Wednesday, July 3, 2013

My PACS has fallen down, and I can't get it upgraded

Summary: Many people have PACS that are not the latest version, and hence cannot use new features; new features are not added to old PACS versions.

Long Version.

In my travels preparing for the Breast Tomo forum that Rita Zuley and I hosted at SIIM (Digital Breast Tomosynthesis & the Informatics Infra-Structure: How DBT Will Kill Your PACS/VNA), I was surprised to discover that the key question was not just "Does your PACS vendor support the DICOM Breast Tomosynthesis SOP Class?", as one might have expected, or even "Do you have the bandwidth/storage/memory/display hardware to handle the large data volume?".

Rather, it was "Do you even have the current version of your PACS?"

This rather surprised me initially, but made sense when I thought of some of the barriers to upgrading, like the need for a fork-lift in some cases (or more seriously, the cost of the necessary server-side hardware). The site that initially exposed me to this dilemma has a problem that may be slightly unusual, extensive customization of additional services added on to a much older version of the PACS, which they cannot do with out.

To try to get a better handle on how widespread this problem was, I did a little survey on a couple of forums, like pacsadmin and comp.protocols.dicom. The response wasn't very great, and in retrospect I should probably not have chosen returning an Acrobat form by email as the survey mechanism, but the online survey tools I checked out first had some limitations too.

Anyhow, since I promised to share the survey results, and did at SIIM, here goes. I ultimately got 23 responses.

Systems were from
  • different countries (18 US, 2 Canada, 2 Europe, 1 Asia),
  • various settings (13 metropolitan, 2 rural, 8 mixed),
  • various scales (5 multi-enterprise, 10 enterprise, 4 multi-departmental, 3 departmental and 1 sub-departmental) and
  • multiple vendors (2 Agfa, 2 DR, 3 Fuji, 6 GE, 2 InteleRad, 2 McKesson, 2 Merge, 1 Philips, 2 Sectra, 1 Siemens).
Only 5 (22%) reported that they had the current (i.e., latest) version of their PACS in use, but 14 (61%) did say that they planned to deploy the current version within 3 months to 1 year (2 in 3 months, 4 more in 6 months, 8 more within 1 year).

The structured capture of reasons for not having the latest included:
  • cost (5)
  • resources for deployment (1)
  • resources for validation (4)
  • Meaningul Use distraction (3)
  • custom RIS interface (1)
  • custom reporting/speech interface (0) 
  • custom data mining interface (0)
  • custom other interface (0)
  • awaiting vendor change (2)
  • awaiting VNA (0)
  • other reasons (13)
Some of the other reasons for delaying that were described in text comments (and which overlapped with some of the structured questions) included the need for validation and user feedback, new features not being "significant enough" (so waiting for next version), server hardware replacement being needed, completing an interim version that needs to be installed first, awaiting a possible vendor change, or the practice of waiting for a while until a release has been generally available (presumably to see what problems it has).

The remainder said they were not going to deploy the current version either for more than 2 years (2 sites) or ever (2 sites). Reasons cited were that the PACS was externally managed & the supplier refuses, or it already "works" so no need for it.

In terms of what they were missing out on by not upgrading:
  • media export (2), import (2)
  • key images (1)
  • annotations (3)
  • 3D (4), fusion (4)
  • DCE (4), breast DCE (3)
  • IHE Mammo Profile (3)
  • Breast tomo (3)
  • JPEG 2000 (4)
  • WADO (2), XDS-I.b (2)
Other stuff mentioned as missing was remote caching, life cycle management and auto-deletion, increased exam capacity, reasonable performance (!), and some new SOP Classes (unspecified).

Note that the survey did not include the initial site that prompted my interest, which has too much customized stuff that depends on an obsolete version, and were certainly missing out on Mammo tomo.

This was not a very scientific survey, and the respondents may well have been biased by the context in which the questions were asked, and selectively been more likely to respond if they had an older PACS version perhaps.

The information that Julian Marshall from Hologic presented at the same forum also suggested that there was poor uptake of new SOP Classes (and sufficient hardware performance) to cope with breast tomo.

Hopefully SIIM will post the slides and transcript on their web site soon, but in the interim, here are my slides from the forum, and if you need any images to kill your lame old PACS with, try these tomo ones. If you have any of your own to contribute, let me know and I will provide a place to share them.


PS. Interestingly nobody mentioned that a reason was that their PACS vendor had failed and gone out of business, which I guess is a good thing :) Or even mentioned that they had been acquired by another vendor, which is interesting too. Too small a sample, methinks.

PPS. Here is a link to the survey form used, in case you are interested, or want to complete it yourself; I will continue collating results.

Digital Breast Tomosynthesis & the Informatics Infra-Structure
How Digital Breast Tomosynthesis Kills Your PACS/VNA - See more at:


josean said...

Regarding your last comment "... a reason was that their PACS vendor had failed and gone out of business ..." that happened to our Hospital PACS in 2005. The dicom server stopped working and when we tried to contact the provider, we discovered that the company did not exist anymore.
We, the IT team, quickly had to deploy a dcm4chee pacs in order to recover all the studies stored into the old system.

David Clunie said...

The recording of the SIIM forum is at ""