Replacement PACS: Is the Grass Always Greener?

Once you’ve had a PACS in place, be it a few months or a few years, you pretty much know virtually everything about it.
You know how it works, how to use it to get the most efficiency, have defined your hanging protocols, created shortcuts, developed workarounds to system bugs and know the system like the back of your hand.
The mantra “once you’ve had PACS you never go back” holds true even if the experience was less than optimal. Some PACS is better than no PACS, and going back to film typically isn’t even a consideration.
The same logic also dictates that moving from one PACS to another should be as easy as driving a rental car – you adjust the seat and mirrors, take a look at the console to figure out where everything from lights to wipers are, put it in drive, and go about your merry way. Unfortunately, buying a replacement PACS isn’t anywhere near that easy.

Next-Gen Angst
It is interesting that the vast majority of end users typically chose a PACS from a different vendor the second time around. The reasons behind this are varied and can include everything from better features and functionally offered by competitors to lower pricing to dissatisfaction with the incumbent vendor’s service or support or any combination thereof.
So why is it that second and third generation PACS create such angst among buyers? There are several reasons.
Transferring data from one PACS to another is not easy. Most of the time it involves much more than a simple DICOM query/retrieve function and involves both costly and time consuming data migration. End users usually aren’t prepared for this and may feel somewhat betrayed by the incumbent vendor for selling them a system that, in their minds, should have allowed seamless and transparent data transfer. After all, the data was stored in an industry standard format (DICOM), and therefore should be able to transfer easily to another system.
That is partly true, but there are things within the DICOM standard that aren’t mandatory that really need to be – grayscale presentation states being one – and without which can and probably will significantly impact the radiologist’s ability to provide an accurate comparison of previous images.
The bottom line here is that some of the money they may have budgeted to buy a new PACS may now need to be diverted to performing data migration. This can impact their end user’s decision on which vendor to chose or even delay the decision making process.
Bells and Whistles
Features and functionality also vary widely from PACS to PACS as well, although all PACS offer the same subset of basic features that are used in everyday practice – window/level, zoom, roam, flip, rotate, etc.
While some features offered by vendors are nice, the reality is if you have been living without a particular feature for years, the chances are that you can live without it longer. That said, most sales depend on selling bells and whistles, so sometimes end users will gravitate towards one product versus another on that basis alone.

Repeat Mistakes
The biggest reason for a second PACS to fail is the classic definition of insanity – doing the same thing over again and expecting the outcome to be different.
End users assume that all PACS are the same, so they don’t ask the right questions and end up selecting the wrong PACS. The converse of that is asking too many questions and becoming so totally confused on which direction to go that the end user has “analysis paralysis” and can’t bring him or herself to make a decision.
I’ve also seen the scientific approach where an extensive and exhaustive RFP (request for purchase) is generated, eight to 10 vendors are solicited to respond, weight factors are given to each area, and at the end of an eight-month evaluation period, and hundreds of hours later, the vendors are ranked so closely together that the differences between them are all statistically insignificant. There needs to be a happy medium.

Shop Around
Here is the reality that needs to be looked at. A year or so before the PACS is due to be replaced, radiologist needs to go out and evaluate the marketplace, looking at every PACS out there, and picking one or two that they really like.
This isn’t as hard as it seems, with radiologists typically identifying one system they like best and having the second system as a backup, so to speak. Those are the systems – and only systems – that should be evaluated.
While evaluating six or eight vendors might show to administration that you have indeed done what they consider proper due diligence, all it really does is waste both the end users and vendors time.
After looking at various systems, the radiologists know what system will work best for them and the radiology department, so why not just focus on that one?
IT’s responsibility then becomes one of making sure the system is designed and configured properly, will work well and integrate with the other clinical systems, and offers long-term growth and minimal increased costs. Fortunately, most IT departments can perform that evaluation in their sleep.

New Approach to PACS
Just as the market has changed in the past two to three years so too has the way most end users approach PACS.
Where my company used to do costly and time consuming RFP’s in the past, today we just offer what we call a PACS Sanity Check. These perform an apples to apples comparisons between the two vendors being considered (or just a review a single vendor’s offering).
We make sure it meets the clients’ needs, and then once we sign off that it meets their needs, we assist the client in the contract review and negotiations. This is done at about one tenth the cost of the full RFP route, yet provides the end user with the same benefits of the full RFP route.

PACS Divorce Rate
So why aren’t second PACS purchases flawless? One only needs to look at marriage and divorce statistics to understand. It is pretty much agreed by most experts that first marriages end in divorce about 40 to 50 percent of the time. The PACS “divorce rate” is much higher than that.
What surprises me is that the divorce rate increases with second marriages to 60 percent and more, while third marriages end in divorce at least 70 percent of the time. Does that mean third generation PACS are more doomed than second?
One would think that an individual who has gone through a marriage and divorce would have “learned his (or her) lesson” and will, therefore, not repeat the mistakes of the past. Alas, this is often not the case. Those who marry to fulfill certain needs, but are not prepared to give in return, usually marry with the same intent the next time around.
The same holds true with PACS. The second or replacement PACS becomes nothing more than a walk down a precipice, a courtship leading to fresh disaster, only because it involves a new partner.
Avoid Disaster
So how do you avoid the disaster? Make a list of what you liked and didn’t like with your first PACS. Evaluate your new PACS partner not just by the freshness they bring to the relationship but by how well they performed during the time you were together.
In doing the detailed evaluation and assessment, it is important to understand that while newer systems might perform better – after all it does run on newer hardware and is one of the primary reasons why you are upgrading – you have to also ask if the better performance helps you or hinders you? That may sound contradictory, but sometimes faster and cheaper isn’t always what you need, especially if you lose a feature you really used before.
Look at the company’s track record in delivering what they promised relative to software updates and upgrades. Did they meet the promised delivery dates? Did it work right the first time? Did it include everything that they said it would or merely provided a fraction of what they said?
How was service? Were they responsive to your needs when you called them by phone? Were the techs knowledgeable and able to help you without passing you on from one rep to the next or requiring multiple calls? How was on site support when you needed it?

The best way to address second time PACS is not just to look at systems yourself, but also talk to those who have made the same move as you are planning. Ideally an end user who had vendor A, like you, and has now selected your choice vendor B like you have selected. What made them make the decision to select Vendor B? What did they like about vendor B that vendor A didn’t have? What did they miss? How did the switch to the new system go, both data migration and integration with other clinical systems, such as the radiological information system (RIS), voice recognition, billing, and so on?
You can also ask what was paid as long as you understand that price is not merely a function of size but has a host of other variables attached to it, including competitive scenarios, volume differentials, connectivity issues, the ability of the site to perform (or not perform) certain integration tasks on their own, hardware configurations, and other situations. That’s why services that provide price comparisons are limited in value at best – they simply don’t understand or take into consideration the dynamics involved in each purchasing decision.

There are two other items that are key to the successful deployment of a second generation PACS. The first is having a project plan that clearly defines responsibilities and timelines and has a clear cut delineation of who is responsible for what. The second is a having a solid contract in place that not only defines expectations but includes penalties if things don’t go as planned. And remember, never, ever sign a contract without knowing exactly what it means and making sure that you are covered.
PACS the second time around can be an easy decision or a hard one, but it must be made with both your eyes and mind wide open.
There will be times when you second guess yourself and your decision – that is human nature – but if you do your homework in advance and get help with the contract, you will make the right choice.

Author: Michael J. Cannavo is founder and president of Image Management Consultants (IMC). Cannavo earned his reputation as the PACSman for his more than 22 years of experience advising healthcare facilities and providers on the essentials of PACS in the healthcare enterprise.