Changing any large system can be one of the most challenging tasks and time-consuming periods for any organisation. Apart from choosing the system, there is also the associated implementation and management of the change. Whether that’s a change of PACs (Picture Archiving and Communication System), a RIS (Radiology Information System), or an EHR (Electronic Healthcare Record)—it’s often a time nobody looks forward to (or forgets!).
In this article (in our series of PACS articles), you’ll learn the nine key considerations that you need to make when buying a PACS for a diagnostic imaging group or network.
What Do Organizations Need To Consider When Planning A PACS Integration?
1. Plan Ahead And Consider Contract Renewal Dates
It is vital to keep oversight of the contract renewal date, and not just of PACS. Also consider the contract renewal dates of related systems such as the Radiology Information Systems (RIS) and the Electronic Patient Record (EPR).
One school of thought is to keep the RIS and PACS renewal dates at least two and a half years apart (or at mid points of each other’s contract) so that you won’t have to go through a RIS and PACS replacement at the same time.
However, changing the RIS and PACS at the same time also holds some advantages, because changing them at the same time makes it easier to choose the same provider for both systems. So, it can be beneficial to renew or replace both systems together, as opposed to two possible rather messy upgrades two and a half years apart.
In general, a PACS contract is 10 years long (although some are longer) with a 5-year hardware refresh point and a major system upgrade.
Even though a PACS contract is generally 10 years long, a generation in PACS is considered to be 5 years long, because during this time so much has changed in system capabilities and global technology. After 5 years, it’s essentially considered a new generation in terms of general technology and PACS.
On top of this, during that time the hardware will have advanced so much that it wouldn’t be able to cope with latest capabilities. While the refresh is less challenging, coming to the end of a PACS contract where procurement will be involved really needs to be planned from 4 years out.
The initial phase is information gathering prior to any procurement rules kicking in. This is when you are free to rack up to RSNA/UKIO and get free system demos and talk freely and openly to suppliers. Once any notice of procurement begins, that’s when it all changes, and strict protocol and rules around engagement kick in.
The best advice is to have as much prep work done in advance. Know broadly what you are looking for and narrow your search down to the most suitable vendors. Distinguish key aspects that you are looking for to enable that focus and get rid of the peripheral distractions.
Narrowing down your search will save a lot of time and effort in the response assessments. The less vendor numbers you have to officially assess through the procurement process the easier and quicker your overall assessment task will be.
And bear in mind that all aspects of the scoring and assessment phase need to be documented. Everything from setting out the scoring criteria in advance, to scoring (by multiple users), calculations, and any other formulas used outlined in advance, such as if you’ll be using the mean or median score, will need to be documented.
It is very important to get your documentation right from the beginning. Because once you outline how you will perform the assessment it is generally then released to suppliers—and would be subject to a challenge if changed at a later date.
It is best to start your process at least 2 years before the contract ends, because irrespective of which channel you choose, procurement can easily take 12 months.
If you leave it too late, you put yourself under pressure as you’ll be coming too close to the contract end—which then becomes your weakness, and any new vendor’s advantage. Once a vendor knows you are under pressure or have minimal competition, their price generally increases. Choosing the right procurement partner is a major influence on the project.
2. Stakeholders And A Good Core Team
Stakeholders and choosing a strong core team are key when buying a PACS. Too many key decision makers and you won’t get anything done. And if you don’t have enough of the right people in your core team you won’t get full engagement or buy-in.
Often, you’ll find yourself purchasing a PACS for several sites and each site will want one person from their IT department, a local PACS lead, and a department manager involved. And imaging informatics has recently become a bigger input requirement too. However, when you start multiplying that from 8 or more sites, and include regional oversight and project management, you’ll find you’re looking at 30 plus people; and there becomes way too many people involved.
In a large group it can often end up in stagnant situations such as talking shops without anyone actually making decisions. You might also find it can create competitive environments where people of the same role from different sites clash. Or time gets wasted because personnel who are happy with proceedings feel they need to say something because other members have.
With large groups, too many tangents can occur in meetings, often without the proper debate of key issues, all the whilst input from the right people gets diluted. Another issue that you might find is that the same people won’t attend every meeting.
Integrity and confidentiality are also very important—you need to be able to trust the stakeholders and your core team. The last thing you need is vendors knowing what’s happening in a meeting before it’s even finished, or knowing what you’re going to ask in advance of a showdown.
Another aspect that might seem obvious, but can be overlooked, is ensuring that you gather a quality team.
You’ll want to ensure that your stakeholders have the desire to commit to the time needed, that they have the knowledge and ability to make and commit to decisions, and the authority to fully support the process properly. They might initially only be required to go to a few meetings a month, but it’s still vital they understand the full landscape and have the flexibility to be available when needed.
You’ll find that you’ll need two people per key area of representation. The key areas of representation are clinical leads (radiologist), PACS management, IT, and procurement. Also, there often tends to be quite a bit of national and international travel involved with the assessment.
It is absolutely vital to get good people in all aspects of the roles required, especially a good project manager and admin support. In total, you don’t really need any more than 8 people to create a successful team.
Each of those representatives are then responsible for filtering information back through their various representative groups, such as a regional PACS managers group to local trust or site level.
Often there will be strong lead characters who may be more vocal and/or persuasive than others. And it’s a key job of any meeting chairs to recognise this and promote an environment of fair inclusion.
3. Create A ‘State Of The Nation’ Map
It is very important to undertake a system’s review at the beginning of your buying journey. The first task is aways to perform a ‘state of the nation’ map, to map out the different systems and interconnectivity between each. It is vital you have a niche expert team that can do this, and your preparatory work will be rewarded later in the process.
As previously mentioned, a generation in PACs is only 5 years—with many contracts actually exceeding that. After such time, hardware will be out of warranty and the latest service offerings will have advanced in line with national policy.
Think about how common technology ages. An iPad that is 5 years old is often unable to cope with the newest requirements of the latest apps and software. And you’ll find a similar situation with PACS hardware. Older PACS hardware often can’t cope with the latest software system requirements and this often translates to slowness.
On top of this, undoubtedly some systems will be left to fall over and you will expect to see dependencies on legacy 15+ year systems, such as PAS (Patient Administration System). Because of this, you can often find situations where there is a myriad of different interconnected systems to cover all of the required functionality.
Here are some examples;
Legacy systems may be unable to share images or not have a web access portal and hence may have bolted on another vendor’s web and cloud PACS system, such as Ambra Health or Cimar (or other DICOM viewer systems).
- Legacy systems may not have a stats or business intelligence (BI) module that can perform free text analysis of reports (which can be used for research or AI algorithms training). And you have bolted on a power BI or a connection into a separate patient data warehouse.
- In some cases, we have actually seen that multiple PACS from the same vendor across hospitals in the same area can’t share or communicate, and this results in the need to purchase another system to sit across the top in order to enable sharing, which is often just a single patient identifier function.
You may want to consider who uses the PACS server, and who are the dependants, including outside of the radiology department? Is it used as a storage for a different front end viewing system, such as cardiology?
Do non-radiology departments have peripheral DICOM standard medical imaging modalities (producing a DICOM image or DICOM files), such as portable ultrasound or head CT scan (Computed Tomography Scan), that are connected?
How about nuclear medicine or MRI exams via an MRI (Magnetic Resonance Imaging) scanner on a lorry in the car park? Or a connected mammography department?
Is it used by academia in the attached university? Are there outsourced services such as scanning or teleradiology that need access or have integrations (such as any patient images)? Or are there any interactions with AI reading? In large university teaching hospitals, you will often find there are patient care dependencies on PACS that the core healthcare provider team are unaware of.
4. Get Clear On The Overall Vision
Subsequent to the ‘state of the nation’ map, it is important to identify the overall direction of travel and strategy, also known as ‘the vision’.
You’ll want to consider things like perhaps moving towards a hybrid reporting model— equal performance on site or remote—with inclusion of PACS based reporting. Or moving towards a full cloud system, or hybrid cloud, and the provision for future inclusion of other ’ologies’.
Often you find with modern procurements that PACS systems are purchased as ’digital imaging systems’ and other ‘ologies’ can be bolted on later without a need for a repeat procurement process for that ‘ology’. By other ‘ologies’ we mean any ‘ology’ such as cardiology, dermatology, digital pathology, ophthalmology, etc, that has become a digital image acquisition and can be stored on PACS system.
Subsequently for vendors, winning the first enterprise imaging system ‘PACS’ can be a loss leader to the more lucrative subsequent medical imaging data systems, such as other ‘ologies’ that come along afterwards.
In the absence of a competitive tender for that specific ‘ology’, the PACS vendor basically has free rein, and can charge what they like, for example—with digital pathology and medical images. And it can be to your advantage to paint that picture within the introductions.
Strong contract management and good overall vision are needed. And within a good vision, it would be important to include future pricing indications for future ‘ology’ additions to avoid being overcharged.
Of course, your vision will evolve during the process as and when you gain more understanding combined with seeing more of the latest offerings through demos and supplier presentations.
Team members’ opinions can shift as they become more aware and educated too. A good point to note is to keep reference to every confirmation a vendor makes with regard to a query, such as the inclusion or exclusion of certain features.
5. Maintain Good Communication Channels
Good communication is vital. A newsletter can be a really handy tool to keep everyone within the loop for the latest updates. You can set up a monthly newsletter that increases to bi-weekly as you get closer to the implementation date.
You’ll want to ensure that the newsletter is distributed carefully so it’s best to have a sign-up protocol, and to vet all the email addresses.
It’s also important to remind team members to disseminate the information down through the various channels of their local trust, to ensure that the right personnel are aware of key final decisions, and progress that has been made, including potential hold-ups.
You can also create a simple but dedicated website or intranet page to keep all the necessary and interested parties up to date. This really helps as it creates a focal point for key information, and ensures that the information is centralised and available to all when they need it. With such a complicated process involving many different decisions, pieces of information, and individuals—having a website or intranet page as a hub for information ensures that information doesn’t get lost or miscommunicated.
It’s also a really good idea to hold monthly stakeholder days, in general six is a good amount. Arrange some system demo days with different vendors and invite members from each site to come to trial the system. It gives stakeholders and vendors a good opportunity to ask for feedback, combined with being able to engage with the system users.
Stakeholder days are also a useful way of demonstrating the progress of the whole project, and you can usually include a number of talks by key users to keep the entire group updated.
6. Practice Good Document And Record Keeping
It probably goes without saying that you need to document everything well. Without good record keeping things quickly become an unmanageable mess! Proper admin support is most definitely required during the process of buying PACS.
It’s also recommended to keep the minutes of meetings as key bullet points, as opposed to verbatim minutes word for word. You’ll have numerous, often daily, meetings which can be lengthy.
This means that the minutes and record keeping documentation builds up really quickly. If your process of record keeping is too long and lots of unnecessary data is kept, then you’ll find the important and key information really hard to find at a later date. Keeping to key bullet points of decisions made and actions taken is more than sufficient.
You’ll need to take into account that certain aspects of the process can’t just be left to procurement input and often need a complete overhaul. For example, documenting all aspects of procurement, the instructions to tender, the scoring and assessment criteria, and BAFO requirements can’t be overlooked and just left to procurement input.
Unfortunately, it’s not as simple as getting an old template from a site that completed a process previously. Often the outsourced procurement resource won’t have the specialist knowledge, and they’ll be keen to move towards completion. Their desire for completion can mean that they’re more interested in choosing a vendor with a higher cost due to the associated higher commission too.
Version control of your records is also vital. Specifications and your documents will change several times over the course of a project, and these may need to be traced back at a later date. And of course, it’s always vital to have the latest and confirmed information available so you’ll always want to ensure your versions are on hand, up-to-date, and in order.
7. Navigate Around The Politics Gracefully
In any large organisation—politics come into play. And this is particularly the case at regional level with the regional procurements of systems.
Documentation is vital because you’ll often find that there are meetings, outside of meetings. Or personnel who have not been invited to meetings who may have a different view. Or authorities who are ‘higher up’ with more power having an influence outside of meetings. You’ll want to ensure that you record as much as you can to keep tabs on what’s really going on.
It is a delicate balance, and you’ll find yourself having to manage the balance carefully. Sometimes you’ll find members trying to lead outside of their specialist areas. And of course, keep a smile ready for the few glory hunters who only appear for a media briefing, contract signing or award ceremony!
There are also the outside influences of other systems and policies such as RIS (Radiology Information System) policies, policies to move to a public cloud, or a new EPR (Electronic Patient Record) medical record system that may have an RIS module.
You may also find that you have different sites or trusts with different agendas. And you may even see rivalry between sites or between different high-ranking consultants or senior managers.
Smaller sites can often feel intimidated by larger sites, with one eye on potential mergers being made easier with a single system. Whilst larger sites can be disinterested as they have bigger projects to focus on.
Navigating the political landscape and outside influence can and will become one of the greatest challenges through the lifetime of the project. However, with some delicate balancing and juggling, you’ll make it through!
8. Ongoing Contract Management
You’ll want to ensure that there is good (and strategic) on-going contract management—and vision—at a regional level, and this is important both before and after the contract is signed.
It’s important that the contract manager is highly involved at all levels, and that they have a high level of input into the final signed contract. You’ll find that once the contract is signed that vendors often will do anything to deflect any shortcomings and they can even try to charge for anything they can in the future. Ensuring that the contract manager goes over such details in the final signed contract helps to minimise unexpected future costs.
The contract manager can also ensure that there is rigorous project management, good meeting management, that the agenda is adhered to, and can help to avoid tangents that arise.
9. Tips For Contract Considerations
At BAFO (best and final offer) during the procurement, you need to include the actual contract that you want the vendor to sign up to. It’s absolutely pointless choosing a preferred PACS vendor and then trying to negotiate a contract afterwards.
At that point, the power shift has already started. You must go to your final three vendors, provide what you want in your final contract, and see who will sign up to it. And they will all be a lot more enthusiastic when they know they have competition!
But remember that once that contract is signed, it’s often a completely different story with the chosen vendor. Therefore, it’s absolutely vital to include every aspect and any future aspect envisaged that could possibly arise over the next five plus years.
You’ll want to include provisions for an exit strategy. For example, if things don’t go to plan how do you get out, get your data back, change vendor, and how much will it cost you?
It’s also a good idea to include some consideration for data management. In an ideal world you should be able to detach your imaging data (such as VNA – Vendor Neutral Archive) or cloud (such as AWS, Azure, or GC) from one imaging vendor and re-attach it to another if you change vendor or when your contract changes. This should technically help to avoid any laborious data migration. However, in practice that may not always be the case and it needs some hard focus and planning in advance.
And my final recommendation is to keep in mind that things can often drastically change once the contract is signed. It’s important to remember this to try and minimise any shocks and surprises.
The common experience is finding that all vendors are your friend, with no problem being too small. You’ll often find that every little bit you think of can ‘be thrown in’ to the deal—right up until the day you sign the official contract.
At that point a power shift takes place, and it is absolutely vital that you have everything you need in place before that happens. You don’t want to get a shock after signing the contract to find that you’re tied in, what you need costs four times the expected price, on top of having to go through hundreds of telephone numbers to get anything done!
Good luck with your journey of buying a PACS for your imaging centre, group or network.
About The Author
Pauric Greenan is an experienced PACS consultant that has been PACS lead on several high-profile PACS projects in both the UK and Ireland. Pauric is internationally available for PACS consulting. Contact him here for more details.
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