Until recently, PACS was feasible only for healthcare institutions with significant financial resources, sophisticated IS departments, and imaging study volume in the hundreds of thousands per year. The networks are more widely available now, however, thanks to new system architectures and infrastructure technologies, as well as new financing, deployment, and management options.
Innovative PACS models such as onsite turnkey implementation, management services, and resource and cost-sharing arrangements with institutional partnerships and co-ops are increasingly available. Flexible financing and bold end-to-end technology and service arrangements are also making PACS more affordable and accessible to a wide range of healthcare facilities.
Facilities performing as few as 5,000 exams per year are now poised to transform the competitive landscape by gaining "big hospital" efficiencies through digital imaging environments.
These alternatives generally enable institutions to gain PACS efficiencies more quickly, while reducing risks and easing deployment and transition challenges. Moreover, healthcare executives, administrators, clinical staff, and in-house information technology (IT) personnel can better maintain clinical productivity during the PACS transition period by not having to attend to all the transition details as an additional duty.
The long and involved transition to PACS can even benefit from single-point accountability. For some institutions, new financing and deployment options place PACS within immediate reach for the first time. Where such comprehensive PACS outsourcing is involved, institutions are free to focus on what they do best: serving patients.
Alternative PACS models have various strengths and trade-offs, and healthcare providers can readily adapt these models to fit their own unique circumstances.
Managed services
PACS typically requires full-time personnel dedicated to deployment. A managed services approach addresses this issue by providing a dedicated PACS professional team that seamlessly collaborates with the institution’s IT and radiology staffs, enabling the institution to focus on maintaining high levels of customer service and patient care. Furthermore, a dedicated team provides single-point response and accountability for a complex, multifaceted PACS implementation process.
With this model, healthcare system personnel remain, as they should, deeply engaged with PACS processes, creating true collaboration throughout every implementation stage. In many cases, viewing radiology exams digitally, on demand, and at all points in an enterprise no longer requires owning, leasing, or even managing PACS. New financing options enable even relatively small institutions -- ones that perform as few as 5,000 radiology exams per year -- to utilize PACS infrastructure and services.
Managed services include PACS deployment, management, training, support, quality control, and periodic technology refreshment, all for a predetermined monthly fee. The fee normally covers all exams up to a specified quantity per month, after which a small incremental charge per exam covers increased volume. There are also variations on this theme: charging the institution "per click" whenever an image is retrieved for display, for example. The variations are completely negotiable, allowing for the financing structure to fit into both the capital and operational budgets of an organization.
Turnkey operating fee arrangements put PACS within immediate reach of many institutions that lack the capital or technical resources to handle the relatively large front-end costs and technical complexities that characterize a traditional PACS acquisition and implementation.
For example, a small healthcare facility performing 5,000 radiology exams per year might wish to adopt PACS for competitive reasons, as several other hospitals and clinics in the area have already leveraged PACS to gain clinical and operational efficiencies, attract referring physicians, and improve patient care while reducing film costs. To respond, facilities need a Web-based PACS environment that can be managed locally and scaled to keep pace with their future growth. Because capital resources are stretched, front-end financing isn’t feasible.
Instead, an organization might turn to an outsourced model that embraces both facility management and technology support services. It includes a PACS infrastructure consisting of image acquisition from all required modalities, image storage in storage area network (SAN) and archival devices, and retrieval and distribution over a local area network (LAN), scaled to meet the needs of the PACS and image display at all viewing locations required to support efficient clinical use.
The PACS must incorporate the appropriate variety of display devices and integration to the required messaging activities of the HIS and RIS. Other parts of the solution are the turnkey deployment services, such as PACS planning, acquisition, installation, acceptance testing, assistance with migrating workflow to a digital imaging environment, and user training. Extending throughout the contract period are further comprehensive services for maintenance, repair, technology upgrades, quality control, performance monitoring, and continuous assistance with ongoing issues such as managing film utilization.
Financing is structured on a "pay as you go" basis. A monthly, all-inclusive operating fee covers a specified number of anticipated exams per month. A modest per-exam fee applies to each additional study. This increment equals a small fraction of what the organization charges for an exam, so the aggregate fee level remains predictable and doesn’t interfere with revenue growth for the organization.
In this example, the financing model works to the facility’s advantage in several ways. For example, the balance sheet isn’t affected since capital is not required. It avoids financial strain on the front end of the implementation. Budget planning is easy because predetermined payments are spread across the system’s anticipated life, and cover all PACS, infrastructure, and service costs. The model readily scales from small to large institutions and multifacility healthcare systems.
Sharing and hosting arrangements
In situations where PACS deployment may be impractical for an institution acting alone, partnering with one or more nearby institutions may be possible. In some cases, rural hospitals have teamed up to share PACS resources and costs. However, PACS complexity further increases when planning and deployment involves multiple boards of directors, executive teams, radiology departments, and medical and administrative staffs, not to mention the complexity of trying to integrate multiple HIS and RIS systems and hospital workflow models with a single PACS archive and database.
An outsourced professional team may provide an optimal solution. The team can serve as a neutral coordinator, collaborating with partners to identify and resolve issues such as:
- Deciding on centralized image storage and archiving, and where such a central store would be located.
- Choosing integrated PACS technology and a RIS that also satisfy partners’ needs.
- Deciding how to allocate costs.
- Assigning primary responsibility for implementation, maintenance, performance monitoring quality control, and overall PACS management.
- Arbitrating HIS/RIS and PACS activities to achieve efficient workflow.
When several potential partners are distributed regionally rather than locally, a cooperative buying arrangement may provide substantial leverage with vendors, driving down costs and yielding more favorable terms. It may also share a pool of expertise and other PACS management resources, including itinerant physics professionals performing PACS quality control for multiple institutions.
Another local sharing arrangement may be possible when a large institution builds surplus PACS capacity. Smaller independent facilities may tap into this resource on a fee basis, implementing PACS based on the central system without a major capital investment.
With hosted storage services, digital images are stored and managed via a third party, and are accessible at any time over the wide area network. A facility no longer has to worry about obsolete technology and management of expensive storage equipment or the resources to manage the storage environment, thus reducing the need for additional infrastructure and capital expenditures. Technology refreshment and data migration at the archive becomes a requirement of the third party.
For example, a nonprofit New York hospital system that Xtria works with employed a similar strategy with its IT department. In that case, IT was spun off as an operating subsidiary that provided PACS services, essentially transforming a cost center into a profit center. The subsidiary now sells IT capacity and services to other institutions, as well as supporting its institutional parent’s own information needs.
Conclusions
Smaller institutions and those with fewer available resources are embracing new ways to gain "big hospital" efficiencies and stay competitive by acquiring PACS capabilities. Emerging PACS strategies reduce complex deployment risks, while opening a range of financing and operational alternatives. Taken together, these alternatives promise to improve patient care and control cost by accelerating the proliferation of digital imaging and information environments, transforming PACS into a competitive necessity at virtually all levels.
Alternative PACS models offering managed services deployment can smooth the transition from a film to filmless environment, especially with regard to complex workflow and training issues. Contractual safeguards can ensure operational performance, HIPAA compliance, and technology upgrades to keep pace with fast-moving advances. Standard data and image formats, plus flexible contract terms, ensure that institutions retain many choices, such as the option to renew a turnkey arrangement, take ownership of the PACS infrastructure, offer self-provision PACS services, or change vendors.
As implementation alternatives emerge, acquiring PACS capabilities increasingly becomes a creative endeavor. In one recent case Xtria was involved in, a nonprofit five-hospital system in upper New York forged a far-reaching agreement that encompassed a PACS acquisition, additional medical equipment, and even financing for physical plant improvements.
As the range of implementation options grows, more and more institutions are finding they can migrate to a digital imaging environment that includes a PACS network.
By John Romlein
AuntMinnie.com contributing writer
September 27, 2004
John Romlein is principal technology officer at Xtria, a Dallas-based company providing digital imaging management, integration, and implementation solutions and services.
Related Reading
Getting everything you expect from PACS, February 2, 2004
Keeping your eye on the PACS ball, September 30, 2003
Smoothing the transition to filmless, June 16, 2003
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