Changing PACS Vendors: Getting It Right the Second Time Around for Radiology and the Enterprise

Change is never easy, but when the switch involves a PACS vendor, it can be downright difficult. (Cue up “Breaking Up is Hard to Do.”) The reasons for a PACS divorce vary from dissatisfaction among radiologists and the IT staff to integration issues to economics. Whatever the reason(s), the process of deploying a replacement system differs from installing a first PACS. It’s kind of like remodeling instead of building a new house. Things can get ugly, but the end result is usually well worth the effort.

For starters, the second-, third- or fourth-time PACS buyer has a more mature understanding of PACS and its true priorities and costs. The experienced buyer also comprehends both department needs, in this case radiology, as well as the bigger picture enterprise requirements. But the experienced buyer comes with baggage including legacy systems, imaging equipment and historical data that must be migrated. Can the site leverage some of its initial investment? Can you reuse workstations and monitors? How will the enterprise handle historical images? And how does migration fit into the purchase decision?

This month, Health Imaging & IT visits with several facilities that have navigated and survived a PACS divorce and remarriage to learn how to minimize the pain and maximize the benefits—and create a new, united family.

The search for the next PACS vendor

Looking for a second (third or fourth) PACS vendor differs from the initial search. No longer a nervous first-time bride, the facility and buying team members may be a bit jaded; they are certainly more experienced with the ins and outs of digital image management. Smart second-time buyers draw on their experience to improve the next installation. “The search for the second PACS is more specific than the initial search,” points out Larry Ranahan, CEO of Meridian Imaging Group in Mundelein, Ill. “The first search tends to focus on imaging and radiology. Our second search was enterprise-oriented and included all of the components of what it takes to manage the business of radiology.”

Genesys Health System in Flint, Mich., found itself with a significant amount of proprietary hardware and data at the end of its initial PACS contract. “The hardware and data needed to be swapped out even if we remained with the first vendor,” recalls CIO Dave Holland. Genesys learned from its experience and placed adherence to open standards as a top requirement in the search for the second vendor.

At the same time, the health system realized that imaging was evolving. “We wanted an enterprise image repository that could play with different vendors across the enterprise, so that each ‘ology’ could choose best-of-breed systems to work with the enterprise archive,” explains Holland. Genesys Health System ultimately opted for Emageon’s UltraVisual PACS. The second solution met its goals, enabling Genesys to leverage its investment in hardware and will allow clinicians to interpret and read DICOM images across the enterprise.

Leveraging that initial PACS investment may be a primary criteria for the second system. The National Naval Medical Center in Bethesda, Md., opted for the low bidder for a three-phase PACS installation in 2000. Unfortunately, the inexperienced vendor could not meet radiologists’ needs. “Two years into the implementation, we convinced the powers-that-be to cut our losses and not continue with phase two,” recalls Hugh Scott, head of PACS services.

The decision left the center with a very limited budget, and it needed to optimize its investment in the second installation. During the search, the medical center stressed the importance of utilizing existing infrastructure. Agfa Healthcare came up with a plan to load IMPAX PACS software onto the center’s existing server-based gateways and workstations, allowing National Naval Medical Center to salvage a significant portion of its hardware investment. Other facilities also find creative ways to recycle PACS hardware. Meridian Imaging Group plans to reconfigure its first PACS workstations to handle a new document imaging system.

Phoebe Putney Memorial Hospital in Albany, Ga., found itself in a similar bind after opting for a ‘more affordable’ PACS. “Radiologists were not satisfied. The PACS was used for archiving and sending images to the floors, but radiologists continued to read from film,” explains PACS coordinator Tim Davis.

The hospital realized it needed to find a viable solution to remain competitive and began a second search. The second time around, radiologists played a more active role in the search, and radiology criteria such as workstation tools, monitor quality and system speed were closely evaluated during site visits. After inviting two vendors to the hospital for a live demo, Phoebe Putney Memorial selected McKesson’s Horizon Medical Imaging PACS. Not only did physicians prefer McKesson’s system, but the other vendor refused to hook into the hospital network to import images.

Sometimes radiologists insist that the first PACS is a match made in heaven. Administrators, however, point to one tiny flaw. That perfect PACS may drain the budget. Take for example Meridian Imaging Group. Financial concerns led the group to abandon its first PACS and look for a replacement more closely aligned with its vision. Radiologists were very happy with the first system, Ranahan says. On the downside, operational costs were very high. Plus, the group was growing rapidly and needed to find a solution that would help it manage growth in an economically feasible manner. Final factors in the decision related to productivity and workflow. “We wanted a vendor to take us down the path to a truly integrated solution where the radiologist never leaves PACS to accomplish the entire workflow,” recalls Ranahan.

Meridian relied on operational costs and the desire for an integrated solution to drive its decision-making process. The group found itself ahead of the curve. When it initiated its search after the Radiological Society of North America meeting in the fall of 2003, the group found that available systems did not yet meet its vision of an integrated solution and decided to wait a year for the technology to mature a bit more. In June 2005, Meridian selected eMed Matrix. “One of the key elements was the relationship between eMed and Merge Healthcare, our RIS vendor,” explains Ranahan. The imaging group appreciated Merge’s commitment to a common vision and plans to transition to Fusion MX RIS/PACS.

Sometimes, ease of interfacing is a key criteria. That was the case at St. Luke’s Medical Plaza Imaging Center in Kansas City, Mo. The outpatient imaging center knew that its system would need to easily download studies to the local hospital’s McKesson Horizon Medical Imaging PACS. Previous experience with Philips Medical Systems iSite PACS proved that the interface between the two systems worked effectively. The existing interface was a big plus, says Administrator John Ising. But the center did explore other vendors. “iSite had two other advantages. The per exam cost model is attractive. In addition, many of our referring physicians had used iSite and liked its functionality,” Ising says. The three factors sealed the deal for St. Luke’s, and the center installed iSite last fall.

Compliance to standards is another important factor to consider. In 2000, when Mount Sinai Medical Center in New York City expanded an initial limited PACS implementation to a departmental solution, the center focused on DICOM-compliance. “DICOM compliance remains important today. Now buyers should stress IHE (Integrating the Healthcare Enterprise; www.ihe.net) as well and determine how many profiles the PACS vendor supports,” says David Mendelson, MD, associate professor of radiology.

Mount Sinai opted for GE Healthcare’s Centricity Web. The PACS includes tools to integrate into other repositories and electronic health records. This means a clinician can launch Centricity Web with a single click from other clinical information systems.

Indeed the degree of clinician-friendliness may be more important in the second installation than it was initially. While earlier PACS were likely to be viewed as a radiology department tool, the current model often defines PACS as an enterprise solution.

Data, data everywhere

A second PACS implementation entails some tough decisions. One of the major choices is maintaining the first PACS or migrating images to the new system. “There’s no right answer,” says Mendelson. Ranahan adds to the list of decisions to be made. “The site needs to determine how to migrate data, how much data to migrate and whether it will take place before, during or after the go-live [of the new PACS].”

Sometimes migration is unnecessary. Mount Sinai Medical Center decided to run both systems because its initial PACS was limited to CT, MRI and ultrasound images.

For other hospitals, data migration is the way to go. National Naval Medical Center decided to move all historical images to its IMPAX PACS. “We ran both systems in parallel, so we wouldn’t interrupt workflow. We had to split our time and energy between both systems for the year and half it took to install new modalities and migrate historical images,” explains Scott. The center also twisted a few arms to get the first vendor to work with the database administrator to facilitate the migration.

The migration process took a full year at Genesys Health. The system had five years’ worth of images to convert. “At 150,000 studies annually, we were looking at a voluminous amount of data,” recalls Holland. But Genesys and Emageon developed a targeted plan. Every night the new system reviewed the next day’s schedule and converted prior images to the new repository. In emergency cases, both systems were manually checked. During the weekend, the system sorted and converted remaining images in chunks.

Database migration isn’t always painful, and the process is likely to improve in the future. “As DICOM becomes more universal, the process will become more streamlined,” predicts Mendelson.

Meridian Imaging minimized the pain of migration by taking a proactive approach and using an outside vendor to manage the migration.

“When doing a longitudinal image data migration, one needs to find the right technical expertise of a person or group that fully understands DICOM and the issues in moving the data,” says Ranahan. “We used Migratek to manage the actual migration including data analysis, cross match RIS and PACS data, and provide the actual software and hardware required to move the data from the old archive to the new archive.”

Buyers need to include migration in the cost analysis; at Meridian Imaging the total cost of migration ran about 10 percent of the system acquisition cost. The group also analyzed the direct costs of a manual migration versus an automated method and saved more than 50 percent by using the outside vendor. The approach paid off; Meridian Imaging Group migrated nearly three years’ worth of data by its go-live date and began reading exclusively from the new system on day one. The group was able to cut costs by dropping the service contract on the first system when it deployed Matrix.

Dropping that first service contract can be a risky proposition. Davis of Phoebe Putney Memorial Hospital jokes that all of the love was gone after the hospital dropped its service contract with its first PACS vendor. First, the redundant back-up failed, and then the primary archive failed, which left the hospital in a bind because it had barely started its migration process. On the plus side, the first PACS implementation had been so unsuccessful that all priors were available on film. The lesson, says Davis, is to migrate in a timely manner and not to drop the first contract until successful completion of migration.

Axcess Diagnostics of Venice and Bradenton, Fla., decided to complete a partial data migration in parallel to its installation of Intelerad Medical Systems Inc.’s IntelePACS as a second system. “We migrated one year’s worth of data because we felt we wouldn’t need all priors online,” says PACS Administrator Gary Wildfong. Remaining studies are held on NAS (network-attached storage) and MOD (magneto-optical disks) storage and pulled as needed.

Conclusion

For some facilities, its takes two installations to realize the promise of PACS—true love blossoms the second time around.

Selecting and installing a second (or third or fourth) PACS is a unique process that tends to be more specific and more enterprise-oriented than the initial installation. Second-time success hinges on a thorough analysis of the costs, needs and goals. The other major issue is data migration; timing, costs and benefits should be considered carefully, and the facility needs to develop and implement its plan in a timely manner and with the blessing of the radiology and enterprise decision-making team.