A PRELIMINARY PROPOSAL FOR AN ULTRASOUND PICTURE ARCHIVING AND COMMUNICATIONS SYSTEM AKA "PACS"

Kathy McCullough-Testa

Tonya Torres

Tamara Vaughn

9 March 98

I. EXECUTIVE SUMMARY

Anywhere Health System is comprised of five hospitals, with the flagship being the 500 bed Medical Center. It is currently in the midst of a major business process re-engineering. The radiology department, hospital administration, and chief information officer are now beginning to realize the advantages of computerizing the Radiology department and its procedures. The Health System has asked for preliminary research on the concept of PACS (picture archiving and communications systems.)

The intention of this proposal is to focus on developing a recommendation for Anywhere Health System's Chief Information Officer on the top five vendors that most closely match the goals and philosophy of the organization in their enterprise-wide Picture Archiving and Communications Systems (PACS) functionality. Specifically, a number of PACS vendors who provide ultrasound PACS systems will be researched and ranked against a pre-established set of Health System criteria. These vendors will, in turn, be recommended to the health system's administration for further research, demonstrations, site visits, and proposal submission. The recommendation will only be based on the implementation of an ultrasound "Mini-PACS" at the Medical Center, with the intent of expansion into other modalities as well as across the Health System.

This research is being conducted in phases so that the Health System can ensure that its purchase of a PACS system will integrate with its Health Care Information Systems (HCIS) software, hardware, and network, as well as with its business plan. A PACS system will bring a number of benefits to the enterprise. These include, but are not limited to:

1. Improving Patient Care by Increasing Services ;
2. Decreasing Lost or Misplaced Film;
3. Increasing Record Accessibility Enterprise-Wide and Remotely;
4. Improving Internal Efficiency;
5. Increasing Patient Referrals;
6. Increasing Communication Throughout the Enterprise;
7. Giving the Enterprise a Competitive Edge.

It is very difficult to quantify the benefits in monetary terms in this early stage of research. But in a study conducted by Anywhere Health System, it is estimated that the payback period for the purchase and installation of an enterprise-wide PACS is five to ten years. Some of the savings would come from decreasing the film costs, processing costs, and storage costs for film.

Clearly, as Anywhere Health System continues on its path of major business process and information technology re-engineering, the enterprise is poised to implement technologies that will positively impact patient care. This includes the implementation of an enterprise-wide PACS system.

II. BACKGROUND INFORMATION

A. Organizational Background

Anywhere Health System was founded nearly 100 years ago. It started with one small community-oriented hospital located in a city neighborhood. Throughout the years, the Health System has expanded to five hospitals with numerous clinics and outpatient centers. In addition, the Health System provides community outreach programs, medical education, and other community-related services. The Health System's mission is very community-oriented and the administration is dedicated to providing the best available health care it patients.

B. Current Business Process Reorganization (BPR)

Anywhere Health System is currently in year one of the implementation of a multi-faceted BPR. This plan includes the implementation of a fully-integrated, enterprise-wide Health Care Information System (HCIS). The Health System has contracted with Shared Medical Systems, Inc. (SMS) to be a partner in this venture. SMS is the second largest HCIS software provider in the United States.

he implementation will be enterprise-wide and effect all aspects of the Health System's operations. It has the unqualified support of the hospital administration, physicians, and staff. To begin this effort, the position of Chief Information Officer (CIO) was created and a well-respected Information Services (IS) veteran was promoted from within to serve in this capacity. As CIO, this individual is directing the IS BPR enterprise-wide.

Specifically, this effort includes the installation and implementation of an admissions, discharge, and transfer system; patient accounting system; medical records system; radiology management system; pharmacy system; lifetime clinical record; nursing station; enterprise scheduling; managed care modules; decision support links; document imaging; and medical imaging. It also supports the overall standardization of procedures and protocols across the enterprise.

C. The Role of Information Technology (IT)

To provide the framework for the HCIS, the Health System has installed a network designed jointly by the IS staff at Anywhere Health System and a major network hardware provider. The network consists of an ATM (Asynchronous Transfer Mode) backbone at the Medical Center. The Medical Center is connected to the four remote sites by four separate, yet dedicated, T1 lines. Each remote site has its own ATM network. In addition, three dedicated T1 lines are connected to SMS to provide the HCIS. The Health System has established standards for the purchase of integrating/interfacing software, networking tools, and hardware to support this effort.

III. THE ROLE OF PACS

A. History

The concept of PACS and their usage has been around in health care circles for many years. Although PACS have been discussed time and again by health care professionals, it is not until just recently that the concept of PACS is catching on. The original PACS systems were invented by Raytel Corporation who sold all of its technology and knowledge to Olicon Imaging Systems, Inc. which is based in the state of California. Since then, the number of health care PACS vendors has grown by leaps and bounds. At last count, there are over 200 vendors offering their own version of health care solutions world-wide. For web-based vendor list click here.

B. PACS and Mini-PACS Defined

PACS stands for Picture Archiving and Communication System. It is an image-based information system for the acquisition, storage, communication, archiving, display and manipulation of medical images. The major driver for the development of PACS is Teleradiology, where its storage and database capabilities are expected to replace radiology film libraries and allow radiologists to send images over communication lines to other sites. A "Mini-PACS" is a small scale PACS, usually implemented in one modality of radiology (i.e. Ultrasound). As a preparatory phase for full PACS implementation, it enables the radiology staff to gain experience using PACS technology. The current PACS standards are DICOM 3.0 and HL7 compatibility.

C. PACS Infrastructure

The PACS Infrastructure consists of (See Appendices A and B for more detailed diagrams):

1. PACS Controller;
2. Database Management System;
3. Communications Network;
4. Optical Disk Archive; and
5. Modality Recording Machines.

IV. EXISTING BUSINESS PROCESSES

A. Anywhere Health System Today

In order to understand the Medical Center Radiology Department's work flow, a walk through was conducted by the Director of Radiology. The radiology department conducts various procedures including ultrasounds; MRI's; CT-Scans; x-rays; vein and lymphatic scans; and aortal angiographies. The departmental statistics are as follows:

Specifically, in the Anywhere Health System's Medical Center ultrasound department, there are two technologists, two receptionists, one radiologist, and one resident assigned to the department on a daily basis. The department hires an outside firm for its radiology staff. The ultrasounds are performed on two instruments. Ultrasounds are performed on both males and females for a variety of different reasons including bladder problems, pregnancy, obstetrics-gynecology, and breast exams.

The current procedure used by the Medical Center's department is outlined following. (See Vignette A on a generic view of today's ultrasound department.) A patient can be referred to the department in one of two ways: (1) inpatient or (2) outpatient scheduling. Both referrals consist of basically the same procedure. The following outlines an outpatient ultrasound procedure at the Medical Center:

1. The patient calls to schedule an ultrasound.
2. The patient is scheduled manually.
3. Instructions are given to the patient on how to prepare for the procedure.
4. The patient comes into the department and is registered by the ambulatory clerk in the RIS computer system using a patient number and a medical record number for tracking purposes.
5. The patient is taken to prepare for the procedure.
6. A technician conducts the ultrasound and the patient goes home.
7. The film is developed.
8. The radiologist on duty reads the film and transcribes the diagnosis.
9. The diagnosis is forwarded to the doctor.
10. The film is filed in a temporary file awaiting the written report from the transcriptionist.
11. The report is forwarded to the radiology department, signed by the doctor, and sent to medical records to become part of the patient's file.
12. The film is put in a permanent folder with a numeric identifier and medical record number used as locators.
13. The film stays on site for five years and then is sent to the off site archives if it is not used. If accessed, the film stays on site.

A radiologist from a competing health system was also interviewed for comparative purposes. The procedure for performing ultrasounds at this health system is basically the same as Anywhere Health System's with two small differences. First, the competing health system's radiologists only read the obstetric ultrasounds, with the gynecological ultrasounds being read by the physicians. Second, film is only stored on site for one month with everything else being stored in an offsite facility.

B. Problems with Current System

As with any system, there are areas which can be improved. Anywhere Health System would like to see improvements in the following areas:

1. Increases in communication between various departments and personnel within the facility, the enterprise, and beyond;
2. Decreases in the amount of wasted film;
3. Decreases in lost or misplaced film;
4. Decreases in or the elimination of the space used to store film;
5. Decreases in the amount of time spent on a procedure;
6. Decreases in the amount of time required to read and diagnose a procedure;
7. Increases in accessibility to past procedures;
8. Increases in ability to use information for decision support.

The department is willing to utilize various methods to address these issues including BPR, enhanced technology in both conducting procedures and in IS, and instituting a PACS system.

C. Anywhere Health System with PACS

By having a "Mini-PACS" installed in the ultrasound area of the radiology department, the Medical Center can begin to address the issues stated in "IV.B. Problems with the Current System". This installation would be the first phase of a multi-phase process of installing an overall PACS system throughout the Medical Center and then, eventually, throughout the enterprise. It is estimated that an ultrasound "Mini-PACS" would require 40 gigabytes of storage annually. (See Vignette B on a generic view of a future radiology department with an ultrasound "Mini-PACS".)

Although Anywhere Health System is committed to improving its business processes, the philosophy of the Health System also stands firmly behind its people. A benefit to installing a PACS may be seen as reducing personnel. At Anywhere Health System, this is seen as a definite disadvantage. The people who provide and support the Health Care services at Anywhere Health System are just as mission critical as the process.

D. PACS Advantages

Radiology's primary mission is to create and store information for the review of others involved in patient care. A PACS system would connect directly to the SMS Radiology Information System (RIS) and exchange data throughout the enterprise. (See Appendix C for a chart outlining PACS placement within the Health System's overall HCIS.) Some advantages of installing an ultrasound "Mini-PACS" at the Medical Center to support this mission include, but are not limited to:

1. Improving Patient Care by Increasing Services;
2. Decreasing Lost or Misplaced Film;
3. Decreasing Film Waste;
4. Decreasing the Time it Would Take to Diagnose and Treat a Patient;
5. Increasing Record Accessibility Enterprise-Wide and Remotely;
6. Improving Internal Efficiency;
7. Increasing Patient Referrals;
8. Increasing Communication Throughout the Enterprise;
9. Giving the Enterprise a Competitive Edge;
10. Possibly Decreasing the Costs Required to Perform Ultrasounds.

Although a lot is stated about decreasing costs by installing a PACS system, there has not been any definitive studies in the area. This is because, until recently, the technology has not been widely accepted by the medical community and therefore, not implemented widely enough to study definitively.

E. PACS Disadvantages

It would not be wise to discuss only the advantages of PACS. There are some disadvantages and they should be outlined here before preceding onto vendor analysis. Some of the disadvantages of PACS include, but are not limited to:

1. The technology, although not entirely new, has not been widely deployed in health care institutions;
2. The financial costs of implementing PACS systems may be great;
3. PACS systems utilize large amounts of bandwidth on a system, with an average use of .3 MB per image, and can "crash" even a very strong network or HCIS;
4. Internet technologies are still not advanced enough to handle PACS traffic efficiently;
5. DICOM modalities are still shaky and any change in a system can throw them off;
6. Special high resolution monitors are necessary for reading procedures which could be costly and with high definition television on the horizon, it may be better to wait;
7. A vendor must be chosen as a partner in this endeavor because the implementation of a large PACS system can take between five and fifteen years - choosing the wrong partner can be costly in more ways than one!!!

Although there are disadvantages to PACS, it is up to the Health System or hospital to determine if the benefits outweigh the disadvantages. This analysis should be conducted against the organization's mission, vision, and strategic plan for the future.

V. RESEARCH METHODOLOGY

The research methodology consisted of five phases: (1) general research on PACS and their advantages and disadvantages; (2) general research on PACS vendors; (3) interviews and site visits of radiology departments; (4) selection of specific PACS vendors to research more in-depth based on these interviews and visits; and (5) the development of criteria that met the requirements and philosophy of Anywhere Health System.

To begin this process, extensive Internet and health care journal research was conducted to gather background information and identify vendors. A listing of over 200 world-wide PACS software vendors was obtained. This list was reduced to five vendors after conducting interviews with the head of radiology at the Medical Center and a radiologist from a "competing" health care facility. The vendors seemed to provide the PACS software solutions that would meet the requirements of the Anywhere Health System.

It was important that each PACS software vendor was asked the same questions, with the same information being collected from each one. This was done to be able to accurately compare the five PACS software vendors. To conduct this research, a "Minimum Requirements of PACS Vendors" form was compiled. (It is attached as Appendix D.) This form details the questions and the information required to ensure the recommendation of the PACS software vendor or vendors that would best meet the needs of Anywhere Health System.

The questions asked of the five PACS software vendors included: Is the operating platform WindowsNT?; Is the software compatible with SMS and is the vendor an SMS strategic partner?; Does the software utilize TCP/IP, HL7, and DICOM 3.0 standards; Does the software and or solution include image archiving?; Does the software include teleradiology features including remote physician software, Internet access, teleradiology archiving, and real-time viewing?; Does the software provide enterprise access?; Does the software manage workflow and provide "push-pull" technology?; Is the software scaleable?; What is/are the vendors' specialty(ies)?; What is the age of the company?; and What are some examples of area installations?

The information provided by the software vendors was then reviewed and compared utilizing a spreadsheet. (See Appendix E.) Any additional information required following this review was obtained from the PACS software vendors via telephone, Web pages, and company literature.

This is the preliminary phase of research and was conducted to identify vendors which could provide a "Mini-PACS" ultrasound system solution for the Medical Center's radiology department only. Utilizing this research as a base, the next phase should include site visits, vendor demonstrations, and preparing a request for proposal which could further expand the Health System's PACS implementation.

VI. PACS VENDORS SELECTED

Based upon the research conducted in the previous section, the following five PACS vendors were selected: (A listing of the vendors, corporate headquarters, and contacts is listed in Appendix F.)

1. Acuson Corporation
2. Agfa - Bayer
3. Dynamic Healthcare Technologies
4. Olicon Imaging Systems, Inc.
5. Shared Medical Systems, Inc. (SMS)

VII. RESEARCH FINDINGS

All five companies offered different services and specialized in different health care areas. Since the findings were so varied, the results were put on a spreadsheet for comparison purposes. The spreadsheet is attached in Appendix G.

VIII. ANALYSIS

The following is an analysis of the five ultrasound PACS vendors. It will be broken down by vendor and will detail some of the company's background, area installations - if available, and the pros and cons that could be identified from the information received. It will go over all of the important facets of each of the vendor's services. This analysis is intended to go in-depth into the vendors' services, as well as delving into the vendors' reputations and some of the "unmeasurable" portions of each vendor.

Each PACS software vendor provided different and varying amounts of information, so the company description for some may be detailed and for others may be very "sketchy." The analysis includes all of the material that was able to be ascertained during the designated research period.

Acuson Corporation

Acuson Corporation is a New York Stock Exchange (NYSE)-listed company based in Mountain View, California providing Aegis software for ultrasound PACS. The company was founded in 1979 and currently boasts 1,700 employees. The company had $346 million in sales in 1996. Acuson specializes in "Mini-PACS" for ultrasounds with it being its sole business - giving Acuson a strategic advantage. Acuson has partnered with Agfa - Bayer, Siemans, Kodak, and Cemax-Icon to provide the overall PACS management systems for its "Mini-PACS" software product Aegis.

Some tri-state area installations include: University of Pittsburgh Medical Center in partnership with Agfa and West Virginia University in partnership with GE Advantage PACS for enterprise-wide solutions; and Pittsburgh's Children's Hospital and AGH at the radiology department-level for "Mini-PACS" solutions. Acuson is currently negotiating with St. Clair Hospital.

1. Acuson has a large number of local installs.
2. Ultrasound "Mini-PACS" are corporate specialty and the only business focus.
3. Acuson offers real-time viewing of procedures.
4. Acuson is a larger company and has been in business for 19 years.
5. Acuson's 1996 earnings, as well as its longevity, point to corporate stability.
6. Acuson markets its own ultrasound equipment for performing procedures, as well as testing and marketing other vendor's instruments.
7. Acuson product representatives were easy to get in touch with and were very helpful in offering information and answering questions.

1. Acuson must partner with another vendor to provide a department and enterprise-wide PACS management system.

Agfa - Bayer

Agfa-Bayer is a worldwide corporation offering the Impax IMS (Image Management System) for medical imaging. Although this is a well-known name, the local product representative could not give corporate information. Agfa specializes in producing film and developing supplies. After realizing that technology and computers were replacing the market for film, Agfa made a strategic decision to add PACS management systems to its business plan.

Agfa's largest project to date is a contract with University of Pittsburgh Medical Center to install a full-blown, enterprise-wide PACS solution. Currently, this is being tested at one site. Acuson is an allied vendor and is installing the ultrasound "Mini-PACS" portion of the project. Other installs include Ohio State University, Columbus, Ohio; Riddle Memorial, Philadelphia, Pennsylvania; and Beth Israel, New York.

1. Agfa provides an enterprise-wide solution for PACS management.
2. Agfa can partner with a number of vendors.
3. Agfa seems to have a lot of larger installations.
4. Agfa can provide an entire PACS solution or integrate various vendors.
5. Agfa produces and sells its own ultrasound equipment.
6. Agfa's specialty is PACS management.
7. Agfa's local representative was easy to contact and provided a lot of information.
8. Agfa claimed to be an SMS strategic partner.

1. The operating system is not WindowsNT.

Dynamic Healthcare Technologies

Dynamic Healthcare Technologies is a Nasdaq-listed company offering the PACsPlus+ PACS software solution. The company has 300 employees, was founded in 1994, and is headquartered in Maitland, Florida. In 1996, total revenues were reported at $16.5 million. The company's specialty is Health Care Information Systems (HCIS). A listing of local installs was not available.

1. Dynamic manages information well due to its HCIS specialty.
2. Dynamic provides work flow management including automatic routing ("push" technologies) of images via HCIS which notify the person receiving the image by pop-up box on the screen and an audio "beep."
3. Dynamic's systems are Internet-based and Dynamic has demonstrated Internet experience.

1. Dynamic has only been in business for four years, thereby being relatively young.
2. Dynamic's main specialty is HCIS and not PACS. PACS seems to be an "add on."
3. Dynamic has a small number of employees, 300, which handle both HCIS and PACS. This indicates that not a lot of employees are dedicated to PACS at this point.

Olicon Imaging Systems, Inc.

Olicon Imaging Systems, Inc., offers the PACSview software product. The company was founded in 1981 and is headquartered in Aliso Viejo, California. In 1990, Olicon purchased Raytel Corporation which was the original developer of PACS. With this purchase, Olicon received a wealth of knowledge and experience in PACS systems. Olicon's specialty is "Mini-PACS". Some noteworthy installs include: Mercy Fitzgerald in Philadelphia which is a partnership with Shared Medical Systems, Inc. (SMS), Wilkes Barre Hospital, and a few sites in Ohio.

1. Olicon is an SMS strategic partner.
2. Olicon's specialty is "Mini-PACS" only.
3. Olicon offers a special feature called "Teleradiology Archiving" where the company stores it clients' current film. Upon request from a client, Olicon digitizes the film and sends it via Internet to the client's PACS system - thereby making film accessibility quicker and digitizing archived film as it is used.
4. Olicon was easy to get in touch with and its product specialist was very helpful in both explaining PACS and the company's product.
5. Olicon markets and produces ultrasound instruments.

1. Olicon is a smaller company.
2. Olicon doesn't have any installs in the local area.

Shared Medical Systems, Inc. (SMS)

Shared Medical Systems, Inc. (SMS) is headquartered in Malvern, Pennsylvania and offers Novius IMS as its PACS management solution. SMS, founded in 1969, is the second largest supplier of HCIS in the world. SMS has nearly 30 offices in the United States, employs 4800 people nationwide, and has over 2,000 customers in the U.S alone. SMS is a NYSE-listed company with over $779 billion in revenue in 1996. Anywhere Health System has selected SMS to be its new HCIS vendor with Phase I of the installation to be completed by the end of 1998. Currently, SMS is installing HCIS systems at AHERF/AGH. There is no available information regarding its Novius product and the number of installs locally, if any.

1. SMS is Anywhere Health System's' HCIS vendor/partner.
2. SMS and Anywhere Health System have a good working relationship and have developed a high comfort level.
3. SMS has had 29 years experience in HCIS.
4. SMS' world headquarters is in Pennsylvania.
5. SMS does partner with other vendors for "niche" areas. For example, SoftMed for medical records applications.

1. SMS hasn't had a lot of experience in PACS management systems.
2. SMS Novius only manages PACS information and doesn't do department level "Mini-PACS."
3. SMS specializes in HCIS.
4. SMS may not have any local installs.

IX. AVERAGE COSTS

At this point in the research, the specific costs per vendor were difficult to ascertain. This recommendation will only provide the average cost of the software purchase for an ultrasound "Mini-PACS" system for the Medical Center's Radiology Department. In assessing this cost, a number of items were held constant. These include:

1. SMS HCIS and Radiology Information System (RIS) installed;
2. Technology infrastructure and network installed;
3. PC's and appropriate monitors purchased and installed;
4. Instruments to conduct ultrasound are DICOM 3.0 compatible or can be converted to DICOM 3.0 using a converter.

The package from the vendor will include a 10-user site license, 10 software modules for individual PC's, a file server, RAID system, and storage for at least 80 gigabytes of images for duplicate storage. This would be the basis of an ultrasound "Mini-PACS" system with an overall PACS management system costing incrementally more. The range of costs for an ultrasound "Mini-PACS" is:

X. RECOMMENDATION

After thorough research and analysis of the five ultrasound PACS software vendors, it is deemed appropriate to provide a dual recommendation to Anywhere Health System. It is recommended that the Health System begin with a "Mini-PACS" strategy by further researching Acuson Corporation. Acuson's main focus is ultrasound "Mini-PACS." Through all of the research, Acuson, when partnered with a PACS management vendor, will provide both the immediate needs of the ultrasound department and the long-term needs of the enterprise.

The second part of the recommendation focuses on an enterprise-wide solution. Since Acuson only provides "Mini-PACS" solutions for ultrasounds, it is recommended that the Health System further research either an Acuson/Agfa partnership or an Acuson/Olicon/SMS partnership. Agfa and Olicon are strategic partners of SMS and even though SMS is the Health System's HCIS partner, it is not always the case that SMS is strong in these auxiliary health care solutions.

XI. CONCLUSION

In conclusion, a "Mini-PACS" system for the ultrasound department and an overall PACS management solution for the enterprise, can bring both advantages and disadvantages to the organization. Proper planning, phased in implementation, and selecting the right vendor to team with Anywhere Health System as a long-term partner, are essential to the success of an enterprise-wide PACS system.

Since it is the goal of the Anywhere Health System to provide quality and cost-efficient health care for all, it is recommended that this research be expanded. Vendor demonstrations, site visits, and preparation of requests for proposals should be the next phase of this study. It is also recommended that an outside consultant, who has experience in "Mini-PACS" and PACS management solutions, be hired to help the administration, radiology staff, medical staff, IS staff, and other appropriate personnel through this process. With proper planning and cooperation, an enterprise PACS system could be a tremendous strategic benefit for continuing to increase the high quality of patient care that is the foundation of the Anywhere Health System.

Appendix B

Appendix C

Appendix D. - MINIMUM REQUIREMENTS OF PACS VENDORS

1. Platform - Windows NT
2. Compatibility

1. SMS
2. TCP/IP
3. DICOM 3.0
4. HL7

3. SMS Strategic Partner
4. Imaging Archiving (Storage)
5. Teleradiology Features

1. Remote Physician Software
2. Internet Capabilities
3. Teleradiology Archiving Program
4. Real-Time Viewing

6. Enterprise Access
7. Year of Experience

1. # of Installs (Tri-State Area)
2. Size of Facilities

8. Graphic User Interface
9. Integrate Use With SMS Radiology System
10. Name of Software
11. Color and B/W
12. Push-Pull Technologies
13. Workflow Management
14. Corporate Specialty
15. Product and/or Market Ultrasound Modalities

Appendix E. PACS VENDOR COMPARISON SPREADSHEET (BLANK)

Appendix F. - PACS VENDOR LISTING

Appendix G -- PACS VENDOR COMPARISON SPREADSHEET

RESEARCH SOURCES

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