Our final installment of this three-part series examining the major strategic trends in the imaging/PACS space looks at strategies for working with vendors. Part I (June) examined the biggest challenges involved in replacing first-generation PACS and RIS systems with second-generation ones; while Part II (July) looked at issues involved in integrating imaging management systems and core EMR and CPOE applications.

Hospital and health system CIOs agree: when considering the topic of vendor selection in the context of PACS and RIS applications, it's important nowadays to think carefully, and think big. In other words, the first step is to know what it is the organization wants from these systems before evaluating product features and functionalities in a market overflowing with choices.

“Before you can think about vendors, you'd better be very clear on what exactly it is you're trying to do, and why, and for whom,” says Lynn Witherspoon, M.D., system vice president and CIO at the seven-hospital Oschner Health in New Orleans. Witherspoon ought to know — he has helped lead an ambitious initiative to create an integrated imaging management system at his organization, which emerged as a multi-hospital system out of the devastation of Hurricane Katrina. Since that time, Oschner executives have been unifying information systems from what had been disparate patient care organizations before the 2005 storm

“If in fact the major focus is on radiology, then certainly, what radiologists think will play a major role” in vendor selection, says Witherspoon. But the reality is that for many large hospitals and most multi-hospital systems, vendor selection in the imaging area is touching most medical specialties, as well as many non-physicians, changing the traditional best practices around picking a partner.

As a result, “CIOs are interested in diffusing images across many specialties,” notes Cristina Guthrie, Oschner's associate vice president for clinical systems. “And when you need to distribute clinical images across the enterprise, you're talking about different types of images; and it becomes important to get vendors whose products relate to the different medical specialties to be able to work together with one another.”

A different landscape

CIOs and industry experts agreed that the environment for vendor selection in this area has changed dramatically in the past few years. Among the key factors to consider are now:

• Integration of RIS and PACS solutions.

• PACS products are becoming largely commoditized with regard to core features and functionalities.

• RIS systems remain more broadly differentiated in capabilities.

• As PACS systems become an enterprise-wide set of tools, CIOs and other imaging IS leaders can no longer focus solely on the needs and desires of radiologists, but must instead think about all types of physicians, as well as other clinicians and non-clinicians, who will be using and sharing images.

• As indicated in last month's imaging article, integration of RIS and PACS with core EMR systems is becoming a very important priority, and the potential for such integration adds another layer of considerations to the mix.

“The key thing is that before looking at any vendor, the CIO has got to have a mental blueprint, basically a global perspective of the big picture, of the electronic health record, and of how he or she envisions all the pieces fitting together,” says George Bowers, principal in the Baltimore consulting firm Health Care Information Consultants, and a former CIO. “If you just start by looking at what the vendors have to offer, it's very easy to get distracted by the glitz factor. And I can't overstress interoperability,” Bowers says.

One of the trickiest aspects of all this, Bowers concedes, is that while PACS has become “an enterprise-wide system for delivering images to the entire organization,” RIS remains largely focused on radiology department workflow (as the name would indicate), even though numerous other specialists, including cardiologists, gastroenterologists, and ophthalmologists are now demanding imaging management capabilities. There is no simple answer to the question of how to handle the RIS vendor selection issue, Bowers concedes. He and other industry experts note that other specialties, with the qualified exception of cardiology, are only beginning to define the workflow requirements they need out of imaging management systems.

In other words, all those interviewed for this article agreed, there remain several problems in vendor selection, including the fact that no single commercial vendor can successfully address the workflow needs of all the medical specialties. Solutions for truly linking all the medical specialties together in a fully integrated continuum — that stretches across specialties, across picture archiving and sharing, and across the EMR — do not yet exist in a truly mature form.

That having been said, Keith Van Camp, vice president and CIO of the 535-bed St. Dominic's Hospital in Jackson, Miss., says, “I've come to conclude that RIS and PACS are really almost inseparable, and really almost need to be one system. They're not yet today, but they're getting closer to that,” he says. And, given that cardiology is the medical specialty with the most mature systems to date, Van Camp says, “A major consideration is that whatever you implement in radiology, you're probably going to end up choosing for cardiology as well. Cardiologists, while they're working on a CAD (Computer-aided design) terminal, can pull up MRs and CTs as well, and you couldn't do that if you had separate vendors,” he notes. “So it's very important to look at all the systems that you're going to be driving; otherwise, you end up with some disjointed workflow and you have a disadvantage.” For now, Van Camp says, it's important to “look for a vendor that has a very robust system; you're shooting yourself in the foot if you don't do that.”

In the current evolving environment, it's becoming essential to really “look under the hood” of commercial PACS and RIS products, all those interviewed agree. In that regard, John Halamka, M.D., CIO of the CareGroup Health System in Boston, notes that traditional RFPs will no longer cut it. As Halamka said in a recent blog, “We do not believe in Requests for Proposal (RFPs). RFP means Request for Prevarication, since most vendors do their best to answer RFPs with as many positive responses as possible.” Instead, he says, “we review the marketplace, often via the Web and by reviewing summary evaluations from KLAS reports. We pick the three or four applications which seem to best meet our stakeholder functionality requirements, and then carefully evaluate those applications, and pursue a process that includes scripted demonstrations.”

Bowers agrees that vendors should be brought in for scripted demonstrations, during which they handle queries established by the provider organization.

And, he adds, “Anytime you're buying a sizeable system — and PACS is a sizeable system — you're buying a relationship with a vendor.”