Riding on PACS Coattails

Ms. PACS: You have probably noticed how PACS is the vehicle that pushes the rest of the software to the end-users. The goal of so many medical applications is to get integrated into a PACS - and then you’re golden.

Take CAD for example, it has been trying for years to become a 'must have' in PACS, but that’s only happened in Mammography PACS – probably because mammography is the one field it has proven truly valuable – despite the debates and backs and forths printed in the NEJM last July. “In response to the NEJM publication, the American College of Radiology (ACR) stated that the decreased accuracy of mammography when using CAD was due to increased false positives, not to fewer cancers being detected. The study was designed in such a way that it was impossible to determine how many cancers would have been missed without the use of CAD, according to ACR.”

On that note, CAD keeps getting a bad wrap – and probably for good reason – apparently, it scored poor marks and fell through the cracks of Medicare.

Another one is advanced visualization. Advanced Vis has become such an integral part of PACS that it’s not a question of if you’re using 3D software, but how you’re using it. 3D images are used in an increasing number of clinical applications and across a widening array of care settings. The PACS vendors recognized this several years ago, but got caught up securing orthopedics and mammography. Finally, by RSNA 2008, vendors showed off their in-house efforts with at least built-in basic 3D functionality (like MIP, MPR) in their PACS. Others took the OEM route and licensed the 3D technology, repackaged it, and turned around to sell it to their customers embedded in their PACS as if it were their own 3D software. The moral of the story is, 3D access has been driven via PACS.

There have been strides also with Speech Recognition (SR) in RIS/PACS. And SR is now stretching the chain of command by driving other applications like critical results, peer review, medical reference programs and data mining applications.

Next, have you heard – if you use your PACS in a ‘meaninful way,’ ie, transferring medical images and data through an EHR, and if your PACS merges with the EHR highway, then it qualifies for those BIG new incentive dollars. Just ask the guys at Certification Commission for Healthcare Information Technology (CCHIT) – they are the official EHR certifiers. Dr. Mark Leavitt told me in an interview: “If PACS is a departmental system that is separate from the core EHR, then it wouldn’t qualify for the incentive, but if it is defined as a module as part of an EHR, then it would qualify.” So, while all of the apps board the “all-on-PACS” bus, now it’s PACS’ turn to ride the coat tails of EHRs and skim a few billions from the economic stimulus package. Just make sure that when you’re using your PACS you do so in a ‘meaninful way.’

At that rate, and now that we’re feeling optimistic, there may come a day when all end-users get built into PACS their own wise-cracking, all-knowing PACSman. And you get your choice: with or without the beard.

PACSman: Getting integrated into PACS might be the first step of goldenness, but I can submit a list of at least a dozen vendors who thought their companies were golden when their products were finally included in a vendor’s PACS. Unfortunately their golden egg turned out to be 10 carat gold-plated, if not spray painted, and in several cases it cost them the company. There is something to be said about putting all their eggs in one basket…

I’ve always been a strong proponent of mammo CAD. Unfortunately CMS (the Centers for Medicare and Medicaid Services) did not agree with my sentiments and has proposed CAD reimbursement cuts of 50% by 2010. Third party payers are also denying breast MRI CAD payments as well. So has the golden goose laid an egg? Probably. Conflicting studies on the value of mammo CAD probably helped kill this one and with it probably more than a few patients as well. But hey, it’s medicine, and that’s why we call it a practice…

Advanced visualization (AV) is great, but how many AV packages do we really need in this market? And how many bells and whistles? Most importantly, with so many good third party packages out there why do vendors feel they need to reinvent the wheel by providing their own packages instead of just integrating a proven solution? True, a few of the smarter vendors just resold other’s solutions, but too many seem to have reinvented the wheel. 3D existed way before PACS as a standalone solution - at least 20 years before - so I would hesitate to say that 3D was driven by PACS. Instead increased utilization of 3D was driven by PACS mainly because the cost to implement 3D in a PACS is about 25-30% as much as a standalone 3D unit would cost.

Speech recognition (SR) has its supporters and detractors. I stand with my good friend the Dalai in being a SR detractor and find the SR can do nothing better than a well designed RIS and transcriber can. In fact, the latter can do it better faster and more accurately than SR can, but let’s not go there. Let’s also not even begin to dissect the world’s most abysmal contract of all time offered by a certain leading SR company whose contract verbiage differs much more than just subtly in its meaning, opinion or attitude than most contracts.

As for using my PACS in a “meaningful way” as part of an EHR- one has to ask who are these bozos defining these rules, and what planet have they been on the past decade or more? There are at least twenty times as many PACS in place than EMR’s, EHR’s, or anything else combined yet now all of a sudden the EHR is driving the bus and if PACS isn’t on board then it doesn’t get the big bucks. CCHIT is the right acronym here because these guys are full of it….and don’t seem to have a clue on the role PACS plays either.

Optimistic? When the times call for it. Realistic? Always. I doubt Ms PACS will ever grow a beard unless she has some overnight hormonal imbalance (and I’m not talking PMS either) and her Irish background may or may not require her to bleach her mustache like many of my great aunts had. I swear, some of them put the men to shame- along with those who had one hair that grew out of this dangling pimple on their face as well (no names please). When I reflect back I wonder why I didn’t use the quote from Uncle Buck- “Take this quarter, go downtown, and have a rat naw that thing off your face.” I guess I was just more politically correct at 13 then I am now, plus the fact that my dad would have beaten me from here to eternity and DCF didn’t exist then either- and if it did they probably would have beaten me too.

I really don’t want to be any part of a PACS- too much downtime with too many exemptions which the gal I am seeing would definitely not appreciate - but wouldn’t mind a little incentive money thrown my way just to keep things interesting and meaningful….