical writer and editor based in Westville,
N.J.
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For
More Information:
MTS-Delft
USA
800-290-2565
www.mtsdelft.com
PCCG (PC
Consultant Group), Inc.
305-860-4449
www.pccgroup.com
www.pacscd.com
Siemens Medical
Solutions
888-826-9702
www.medical.siemens.com |
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