Most people hear the name Memorial Sloan-Kettering Cancer Center and think excellence in cancer treatment. But behind the scenes at one of the marquee names in healthcare stirs another imperative: excellence in radiology.
Distinguishing between mirages and malignancies is just the beginning, though. These days high-performance radiology at Memorial Sloan-Kettering in New York-and plenty of other hospitals-means far more than mere clinical accuracy.
Speed, savings and service to referring physicians are equally important in defining radiology success.
As a result more hospitals and health systems, like Memorial Sloan-Kettering, are looking to beef up the electronic "plumbing" of their radiology departments, making fleet and infinitely reproducible digital images their new clinical currency.
By networking diagnostic imaging equipment with high-resolution monitors and electronic storage banks, these hospitals hope to do away with images captured on film, reducing or eliminating one of the largest expenses in every radiology department. Ultimately, they expect vast file rooms will give way to digital warehouses on hard drives, tapes and CD-ROMs. Efficiency will reign as the problem of lost film fades into history. And clinical care will improve because radiology reports will be available faster and patient images can be splashed on computer screens in just seconds wherever they're needed.
In a nutshell, that's the promise of clinical image networks, or picture archiving and communication systems, commonly called PACS. New demands from affiliated outpatient centers and multiple hospitals within sprawling health systems only whet the appetite for the electronic transmission, display and storage of clinical images. Those demands are fueling growth in the $400 million-plus PACS industry.
At Memorial Sloan-Kettering, for instance, the system was a key design feature in a plush 190,000-square-foot outpatient facility that opened in June 18 blocks from the main hospital campus.
Across the street from the slant-roofed Citicorp building in midtown Manhattan, the Laurance S. Rockefeller Pavilion includes a full floor of the latest radiology equipment, including one magnetic resonance imaging scanner, two computed tomography scanners and a state-of-the-art system that electronically captures, routes and stores patient images and links to the inpatient hospital uptown. On the drawing board are similar connections with several suburban satellite facilities.
Not a conventional department. The outpatient radiology department is filled with computer monitors. Conventional light boxes are still around but are few and far between compared with the equipment at most hospitals.
"We opened this place filmless. We didn't even build a darkroom," says Brad Haspel, radiology manager at the outpatient center. "The nicest thing to me is not to have a file room."
Nice is an understatement. Besides eliminating the misfiling headaches that plague hospitals, the absence of a file room means big savings on rent.
In the booming Manhattan real estate market, midtown office space runs $60 to $70 per square foot, and even a modest storage room could easily drain millions from the operating budget.
To be sure, the systems aren't exactly cheap. Memorial Sloan-Kettering spent millions on it system, made by General Electric Medical Systems, though officials declined to specify a figure.
But hospital officials expect film savings and increased productivity to go a long way toward offsetting the expense.
Clinicians will also benefit from faster turnarounds of radiology reports, which will speed diagnosis and treatment.
And that, says management, is what PACS are really about.
"The decision to do this was driven by a real firm belief that it will improve patient care," says John Gunn, executive vice president at Memorial Hospital for Cancer and Allied Diseases, the clinical arm of Memorial Sloan-Kettering.
"A very big thing in the cancer business is to look at the last X-ray," Gunn says. Doctors and patients like to compare the latest post-treatment images with the before shots.
"PACS seemed to play beautifully to that," Gunn says.
Different this time. For the past decade, vendors and clinical visionaries have promised that widespread use of PACS was just around the corner.
Nearly everyone who heard the spiel nodded knowingly and moved on. Although the theory of PACS made perfect sense, getting all the radiology equipment to speak the same language turned out to be quite difficult. That challenge translated into high cost. And most hospitalwide installations of PACS, as a result, have been multimillion-dollar affairs limited to the highest-end institutions that have the patience and the budgets to work through the engineering and clinical hassles.
In the past few years, however, PACS have made another run at the mainstream. Prices have dropped. Project financing is more flexible. And the stuff just works better.
"We are at the threshold of realizing the true benefits of PACS," says Gary Reed, president of Integration Resources, a consulting firm in Lebanon, N.J.
Reed says today PACS are more smoothly integrated with radiology information systems, which are used to schedule patients, manage workloads and automate record-keeping. Though far from being perfectly implemented, this ongoing advance is critical to realizing the efficiency gains that PACS boosters have touted for more than a decade.
Likewise, only in the past three years has a standard for clinical images become reality. Previously, proprietary image file formats-similar to the technicalities that prevent the easy transfer of files created by different word processing software-have changed to an industry standard known as DICOM. That means CT scanners, routers, laser printers and storage devices from different vendors can finally exchange information right out of the box. Consequently, off-the-shelf hardware is finally easing out expensive proprietary systems that many vendors had pushed.
Many PACS today run on personal computers rather than the pricey technical workstations required a few years ago.
Equipment costs are falling. Across-the-board, computer memory and image storage are much cheaper. The price of network bandwidth, or the diameter of the electronic pipe connecting the PACS pieces, has also dropped. Fatter pipes are faster, and now they're not that expensive.
A full-blown system that cost $8 million five or six years ago costs half that today, Reed says.
Meantime, doctors are less resistant to reading cases directly from computer monitors. Administration in many hospitals has finally seized upon PACS as efficiency tools. And the Internet explosion has helped by making the transfer of images and reports to referring physicians' offices as easy as pie.
Reed says, this time around, PACS are for real. "The sign is that you can actually go to places and see them work."
PACS taking off. Sales are rising fast. They hit about $400 million last year, and Reed estimates they will exceed $1 billion within five years (See chart).
Of hospitals with 200 or more beds, nearly one in five, or about 18%, has at least a starter system today, he says. And installations have been growing by about 12% to 15% per year. Among hospitals with fewer than 200 beds, less than one in 10 has a system today, but Reed predicts this segment will soon grow the fastest as vendors roll out less-expensive products.
Enthusiasm runneth over at major PACS suppliers.
Reliable market share figures are hard to come by, partly because PACS are customized products configured for each hospital and because nobody can agree on exactly what constitutes a system.
But several sources said Agfa Corp., General Electric Medical Systems and Siemens Medical Systems are duking it out for PACS leadership. In the next tier, Eastman Kodak Co. and Picker International are putting up a strong fight. And behind them a host of specialty companies, some with backgrounds in information systems, are scrapping for their piece of the PACS pie.
"Most of the companies that are in PACS never in their history had a better year than last year," says Henri "Rik" Primo, director of information systems and PACS at Siemens Medical System, Iselin, N.J.
Primo figures that in years past, 5% sales growth was the norm, but in 1998, industrywide sales climbed by 20%. He expects that beginning in 2000, sales will increase at 30% annually.
Other suppliers share the newfound PACS enthusiasm.
"The waiting is over," says Bruce Johnson, PACS marketing manager for the Americas at General Electric Medical Systems, Mount Prospect, Ill. "It's here; it's arrived."
At Agfa, Dean Kaufman, marketing manager, declares: "PACS have entered the mainstream."
Elusive savings. Even converts to the system caution that technology alone is no panacea.
At the University of Utah Hospitals and Clinics in Salt Lake City, for instance, radiology productivity actually declined after a multimillion-dollar system was installed.
Mary Freeh, operations manager for radiology, says, "PACS do not improve speed of performance in the beginning because you're asking the radiologist to do some of the work."
At first radiologists at the Salt Lake City hospital read 80 studies per day instead of the 100 studies they averaged before the system was installed.
They were spending time jockeying image worklists around on computer screens. Previously, the file room staff waited on them "hand and foot, pre-hanging each set of films," Freeh says.
Reliability is another sore point-the system is down about 10% of the time, and film savings have been less than expected.
Nevertheless, Freeh remains confident in PACS, declaring the positives far outweigh the teething pains.
Freeh says that once the PACS network extends beyond radiology into other departments and to satellite clinics, and the staff has adapted, she is sure the promised productivity will come.
"Even though this first year has been quite a struggle, it works well," she says. "Everything flows where it's supposed to flow."
Be a hero. Administrators at Crozer-Keystone Health System, Springfield, Pa., have been watching PACS unfold for several years and recently decided to give the system a try in their MRI service.
"We saw the technology reach the point that we thought the value to our referring physicians is finally there," says Frank Kline, administrative director of radiology, who is leading the evaluation of PACS technology at Crozer-Chester Medical Center, Upland, Pa.
Soon Kline expect to extend a request for bids on a system that would link four MRIs at outpatient centers with the hospital's radiology department.
"My bet is that we will save the cost of the PACS investment just in the avoided cost of film," says John McMeekin, president and chief executive officer of Crozer-Keystone. And if that's so, he says, "it's a slam-dunk."
At Crozer-Keystone, PACS is still in the planning stages, but McMeekin says he would like to hold vendors to their savings promises by contract, a tack he's used successfully with information systems projects.
If the system is, in fact, cost-neutral, buying it "would be one of the easier issues for a CEO," McMeekin says. "You can be a hero."
Blazing PACS trails. Princeton (W.Va.) Community Hospital is a trailblazer in putting PACS to work outside academia.
Planning for the electronic future started in 1991, says Steven Curry, director of networking and diagnostic imaging services. But, he says, the system they wanted would have cost a "ridiculously prohibitive" $8 million-plus.
A system had to be PC-based and smart enough to move images automatically to reading stations in the right clinical departments as the patient moved through the hospital. So CT images of a trauma patient in the ER would automatically go to radiology and upon admission would be transferred to intensive care.
Curry's hospital selected a system by Data General Corp., Westborough, Mass., last year.
The ER physicians, who fought the idea of filmless radiology the hardest, are now among the greatest supporters of the system.
"We don't have doctors scurrying around fighting over images," he says. "All of them have access to the images now, and it makes things much more efficient."
Realizing the promise. So far, though, PACS have failed to catch fire with many community hospitals.
"You've got to be a pretty-good-size hospital to justify some of the anticipated savings," says Robert Maier, president and CEO of Regents Health Resources, a radiology consulting firm based in Brentwood, Tenn.
Besides, until recently, savings in radiology weren't considered all that sexy. Many hospitals executives faced with limited capital budgets were skittish about investing in radiology equipment that didn't generate more procedures and thus more revenues.
Recently vendors have begun to offer more-creative financing packages to overcome that hurdle. Clever leases can transform spending on PACS into an operating expense rather than a capital outlay. And several vendors are starting to exploit their appeal.
"Hospitals traditionally don't understand how important radiology is to their survival," Maier cautions.
Practically every patient encounter involves medical imaging, he says, and PACS offer many hospitals a better way to manage those critical data. For those who have waited on the sidelines, he offers some comfort:
"The promise of PACS has been there for the past 10 years, but it's only in the past two or three years that we've seen systems that are working well."