Deconstructed PACS: 12 Tidbits on Hype, Reality, Caveats, Prospects

There are few topics that create more controversy and inspire more animated ‘spiels’ in the imaging informatics marketplace today, than does the topic of deconstructed PACS. Market hype and a strengthening track record as a viable radiology PACS alternative, are evidently causing disruption to the established PACS industry. The probability of it severely altering revenue flow in imaging IT, while yielding a profound impact on vendors’ go-to market strategy, make deconstructed PACS one of the hottest, most debated matters in this industry.

A deconstructed PACS approach consists of uncoupling the different functions offered by a conventional, all-in-one PACS system, into its constituent elements while being able to make independent, vendor-neutral purchase decisions for each one. Typically, this PACS ‘deconstruction’ results in broadly four modular, hardware-agnostic solution components: image management and archiving, diagnostic and clinical viewing of images, enterprise workflow orchestration, and finally, imaging analytics – along with all the necessary ‘plumbing’ middleware (enterprise master patient index [MPI], DICOM tag morphing, and open standards such as HL7, FHIR, DICOMweb, XDS, among others.)

Where do things stand right now on various fronts?

1. Market Perception: Yes, the deconstructed PACS model might be somewhat over-hyped, but no it is not merely a ‘marketing gimmick’ or a coordinated effort led by a few industry consultants to spur confusion in the marketplace, as some opponents to the model would like to describe it. With the frustration of previous generation proprietary PACS still very much present, the imaging market (in particular hospitals, integrated delivery networks, and health systems) is finally giving it the serious consideration it deserves.

2. Market Adoption. So, how far ahead are we on the adoption curve? In essence, the U.S. market is probably just past the Innovator phase and entering the Early Adopter phase: a few dozens of IDN’s and health systems (out of ~2,000 IDN’s and ~1,000 health systems) have, or are well underway with implementing a deconstructed radiology PACS replacement. This translates into a current U.S. market penetration of deconstructed PACS in the low single-digits – and growing.

3. Adoption ‘Sweet-spot.’ Based on early adoption patterns, the deconstructed PACS approach is being implemented at the larger ends of the provider spectrum. Currently, the market ‘sweet-spot’ seems to be in the large to very-large health systems, such as IDN’s and geographically-distributed radiology groups, with dynamic merger-and-acquisition activity, and which operate a multi-vendor, multi-PACS imaging IT environment. 

4. Decision Makers. IT departments, notably the Chief Information Officer (CIO) or the Chief Medical Information Officer, have been the most influential stakeholders in defending the strategic direction for ‘deconstructed PACS’, as well as driving subsequent purchase decisions and funding.

5. Adoption Drivers. Much of the early adoption of the deconstructed PACS model is being driven by the IT mandate to achieve higher vendor-independence in their PACS replacement plans, compel standards adoption to avoid any future vendor lock-in, consolidate vendor relationships in imaging IT, drive economies of scale, and optimize otherwise disparate radiology service lines by thriving to unify, harmonize, and virtualize inconsistent reading environments.[[{"type":"media","view_mode":"media_crop","fid":"50334","attributes":{"alt":"im Michel Daher, Industry Principal, Medical Imaging and Imaging Informatics, Frost & Sullivan","class":"media-image media-image-right","id":"media_crop_9030299989111","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6135","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 250px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"im Michel Daher, Industry Principal, Medical Imaging and Imaging Informatics, Frost & Sullivan","typeof":"foaf:Image"}}]]

6. Business Rationale. There is no strong evidence yet in the marketplace of a strong financial incentive to take on a deconstructed PACS approach, partly because of the cost of ‘reconstructing’ PACS and it is too early to tell. Early adopters seem cognizant of the fact that any tangible return on investment (ROI) or any significant reduction in the total cost of ownership (TCO) will take time to materialize, and have not jumped on the opportunity for financial considerations. That being said, the modular and phased deployment models associated with deconstructed PACS make for a less capital-intensive and more flexible financial model.

7. Market Potential. With more enterprise viewers now FDA-approved for primary diagnostic reading, this completes making the deconstructed PACS an entirely viable, tried-and-tested PACS replacement solution. However, in practice, enterprise viewers are being leveraged mainly as universal clinical viewers, not as primary image viewers - with few exceptions, notably Visage. This may limit the market potential to radiology and breast imaging, and limit its potential in other image-intensive clinical departments to constitute a comprehensive multi-ology imaging IT platform.

8. Adoption Limits. The integration and interfacing effort required in reconstructing the technology stack can be expensive and technically challenging in a multi-vendor scenario, and is probably realistically achievable only by the larger IT-savvy organizations. As such, there is a high degree of skepticism about the ability of the deconstructed PACS model to gain ground in smaller-scale organizations and hospitals. It appears so far that the model may only ‘make sense’ for the larger organizations.

9. Tie to Enterprise Imaging (EI) - A deconstructed PACS approach may contribute, but is absolutely not pre-requisite to implementing a successful EI strategy. In fact, many institutions are already achieving positive outcomes from EI initiatives they have built over fairly conventional PACS and VNA systems. This fact serves to highlight that EI success is less about technical IT considerations and more about change management, stakeholder alignment, and leadership in governance.

10. Vendor Strategy. Deconstructed PACS has revived the ever-lasting industry debates about the ‘right’ vendor approach to take in imaging IT: multi-vendor, best-of-breed, single-vendor, single-source are all back on the table, with larger vendors obviously defending the latter.

11. Technical Caveat. In their own defense, the larger vendors which are able to cater to all of the technology stacks comprising a deconstructed PACS, emphasize that only with a single-vendor approach, can all of the imaging data and related information flow seamlessly and efficiently between the different modules. In addition, they also highlight the customer benefits of having a ‘single throat to choke’ in managing a single vendor relationship.

12. Strategic Caveat. Many argue that deconstructed PACS is not the way to go in trying to achieve an integrated, multi-ology imaging platform beyond radiology. While it may be a viable radiology PACS alternative, the fact that each specialty has its own viewing, tooling, and workflow requirements, would mean the model has to be replicated in every specialty – which would essentially defeat its original purpose.

In the end, success in ‘deconstructing’ PACS deployments boils down to good governance: striking the right balance between clinical, operational, and IT forces that shape up enterprise imaging dynamics is key. As evident among early adopters, the most successful enterprise imaging initiatives, including those ‘deconstructing’ PACS, are those where IT - the bearer of enterprise imaging IT – and radiology – the traditional owner of PACS – have partnered under a transparently defined and well-balanced collaboration framework.