PACS has become an integral part of the healthcare landscape, with digital image management installed in some form in nearly every hospital in the U.S. and in many facilities overseas. However, the complexion of the PACS market has changed dramatically over the past few years.
Very few new PACS networks are being sold into the hospital marketplace despite various reports that peg overall PACS growth as high as 10% annually. In addition, fewer than 10% of facilities with existing PACS replace their current vendor after the requisite five- to seven-year return-on-investment (ROI) period. Unless there is a very good reason to change, most facilities simply stay the course with the initial vendor of choice.
PACS consultant Michael J. Cannavo.In a world of depleted and/or redirected capital budgets, most of the activity in PACS today concerns upgrading hardware and software, updating applications software, implementing specialized add-on software such as speech recognition systems, establishing a vendor-neutral archive (VNA), and integrating PACS with other clinical information systems.
Interestingly enough, many facilities are holding off on making any large-scale (more than $250,000) investments in PACS until they evaluate how they can better leverage their existing PACS; instead, they are making investments in other areas. There are a number of reasons for this, not the least of which is meaningful use (MU).
On the back burner
The one thing radiology and IT departments alike are looking for most in their PACS -- and, frankly, all existing clinical information systems -- is how to get the most bang for their buck and make minimal investments in time and resources. Many of the past few years have been focused on dealing with ways to meet the meaningful use deadlines and grab a share of the $29 billion Congress set aside as part of the American Recovery and Reinvestment Act (ARRA) for the MU program. This includes implementing an electronic health record (EHR) system.
These systems can easily cost tens of millions of dollars. That has tied up nearly all of IT departments' available technical resources, as well as a large chunk of hospitals' money. This also includes added costs in bringing in outside consultants to assist with the implementation process.
Why is this important to know? With few exceptions, most PACS upgrades and other related implementations require IT support. This is especially important with things like VNAs, which store information and image data from multiple departments. This also includes the integration of PACS into an EHR so images can be viewed anywhere at any time, including the use of mobile medical apps.
If IT is busy addressing other areas such as helping the facility meet MU and implementing an EHR, any PACS-related project may be postponed until these resources become available. Couple that with the fact that IT resources have been subject to severe cutbacks that affect the number of projects they can implement at one time, and you have the perfect storm for putting PACS on the back burner.
A study released in January 2014 showed that while 78% of respondents reported some use of an EHR, only 31% used a "fully functional" EHR. That means that more than two-thirds of all hospitals in the U.S. either need an EHR or need to upgrade their existing EHR to meet the requirements defined by MU stages 2 and higher.
Even more enlightening is that while two out of three physician's offices said they intended to participate in MU programs, fewer than 20% actually had the capability to meet the stage 2 core set requirements. The numbers alluding to readiness vary from report to report, but the bottom line remains the same: Meeting MU requirements is and probably will remain most hospitals' No. 1 priority.
It is also highly resource-dependent. Resources for MU aren't readily available, and the cost for implementing an EHR to meet MU is much higher than initially expected. In addition, the implementation of an EHR typically takes much longer than expected -- sometimes fivefold or longer -- with costs coming exponentially close to the implementation time extension. All of these factors affect PACS by tying up valuable IT resources.
End of XP support
Another item to consider regarding IT availability is the need to migrate from Windows XP to Windows 7, as well as requisite ICD-10 upgrades and implementation. Microsoft will stop supporting Windows XP on April 8, 2014. While the lack of software upgrades is a concern, a bigger issue is HIPAA compliance.
Because Microsoft will no longer offer support for its 12-year-old operating system, XP users may be left vulnerable to security breaches. The discussion about whether this affects HIPAA compliance goes round and round as to what could be done, should be done, and needs to be done, but cooler heads are not taking chances and are replacing the operating system before support ends.
The technology safeguards component to the HIPAA Security Rule specifically looks at the totality of your systems, not just the interplay between your hosted EHR and the terminals that access and view data from the hosted application. Keep in mind, an operating system that is no longer supported is one that no longer receives patches and updates to modify and upgrade its security.
Thus, in the mind of the U.S. National Institute of Standards and Technology (NIST), which sets the standards by which HIPAA compliance is measured, an unsupported operating system is insufficient to ensure the protection of the facility's data or that provided by a third party-provider business associate agreement (BAA).
As background, NIST 800-66 states, "Ensure that updates and patches are regularly applied to the operating system and primary applications, such as Web browsers, email clients, instant messaging clients, and security software." If you cannot patch your operating system because the vendor no longer supports it, it would seem you are not compliant.
Upgrading 100, 500, or 1,000 computers from Windows XP to Windows 7 is an exceptionally time-intensive task that, like MU, takes priority over nearly everything else. Although minor by comparison, April 8 also marks the end of support from Microsoft for Office 2003 and Internet Explorer 6, which many smaller offices and smaller sites may still utilize. This once again taxes IT resources.
Radiology still relies heavily on PACS to help the department run smoothly, yet having limited human and financial resources makes keeping the system current a challenge. Radiology can and often does install new application-specific software on its own, including critical results reporting, dose management and clinical decision-support software, mammography reporting, and even orthopedic templating.
Most of this software is fairly cost-effective -- less than $50,000 -- and implementing it provides a solid return on investment and also helps to meet mandated requirements. Many software add-on options are available and they often only require coordination between the PACS administrator and the vendor. Installation and training also need to be part of the package for system implementation to run smoothly, but this usually comes bundled with the software sale.
Projects such as implementing speech recognition can also be done by radiology, but things of this magnitude usually require a degree of coordination with IT to ensure proper network connectivity and integration with the RIS and other clinical systems. You also need to ensure that the existing version of PACS can handle the latest version of the speech recognition system. Because of this, a speech recognition implementation is almost always a joint project between radiology and IT.
