Monday, October 24, 2016

Deconstructed PACS part 4 of 4: Q and A with industry expert/consultants

This is part 4 of 4 of the Deconstructed PACS series, the recorded video and corresponding slides of the webcast video can be viewed as well here. In this final part we have the opportunity to interact with the VNA experts, Mike Cannavo (MC) and Michael Ryan (MR) to ask any deconstructed PACS related questions

Q1 Would you implement the VNA before or after the PACS implementation?
(MC) I prefer a VNA to be on the front-end because the migration has been done already and they have experience with it. The VNA implementation can easily take a year with the data migration taking a great part of that. Michael Ryan did it kind of on the back-end, it is probably a personal preference. My preference is to do it on the front-end.
(MR) If you have a choice, I would say implementing the VNA first makes the most sense.

Q2 What about the dataflow, do the images go to the VNA first and then to the PACS or the other way around?
(MR) That would really depend on the facility requirement, it can be done either way.
(MC) I disagree, the data should always go to the PACS first. By the way, I typically configure the local PACS to have 2 years of on-line storage.

Q3 Is the enterprise viewer in the VA environment used for primary radiology viewing?
 (MR) There is one application for the primary radiology and physician viewer, it is not a zero, but very small, footprint. That is how we can provide the clinical users with advanced viewing capabilities, especially the neuro-surgeons and orthopedic specialists. They are on separate networks though.

Q4 Is a deconstructed PACS less expensive than a “conventional PACS?”
 (MC) Most PACS vendors are selling bundled solutions that are 60% to 75% off list price, which means that a turnkey PACS solution will be significantly less. There is also integration, testing and internal support costs to deal with in the case of a deconstructed PACS.

Q5 An issue is having a consistent body-part, study and series descriptions etc. to allow prefetching the relevant prior studies for comparison, what is your solution for that?
 (MR) We standardized body-part and study descriptions. For the VA, the study description starts in our VISTA EMR. We had some success standardizing it over the facilities but it did not really meet the end-user requirements. Also, there is a trade-off between making it too generic or too specific. In our experience, “body part examined” contained a lot of “Other” values. This is especially an issue with older studies.

Q6 Why do you need a PACS archive and VNA archive if you have a viewer that has full radiology functionality and you have the other key pieces of the deconstructed PACS. Having a PACS seems redundant. 
(MC) I don’t see the vendor portion of the archive lasting, as there is too much proprietary and vendor specificity, which a VNA will eliminate. It will neutralize this, which is the “N” in the Vendor Neutral Archive. A VNA allows you to connect and reconnect any other PACS system without having to go with the added expense and time of the data migration. 
However, we still need a PACS as 80 percent of the US hospitals are under 200 beds in size and the majority won’t have the resources for doing a fully deconstructed PACS. However, if an institution is part of a large enterprise, and there are corporate resources available, than by all means they should consider it. For right now, and for the next 2-3 years, it will be mostly for the larger institutions that can afford to support it. 
(MR) There seems to be a lot of mergers and acquisitions outside the government world so I can imagine that it starts to make sense allowing them to tie it together and use viewers that can access multiple VNA’s. Indeed, for smaller institutions it would be a challenge both from a budgetary and personnel perspective.

Q7 How have you implemented integration of specialized applications, such as orthopedic templating?
(MR) we used to have a third party plug-in for our legacy PACS and we can do the same, i.e. launch that from our new enterprise viewer. We do have a dedicated 3-D solution from a third party. For image fusion, some of our facilities use a workstation plug-in as well and some do the fusion at their modality workstations.

Q8 What are your closing comments on this topic?
(MR) For us, the deconstructed PACS was a good solution as we were able to find vendors that can meet our requirements. In addition, in the VA there are time and budget constraints, which make a piecemeal purchasing and implementation a better solution. I believe that five years from now, when my colleagues are looking back, they will find that it was a good decision to go this route. 
(MC) The most important part is that you have an action plan in place that considers what you have in place, what you can use, what you want to replace, and sit with someone who understands where you are and where you want to go. Look at the requirements and financial and personnel resources you have. Make sure you document this and realize that it could take 2-3 years to get to what you need. As Mike Ryan demonstrated with the VISN23 VA implementation, you can be successful if you do due diligence and plan it carefully.


  1. I would say implementing the VNA first makes the most sense. what is secondary market research in this reference matters a lot to answer lets see what is good.

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