Thursday, February 19, 2015

The road ahead for PACS Administrators in 2015

Josh Baker, Director of Operations for ThinAir Data Corporation
2015 is poised to be a pivotal year as the move from PACS systems to enterprise imaging picks up steam and begins to transform what it means to be a PACS administrator. Josh Baker, Director of Operations for ThinAir Data Corporation has seen multiple transformations in information and imaging technology over his 17-year career. In addition to managing such transformations, he has co-written and edited with Herman Oosterwijk multiple course books and study guides for OTech, Inc., as well as PARCA certification tests. PARCA eNews asked him to share his perspectives on what PACS administrators might expect in the coming year.

Q. What initiatives do you think are most important for a PACS administrator to focus on in 2015?

We tend to think of PACS first in technical terms, as it is clearly a technical field, but in 2015 I think it is critical for a PACS administrators, regardless of their level of experience, to be keenly aware that the business dynamics of PACS have fundamentally changed - and to identify how that impacts their organizations.
Most PACS admins have recognized that Enterprise PACS is an unstoppable trend, which will soon be the universal norm for hospitals.   Resisting this drift in ownership is akin to being a film holdout.  Those of us old enough can remember radiologists who outright refused to give up their light boxes and cassette tapes and how they were passed up.  Non-hospital PACS administrators will need to prepare for an additional level of complexity and bureaucracy when heading up integration projects with enterprise health systems.  They also need to be aware of patient care solutions, which are both marketable as patient friendly, as well as being referring physician-friendly. 

More patients than ever are reading their own reports due to the widespread deployment of EMR/EHR web portals.  New advances such as multimedia-structured reports require additional overhead but may entice more referrals to your imaging center.  However, this kind of detailed reporting is contrary to studies indicating that patients desire short and easy-to-read reports.  Time will likely provide a balanced solution for addressing both of these needs, but for now the jury is out. 
It is important to know that your role as PACS administrator in this new age will continue to be fluid and require vigilance as new solutions emerge. With incorporation into the enterprise, PACS as a commodity has changed.  There has been an effort, as we have seen with VNAs, to dismantle the radiology exclusivity of PACS.  

One of the effects of this effort is how dramatically radiology specific trade shows, such as RSNA, have changed.  Foot traffic to vendor booths by individuals responsible for purchasing PACS products has greatly dissipated, at least domestically.  There is a heavier international and student presence now.  RSNA reported a 2 percent decline in vendor attendance last year.  I would say that consistently, year-over-year, individual exhibitor footprints have shrunk significantly – smaller booths, fewer members of the marketing army out in suits.
The PACS deal itself has changed.  The widespread use of online meetings and collaboration has eliminated the necessity of showcasing your wares just once or twice a year.  Vendors are conducting online demos and responding to standardized (somewhat) RFPs all year long now.  Additionally, the enterprise is not going to be as inclined to swap out full PACS installations.  I think going forward we will see an emphasis placed on augmenting existing PACS environments with new features versus blowing it out and completely replacing.   The policies of fiduciary responsibility in the enterprise won’t allow it.  The managerial overhead alone required to replace a PACS environment in the enterprise is enormous. Consider all the training, policies and procedures, integration that gets tossed out when you replace a PACS.  A successful PACS administrator needs to be cognizant of the social, political, operational, and business challenges to emerge from enterprise imaging, not just the technical challenges (which are also substantial).

Q. Can you elaborate on what social changes you expect PACS administrators to encounter?

Up until now, the growth of high-ticket technological advancements in radiology was sustained by the ability to improve throughput, and in turn, profitability.  With continually decreasing reimbursement rates, this became a necessity if radiologists were to ever see a return on these investments.   Now that PACS is shifting to the enterprise, it is subject to the mission of the hospital system, which is likely patient-centered imaging with an emphasis on value – in-line with governmental directives. 
“Too many clicks!” will no longer be a cry for not being able to read a large enough slice of the pie; it will be related to delaying patient care.  So socially, the lens through which your interactions take place will need to shift from primarily being profitability-based to also incorporating elements of value-based patient care.   You need to have a balance, because the best patient care is keeping the lights on.

Additionally, it is important that PACS administrators step-up their C-Level interpersonal skills.  Initially, during this shift to enterprise imaging, there will likely not always be a buffering rung in the ladder between you and C-Level management.   Let’s face it, technical personnel do not have the greatest track record when it comes to face-to-face communication– a generalization, yes, but an accurate one in my experience.   That isn’t to say these skills can’t be improved with some effort. 
PACS administrators may find themselves out of their element when dealing with upper managers whose style of interaction is very different than what they are accustomed to.  Some things to keep in mind are that C-Level managers are interested in high-level concepts and don’t want all the technical details.   Use your interactions wisely, boil down the core of what you want to communicate ahead of time and net it out.  State your conclusion outright and then work backwards to substantiate your position with short bits of supporting reasoning.  Use easy to understand analogies and metaphors.   These managers want to know from you (the expert on their PACS environment) what is needed, why it is needed, the costs associated, the return on any investment, and most importantly, how does it specifically relate to enterprise objectives. 
Having worked with radiologists, you are already accustomed to strong personalities and communication on the listening-ear’s terms. Expect that what you have prepared to communicate, in its carefully rehearsed form, will likely be interrupted and obliterated.  Know your key points so you can return to them easily, remove the emotion, and don't get take it personally.  Interruptions indicate interest in what you are conveying.  This is the style.  Expect that you will be pressed with challenging questions. Don’t feel the need to rush your answers and blurt them out immediately. If you need a moment to construct the most effective response, take it.  A higher quality, easier to understand, answer is always worth the pause.

If a question posed to you contains multiple components, or is ambiguous, repeat it back as you understand it and ask for confirmation of your understanding.  It is okay for you to state that you do not have an answer, and indicate that you will go and get the answer, and then follow up.  This demonstrates professionalism and maturity.  Know your role in the act of communicating with C-Level management – to provide concise information you possess in simple-to-understand terms.  

Q. What other technical challenges on the horizon not related to enterprise imaging do you feel PACS administrators should be prepared for?

The combination of a shift in radiology focus to patient care, and deploying feature upgrade solutions instead of complete system replacement will result in new workflow.  For example, CT dose tracking has been mandatory in California since mid-2012.  While only California, Texas and Connecticut have enacted dose reporting requirements, the Joint Commission has added radiation dose documentation to its 2015 standards.  CT manufacturers are, in some cases, incorporating dose recording directly into the modality.  I believe this is what we can reasonably expect to see in the way of future patient care initiative deployments.  Managing the data collected, and incorporating it into your existing workflow will require careful planning.

Also related to patient care initiatives, but not restricted to the hospital enterprise, are the multi-year studies being conducted on the effectiveness of 3-D breast tomosynthesis.  Initial speculation suggests that 90 percent of women who receive this diagnostic study vs. traditional mammogram would benefit.  Those are compelling numbers if they turn out to be even remotely accurate.   The elephant in the room for PACS administrators is that the average image size for breast tomosynthesis is 0.5 GB. It is not unreasonable to expect that Mammography Quality Standards Act (MQSA) would ultimately endorse this higher quality scan (if the studies pan out) and at the same time permit compression to be used on non-prior studies, as that would potentially decrease the overall quality of patient care.  Consequently, I would recommend always keeping in mind the need to accommodate big datasets in your planning.  A lot can happen, technology wise, between now and when this may become mainstream, so keep up on your reading.   For imaging centers, breast tomosynthesis may become an effective tool in the marketing war chest.  We’ll see…

The governmental role in pushing improved patient care may also prove to be an effective catalyst for fast tracking digital pathology adoption beyond the research and educational arenas.  More data, more transactions, more interoperability, more complexity, and more work for you as a PACS administrator.  Again, keep up on your reading!

One more tenant I stress is: just because you CAN do something, doesn’t mean you SHOULD.  Putting it “in the cloud” because the Jones’ did, or “virtualization” for the sake of virtualization, is not indicative of good PACS administration.  Stay objective, and don’t get caught up in the latest buzzwords or shiny objects.  Let technologies mature a bit before adopting unless you have an exorbitant amount of testing resources at your disposal.

Q. Do you foresee any long-term, negative side effects to radiology development due to enterprise imaging?

It has been a privilege to have worked in radiology over a span of time where I have witnessed firsthand numerous advances in technology and workflow.   It doesn’t seem that long ago that I was feeding magnetic tapes into a mysterious vacuum.  There are definite milestones, such as the migration from film to digital, but as a whole, I would say it has never been stagnant in nature.  This move to enterprise imaging is definitely a milestone, but by no means will it stifle radiological imaging advancements.  Imaging informatics is an elegant ecosystem that thrives on change, and self corrects given the opportunity.   Look at how FHIR has blossomed to bridge the deficiencies between HL7 V2.x and 3.0.  Elegant.  Self-correcting.   Mandates to improve existing architecture instead of throwing it out will provoke new and exciting middleware solutions.  I am excited and optimistic about the future of radiological imaging.


  1. Forget about image size for breast Tomosynthesis how about Pathology PACS! -Dan Hudson PACS Admin Mass General Hospital

    1. "Hi Dan, yes you are correct in recommending that Pathology PACS should be on everyone's radar. As stated in the interview, the governmental focus on improved patient care may likely drive expansion of digital pathology from research and education into mainstream adoption. Cheers!"