Top 10 PACS Problems—and Solutions

PACS has transformed radiology. But as more imaging-based specialties jump on the bandwagon and adopt or customize their own versions of PACS, many in radiology are reporting more problems with PACS. Health Imaging & IT spoke with radiologists and administrators to compile and address the 10 most vexing challenges.

1. Integration

With the government-supported rush to EHRs and radiology's links to multiple providers and specialties, integration with hospital information systems (HIS) seems a never-ending struggle. Sharing images between specialties or loading patient information to other providers' EHRs are common problems. Integrating PACS with RIS, voice recognition and billing are too often a struggle.

Although a lack of inter-vendor device and IT integration can often make the problem worse, the market is improving as providers and meaningful use demand greater integration. Still, many radiologists and PACS administrators prefer to make full use of hospital IT to configure their own systems and achieve a bit more autonomy.

"Don't customize when you can configure," recommends Richard L. Kennedy, MSc, technical director of imaging informatics for Kaiser Permanente Medical Group in Sacramento, Calif. Additionally, integration engines enable practices to forge ahead with individual best-of-breed hardware and software that can be integrated with almost any platform. Experts unanimously recommend sorting out proprietary rules before inking any contracts, which allows clinicians and executives to establish reasonable expectations and plans.

2. Downtime

It happens: deal with it by planning for it. "Every system has downtime," Kennedy points out. "You need to establish alternate workflows." Both scheduled and unscheduled outages are inevitable, but they need not have too serious an effect on patient care. Business continuity systems are essential and can be as simple as a small public domain mini-PACS or as sophisticated as a fully redundant primary PACS.

3. Hanging protocols

Non-standardized hanging protocol display is a common and pesky challenge for PACS users. Because images from different modalities are not organized by default, each study takes a little longer to read—which can add up to a lot of wasted time for radiologists, notes Nicole Fennell, PACS administrator for Scottsdale Medical Imaging in Scottsdale Ariz. As the number of scanners increases and the sample of vendors expands, the problem grows worse.

Some success can be found in renaming or normalizing the image series descriptors on each scanner, say Fennell. Joseph Johnston, PACS administrator at Bethesda North Hospital in Cincinnati, agrees. Both Fennel and Johnston report that normalizing the series names has standardized the hanging protocols in 85 percent of cases.

4. Interoperability

Integration problems concern hardware, from digitizing pre-DICOM modalities to integrating systems for advanced image reconstruction. Add-ons like a DICOM converter can help squeeze out additional value from older CT, angiography and fluoroscopy systems

Eliot L. Siegel, MD, professor of diagnostic radiology and nuclear medicine and associate vice chairman for informatics at the University of Maryland School of Medicine in Baltimore, would like to see much better integration between PACS and advanced visualization systems including a shared image archive and for PACS workstations to be able to display thicker CT sections using thin section data to avoid the need to save both the thin and thick slices.

A robust IT staff provides a strong palliative to interfacing various vendor systems. "My No. 1 challenge right now is managing the hardware between different vendors," explains Paul Leonhardt, RIS/PACS administrator for Caldwell Memorial Hospital in Lenoir, N.C. He notes, "Meaningful use is basically expanding the 'bolt-on revolution.'" If opting for in-house configuration or individual best-of-breed systems, additional software for integration is often the next-best solution to new devices with pre-negotiated vendor contracts.

5. Support

As with downtime, failures are unavoidable, and selecting a PACS vendor with strong experience and demonstrated support is key. Leonhardt notes that as systems within radiology and between radiology and other specialties become increasingly interdependent, yet tied to disparate vendors, "there is a domino effect when errors occur." Moreover, as service switches increasingly to remote support, quality has declined even as prices rise. These points underscore the importance of vendor selection—not only selecting a PACS that is likely to bring fewer errors—but also choosing a vendor that will be around long enough to right the inevitable wrongs.  

6. Training

Effective training is less a means to solve a specific problem than preparation for administrators to solve many problems. Training can be a cost-effective way to demonstrate to administrators and physicians many of PACS' underused and undervalued features. "Training helps expose staff to what the system can do to make their jobs easier and more efficient," explains Howard Epstein, MHA, PACS administrator at University Medical Center of Southern Nevada in Las Vegas. Radiology, IT and the education department at University Medical Center now collaborate on a program to educate all new administrative staff and medical faculty, which helps get around the disruptions to workflow associated with training a large number of employees.

7. Out with the old

Replacing a legacy PACS offers promising advantages for both clinical and administrative workflow, but there is no denying that it is often a major headache in the short-run. "It's a painful process at best," admitted Steven C. Horri, MD, a radiologist at the University of Pennsylvania in Philadelphia, at RSNA 2010. Johnston adds, "Oftentimes, IT departments do not really understand the magnitude or mission-critical status of radiology workstations and therefore treat them as regular pool computers. That is a major problem."

The migration of data to the new PACS is often the most challenging part of the process, both in negotiating the release of data from the current PACS and in sorting out all the data entry errors that have accumulated over the lifespan of the system. (This isn't an issue, however, if sites use the legacy archive.)

IT can go a long way in identifying common problems and authoring solutions to them. Horri's recommendation? "Negotiate a prenuptial agreement with your new vendor," as costs always exceed estimates and what seems like your data may, according to the contract, actually belong to the vendor.

8. Whose PACS?

As other specialties realize the value of PACS, the system is slowly being taken out of radiologists' hands. "PACS has become a mission-critical enterprise-wide tool used by nearly all specialties. With this change, decision-making for PACS-related purchases, upgrades and configurations has, in some cases, shifted from radiologists to a more central process. In such cases, decisions might be based on attempts to please a high-volume referring specialty group, or the often ill-advised desire to consolidate all technology with a single vendor," says David L. Weiss, MD, associate professor of radiology at Virginia Tech Carilion School of Medicine and physician coordinator for imaging informatics at Carilion Clinic in Roanoke, Va.

The end choice may not be optimized for radiology and often leaves the radiologist with less than optimal workflow, continues Weiss. Because radiologists spend more time than any other specialty at PACS workstations, it is vital that radiologists maintain strong communication with IT and other specialties to hang onto their influence in PACS decision-making.

9. Ergonomics

Hiring a certified public ergonomist to evaluate the department's workstations can ease radiologists' repetitive stress symptoms and contribute substantially to productivity. Despite accelerating advances in technology, many interface tools have changed little since the introduction of PACS. Weiss notes that, "Although the two-button mouse and keyboard remain useful for conventional computer interactions, they are detrimental to PACS workflow." He prefers a 17-button mouse. Many PACS vendors are picking up on the ergonomic trends, by making more of the interface user-configurable.

10. Disaster Recovery

Like business continuity, disaster recovery can prevent a painful experience from becoming fatal. Many hospitals opt for either redundant servers, cloud storage or both. At the very least, preparation for downtime can spare physicians and patients from experiencing significant losses.