Thursday, October 22, 2015

I think she's dead ... no I'm not ... Is PACS pining for the fiords?

Summary: The death of PACS, and its deconstruction, have been greatly exaggerated. Not just recently, but 12 years ago.

Long Version:

Mixing quotes from different Monty Python sketches (Death of Mary Queen of Scots, Pet Shop) is probably almost as bad as mixing metaphors, but as I grow older it is more effort to separate these early associations.

These lines came to mind when I was unfortunately reminded of one the most annoying articles published in the last few years, "PACS in 2018: An Autopsy", which is in essence an unapologetic unsubstantiated promotion of the VNA concept.

Quite apart from the fact that nobody can agree on WTF a VNA actually is (despite my own lame attempt at a retrospective Wikipedia definition), this paper is a weird collage of observable technological trends in standards and products, marketing repackaging of existing technology with new labels, and fanciful desiderata that lack real market drivers or evidence of efficacy (or the regulatory (mis-)incentives that sometimes serve in lieu).

That's fine though, since it is reasonable to discuss alternative architectures and consider their pros and cons. But wait, surprise, there is actually very little if any substance there? No discussion of the relative merits or drivers for change? Is this just a fluff piece, the sort of garbage that one might see in a vendor's press release or in one of those junk mail magazines that clutter one's physical mailbox? All hype and no substance? What is it doing in a supposedly peer-reviewed scientific journal like JDI?

OK, so its cute, and its provocative, and let's give the paper the benefit of the doubt and categorize it as editorial rather than scientific, which allows for some latitude.

And no doubt, somewhat like Keeping Up with the Kardashians and its ilk, since folks seem to be obsessed with train wrecks, it is probably destined to become the "most popular JDI article of all time".

And let's be more even generous and forgive the drawing of pretty boxes that smells like "Marchitecture". Or, that it would be hard for a marketing executive to draft a more buzzword compliant brochure. And perhaps as an itemized list of contemporary buzzwords, it has some utility.

My primary issue is with the title, specifically the mention of "autopsy".

Worse, the author's follow up at the SIIM 2015 meeting in his opening address entitled "The Next Imaging Evolution: A World Without PACS (As We Know It)" perpetuated this theme of impending doom for PACS, a theme that dominated the meeting.

Indeed, though the SIIM 2015 meeting was, overall, very enjoyable and relatively informative, albeit repetitive, the main message I returned home with was the existence of a pervasive sense of desperation among the attendees, many of whom seem to fear not just commoditization (Paul Chang's theme in past years) but perhaps even total irrelevance in the face of the emerging "threat" that is enterprise image management. I.e., PACS administrators and radiologists are doomed to become redundant. Or at least they are if they don't they buy products with different labels, or re-implement the same solutions with different technology.

When did SIIM get hijacked by fear-mongers and doubters? We should be demanding more rigidly defined areas of doubt and uncertainty ... wait, no, wrong radio show.

OK, I get that many sites are faced with the challenge of expanding imaging beyond radiology and cardiology, and indeed many folks like the VA have been doing that for literally decades. And I get that Meaningful Use consumes all available resources. And that leveraging commodity technology potentially lowers barriers to entry. And that mobile devices need to be integrated. And that radiology will no longer be a significant revenue stream as it becomes a cost rather than profit center (oops, who said that). But surely the message that change may be coming can be spun positively, as an opportunity rather than a threat, as incremental improvement rather than revolution. Otherwise uninformed decision makers as well as uneducated worker bees who respond to hyperbole rather than substance, or who are seeking excuses, may be unduly influenced in undesirable or unpredictable ways.

More capable commentators than I have criticized this trend of hyping the supposed forthcoming "death of PACS", ranging from Mike Cannavo to Herman O's review of SIIM 2015 and the equally annoying deconstruction mythology.

Call me a Luddite, but these sorts of predictions of PACS demise are not new; indeed, I just came across an old RSNA 2003 abstract by Nogah Haramati entitled "Web-based Viewers as Image Distribution Solutions: Is PACS Already a Dead Concept?". Actually, encountering that abstract was what prompted me to write this diatribe, and triggered the festering irritation to surface. It is interesting to consider the current state of the art in terms of web viewing and what is currently labelled as "PACS" in light of that paper, considering it was written and presented 12 years ago. Unfortunately I don't have the slides, just the abstract, but I will let you know if/when I do get hold of them.

One has to wonder to what extent recent obsession with this morbid terminology represents irresponsible fear mongering, detachment from whatever is going on in the "real world" (something I am often accused of), self-serving promotion of a new industry segment, extraordinary popular delusions and the madness of crowds, or just a desire to emulate the breathless sky-is-falling reporting style that seems to have made the transition from cable news even to documentary narrative (judging by the "Yellowstone fauna are doomed" program we watched at home on Animal Planet the other night). Where is David Attenborough when you need him? Oh wait, I think he's dead. No he's not!


plus c'est la même chose


Grahame Grieve said...

How can VNA - a PACS service - lead to the 'death of PACS'? Maybe it might - or has - moved the deck chairs around...

Martin Peacock said...

Grahame.. a VNA is not a 'PACS service'. The value proposition for VNA is not that that it is 'backup PACS', but that it serves all disciplines. That Radiology takes ownership of that value proposition holds it back.

Grahame Grieve said...

It's still PACS, using DICOM, no?

Razmerita said...

So refreshing to read... Coming from the trenches of programming in a small company, creating solutions for some pretty darn complicated problems that our customers had, I have always been astonished about how the Medical Imaging market appears to take head on the marketing cool aid.
VNA, tag morphing, deconstructed PACS...
As they say in my language (trying to adapt to English), "Same Mary, different story"...
Yet billions are spent on these new stories, hoping to find a radically different Mary.
Many of the VNA vendors are completely unprepared for the challenges out there.
But somehow, they manage to sell it, big time.
Seems to me sometimes that the rift between sales and implementation teams is all too big.
I'd put the sales team install the software at the sites they sold it and act three months as tier one support.
Maybe that will change something.

Anonymous said...

I have probably worked in this industry as long as you have and have seen the rise and fall of quite a few hyped concepts. Over the years many times I would like to have screamed “come on you gotta be joking”. As I work for a vendor it is difficult to be as straight-from-the-shoulder as you are though without being blamed for pushing your own thing or piss potential customers off. Thank you Dave for your refreshing words. As you, when I read the "PACS in 2018: An Autopsy" I was amazed that a so called scientific journal could publish such an amount of non-scientific subjective opinions. Where's the science and what problem did the author really address? Some years ago I watched the VNA-trend start and take off in the US. At first I couldn’t believe highly educated people in our industry would buy into it. But they did, much thanks to great marketing work by team Acuo and Grey. Hats off to them. Before that InsightOne and others had tried to push for similar concepts. They didn’t market it as well though “DICOM Archive” – little bit like “raw fish on rice”. It was never very well thought through and didn't work in practice, technology for its own sake seldom do. We had to hook up to these archives sometimes and we always ended up having unhappy customers. Same now with the VNAs - sure we can get it to work (sort of) but does it work well, does it provide any additional clinical benefits and is it cost effective? It now seems like the discussion around VNA, at least in the US, has become a bit more realistic. Good. Consolidation is not a bad thing, on the contrary, but it has to be done with care not just for the sake of it. Unfortunately the emperor with his new clothes has crossed the Atlantic and there are still many out here in Europe that haven’t realized he's naked. You mention that many sites are faced with the challenge of expanding imaging beyond radiology and cardiology. That is true but without diminishing any other –ologies, radiology sits right in the middle and patients actually die on the operating table if the right diagnosis is delayed. The outcome for a stroke patient is directly dependent on the time it takes to put in the right treatment – here radiology plays an essential part. Instead of trying to do a trade they don’t master, i.e. engineering and SW development, I think radiologists need to go back to their roots, step up, take back control of their area of expertise and realize that the work they provide is what we IT folks would label "mission critical". They have to take a stance when the IT manager wants a new consolidated system where he can archive all the hospitals e-mails, documents and images of all kind. Call it VNA, call it PACS, whatever as long as it provides high-availability, high performance and tools/user experience that delivers the right information in a way that helps the clinicians to take the correct decision.

Anonymous said...

I had to laugh the first time I heard the term VNA.. I was like, what da...
At first I thought maybe I had missed too many RSNAs, but no...
Vendor Neutral Archive. I was around before we had DICOM and was sending nuclear medicine interfiles by xmodem.
Then I was thinking, "wow wouldn't it be nice if there was a vendor neutral was of transferring data?!"
Well along came DICOM and it's whole raison d'etre was to be a vendor neutral method of representing data and transferring it.
I heard they called it a PACS!
So really.., to me, this is just a way of selling a car to people who already own one.
New and improved!

David Clunie said...

Here are the slides of the 2003 RSNA presentation that Nogah shared with me, by the way: ... David