PACS Facts: Constructed vs. Deconstructed

It can be safely said that the healthcare services industry is in a state of flux like never before. Reform initiatives driving the mandate to create interoperability are not in any way exempting medical imaging. As such, we are experiencing a rapidly evolving technology shift that is creating a great deal of confusion in the market. In part, this trend is fueled by the shifting sands of healthcare delivery in that nobody can clearly articulate what healthcare is going to look like in the next decade. So, in response we seem to be hedging our bet towards systems’ flexibility when we should be focusing our attention on systems’ standards, or both.

Today we live in a new world where selecting imaging technology in component parts (deconstruc­ted) has gained some traction and begun to chip away market share from the more traditionally packaged sys­tems. The determination to go either way is one that requi­res a good deal of thought and a better than average understanding of imaging technology and workflow.

What does deconstruction actually mean?

de·con·struct (dë'ken-strûkt')
tr.v. de·∙con∙·struct·∙ed,de∙·con∙·struct·∙ing, de∙·con·∙structs

• To break down into components; dismantle

It is imperative to define what exactly deconstruction means in order to assist the reader in determining the contemporary market interpretation. It is pos­sible today to completely dismantle a PACS into sepa­rate and independent components only to glue them together again in order to match the functionality of a constructed “standards-based” PACS. One might ask why anyone would go to the time and cost of perfor­ming such a task unless there is strong data supporting significantly improved functionality, performance and sufficient and coordinated support, all at an equal or lower cost structure. Deconstruction is so new to the industry and so few organizations have implemented a fully deconstructed environment that it would be reck­less to say with any validity that deconstruction proves to boast anything better and cheaper.

So much has been written about deconstructing the PACS environment to provide flexibility. Somehow by tying deconstruction to phrases like “best of breed” or “plug and play”, the unknowing consumer reads “simplicity”. The idea of the “plug and play” flexibi­lity is a nice sound bite, but in reality not as easy as it sounds.

New companies have emerged in this space as well as steady growth among existing PACS vendors that have always been focused on IHE/DICOM standards. This market shift has created a pull from the once full sales funnels of the legacy PACS vendors. What we find now is that the once proprietary PACS vendors have begun course corrections by either driving their software towards open standards or by acquiring the newer vendors to augment their legacy systems. In consideration of the constant mergers and acquisitions occurring in the imaging vendor space, we can make an argument that the once deconstructed is more and more becoming the reconstructed. As this trend continues, the industry is left with the following choices each of which must be understood in the context of an organization imaging goals:

• Fully constructed Legacy (proprietary) PACS (single vendor solution)
• Fully constructed (standards based) PACS (single vendor solution)
• Partially deconstructed PACS (PACS database with a VNA)
• Fully deconstructed PACS (multiple vendor integra­ted software stack)

Considerations for a Multi-Vendor Approach

One of the trending marketing sound bites being used in the new paradigm of deconstructed PACS is “Plug and Play.” This term denotes the ease of lay­ering together and integrating a software stack where the effort can be seemingly done from a one page instruction manual. This is in fact not the case. With that in mind, each organization must determine their individual path based on understanding the pros and cons of a deconstructed PACS environment and taking into consideration their individually defined goals and capabilities.

Here are just a few of the common issues that must be addressed as part of a partial or full deconstruction of PACS:

• Poor organizational governance pertaining to an enterprise imaging strategy that will not only address radiology in a deconstructed manner, but can ultimately provide the ecosystem for other image producing service lines.
• Underestimating the complexity of fully deconstruc­ted PACS implementation.
• Synchronization of the image data as it relates to Image Object Change Management (IOCM) between the VNA and the application layer of the systems.
• In a PACS to VNA (partial deconstruction), it is imperative to understand the PACS DICOM SOP classes as the functionality and synchrony may call for a system to be both a Storage Class User (SCU) and Storage Class Provider (SCP) versus one or the other.
• The flow across systems related to image presenta­tion states. Are the presentation states, (annotations for instance), stored in the database or the archive of the systems you plan on stacking as one. Integrated Service Level Agreements (ISLA). When you have a deconstructed PACS, the vendors in the software stack individually manage the service levels expected from their system. When you bring the deconstructed systems together, it is critical to define the service level agreements for each indi­vidually, but more importantly, the handoff points between them. If a unified system goes down, the vendor team/s works collaboratively to find and fix the break. In a deconstructed system, it is up to the customer to articulate the expectation of service and the hierarchy and escalation path that all vendors will agree to be held accountable. This process can be a bit daunting because nobody wants to be holding the ball when things are going badly.

Best of Breed vs. Best of Suite – Finding the Fit

The industry vendors providing a consolidated solution have over the past few years moved to develop their sys­tems in a less proprietary way by embracing industry standards. Some PACS vendors have always adhered to standards and are likewise gaining market share, while some continue to lag behind.

The choice to go with a fully or partially deconstructed “Best of Breed” or a “Best of Suite” option where the system is built upon industry stan­dards is an important decision for any organization. It is imperative to know what the organization is trying to accomplish as one size does not fit all.

The best fit may be the constructed or partially deconstructed option where workflow functionality of a system is driven by a single application layer, while creating flexibility in the archive space with the selec­tion of a VNA. Most contemporary PACS vendors have realized this trend and offer a native VNA option, or show willingness to work with a third party VNA as part of the overall solution. Rest assured that even the addition of a third party VNA to support a more enter­prising archival solution is not without its challenges.

The “Best of Suite” option where a vendor provides their own native VNA simplifies both the integration and the service and support component as you have in industry terms “One throat to choke”. Be cautious in this selection as the term VNA is used as an ear worm to get the attention of the buyer. Not all VNA’s boast the same functionality, so know what you are expecting the VNA to do for you short and long term.

On the flip side is the option of a fully deconstruc­ted “Best of Breed” option where an organization has determined that selecting individual systems to stack together is the better choice. It is not prudent to go the path of deconstruction because it is “trending”. This decision must be made on the heels of a well-defined and thoughtful process taking into consideration the goals, objectives and organizational capabilities devoid of the market noise where deconstruction is touted as the messiah solution.

To learn more on this topic, attend the Sectra-sponsored symposium at the 2016 AHRA conference on August 1 from 5:15-6:15pm.

This article is excerpted from an article that appears on Sectra.com.