By Herman Oosterwijk, AuntMinnie.com contributing writer

April 16, 2018 -- In 2017, the vendor replacement rate was 14% for single-source PACS users and 28% for best-of-breed systems, according to a recent report by market research firm Reaction Data. Those are significant percentages, which begs the question, why would anyone want to change a PACS vendor?

Unlike changing a car make, where the brand loyalty is about 50%, changing PACS vendors is a big deal. It is painful, costly, and time-consuming. When leaving a vendor, one will often find out that the prenuptials might not have been properly spelled out, similar to a divorce, causing potential disputes about migration costs, service contract costs during the transition, and access to the archived data and its database scheme.

Why would one consider changing PACS vendors in spite of the cost and pain? Here are my top 10 reasons based on discussions with PACS professionals and, most importantly, feedback from my many PACS administrator students.

1. A vendor goes out of business or is acquired.

Remember Kodak, DR Systems, Emageon, Applicare, and many others? In most cases, these companies were acquired by another PACS company, and supposedly product support was taken over by the new parent company.

Herman Oosterwijk
Herman Oosterwijk of OTech.

The problem is that employees from the old company leave and support is taken over by a consolidated support center that is unfamiliar with the old product; or, in many cases, the company was taken over simply to get access to the customer base. In that case, the product is put on life support instead of being enhanced or updated.

2. An upgrade is not affordable.

Especially for so-called "forklift" upgrades, where the hardware, monitors, and servers are upgraded along with the software, the cost can easily be the same as what you pay for a new system. If a more cost-effective alternative is available, especially using a new architecture (cloud storage or enterprise archiving), one might want to consider looking at alternatives.

3. The system no longer meets specifications.

Some PACS are not as scalable, meaning the performance and reliability cannot stay consistent with the increasing amount of images and information being stored and managed. For example, one of my PACS students mentioned that his system goes down on average once a week. This might be a good reason to start looking for a replacement.

There are also new security requirements to keep your system safe from viruses, hackers, and other threats. Some of the existing systems do not have the architecture to combat these.

4. Service and support is poor.

I would argue that a PACS is as good as its service. Support is severely lacking, for example, in developing and emerging countries due to a lack of training of local dealers and end users, as well as poor remote support.

I experienced this myself when it took a month to solve a problem with a customer in Mexico City, despite the hospital's relatively short distance from the support center (based in Dallas at that time). Although it was only a two-hour flight, the customer was not covered by the U.S. service organization. Note that the same service center covers Alaska without any problems, even though it's eight hours away.

Even in the U.S. or European countries where most of the PACS vendors are based, I have noticed that service and support can be spotty. One factor is that the service engineers, who used to be PACS specialists, are now "generalists" who are trained on CT, MRI, and -- by the way -- also PACS.

5. New corporate purchasing contracts are being enforced.

A large hospital group or government agency will negotiate a multiyear, multimillion dollar contract for imaging equipment including cath labs, CT, MRI, ultrasound, and also PACS. This remains the case despite the number of mergers and acquisitions -- about 100 per year -- in the hospital industry. That's a significant number considering there are about 5,500 registered hospitals in the U.S.

When a hospital is taken over, there is often a great desire to standardize the PACS vendor for various reasons, among them support and cost savings.

6. New specialties and users require different functionality.

My guess is that at least 50% of all users have a dedicated workstation for displaying and manipulating digital breast tomosynthesis (DBT) images, performing fusion for PET/CT, or providing other functionality not performed by their PACS. Needing dedicated workstations for these tasks complicates the architecture, often creates proprietary data (such as with DBT), and makes prefetching prior exams a challenge.

Also, some PACS cannot handle enterprise imaging needs, lack the capability for a vendor-neutral archive (VNA) upgrade, or can't facilitate other specialties. There might also be a need for electronic medical record (EMR) connectivity, Integrating the Healthcare Enterprise Cross-Enterprise Document Sharing (XDS) support, or Fast Healthcare Interoperability Resources (FHIR) data exchange standard capabilities for use in reports. Typically, these combinations of increasing requirements often cause the user to look for a PACS replacement.

7. There is a lack of "built-in" features.

Some of the noncore features such as dose reporting, critical results reporting, reject analysis, peer review, clinical trials, teaching, and file support are becoming more important. Having multiple middleware solutions and integrating all of these is a challenge.

Some PACS vendors lack even features that I would consider "core," such as sophisticated routing, a flexible modality worklist, a workstation worklist consolidating multiple PACS systems, flexible CD image input and output, and teleradiology functionality. One can purchase all of these features from third-party vendors, but again, having too many boxes complicates system integration and support.

8. The system lacks regulatory requirements.

Supporting the meaningful use (now called the Medicare Access and CHIP Reauthorization Act, or MACRA) program or accountable care organization (ACO) participation requirements could be critical to gaining access to government grants; the lack thereof can impact reimbursements.

9. Critical users prefer a different vendor.

A new radiology group or chairperson who has his or her favorite vendor -- or hates the current vendor -- can make a difference. New management changes often affect who is staying and who is leaving, including what vendor is used.

10. The grass is always greener.

Alternatives seem to be more attractive than staying with your existing vendor. However, in most cases it is hard to view the total picture. For example, one might change vendors for increased functionality and then find out the service is substandard, the new system does not quite fit your workflow, or it does not integrate well with your speech recognition system or EMR. Beware of buyer's remorse, and make sure you look at all of the different aspects before making a change.

Conclusion

Sometimes changing your PACS vendor is inevitable, but I would definitely suggest that you do your homework. I've seen people switch and then switch back after a year or so, having gone through a lot of unnecessary work, effort, and expense. As an analogy (without firsthand experience), I have read about people who get divorced and then wind up remarrying each other. Sometimes it might be good to depart in order to find out how good it was with your original partner. Then you can get back together and be happier than you were before.

Herman Oosterwijk, president of OTech, is a healthcare imaging and IT trainer/consultant for image management companies, specializing in PACS, DICOM, and HL7.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.


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