review article picture archiving and communication system - rbrs

JBR–BTR, 2004, 87: 234-241. 

REVIEW ARTICLE 

PICTURE ARCHIVING AND COMMUNICATION SYSTEM – PART ONE 

FILMLESS RADIOLOGY AND DISTANCE RADIOLOGY 

A.I. De Backer 1 , K.J. Mortelé 2 , B.L. De Keulenaer 3 

Picture archiving and communication system (PACS) is a collection of technologies used to carry out digital medical 

imaging. PACS is used to digitally acquire medical images from the various modalities, such as computed tomography 

(CT), magnetic resonance imaging (MRI), ultrasound, and digital projection radiography.The image data and pertinent 

information are transmitted to other and possibly remote locations over networks, where they may be displayed 

on computer workstations for soft copy viewing in multiple locations, thus permitting simultaneous consultations 

and almost instant reporting from radiologists at a distance. Data are secured and archived on digital media 

such as optical disks or tape, and may be automatically retrieved as necessary. Close integration with the hospital 

information system (HIS) – radiology information system (RIS) is critical for system functionality. Medical image 

management systems are maturing, providing access outside of the radiology department to images throughout the 

hospital via the Ethernet, at different hospitals, or from a home workstation if teleradiology has been implemented. 

Key-words: Picture archiving and communication system (PACS) – Radiology, digital – Images, storage and retrieval. 

In conventional radiography, 

X-ray film serves to capture, display, 

transport, and store the image. It 

has aided medicine well in making 

diagnoses since 1895, when Nobel 

Prize winner Roentgen produced the 

first medical radiograph. However, 

over the years several factors have 

been a source of concern, such as 

the high loss rate of conventional 

radiographs (up to 20% of radiographs 

cannot be found at the 

required time, creating a serious 

practical problem), limitation in 

viewing radiographs at only one 

place at one time, and the time 

required to process images chemically. 

Transport of radiographic films 

is time-consuming, and conventional 

film archives are labor-intensive 

and notoriously unreliable. Even 

with a well-organized film library, a 

considerable amount of time in a 

radiology department is spent 

searching for previous films or arguing 

with clinicians about the location 

of films. Not only storage and 

retrieval of radiological images, but 

also reporting of diagnostic information, 

have become increasingly difficult 

using conventional means (1). 

Over the past decades radiology 

departments have witnessed a pro- 

gressive shift from trapping an 

image on a photographic plate to 

capturing it with radiation detectors 

whose output signals may be digitised. 

Methods such as CT, MRI and 

sonography are inherently digital 

because the images are reconstructed 

by computers. When these 

modalities were first developed, 

computerized images needed to be 

converted to film. These modalities 

were already in a true PACS format. 

However, they were limited with 

regard to data storage and data 

accessibility through a central processing 

system. Since general radiographic 

technology was already 

being directly obtained on film, the 

decision was made to convert CT, 

MRI and sonography images onto 

film – a step back in technology. In 

the more recently developed computed 

radiography (CR) and digital 

video-fluoroscopy, the signal that 

would previously have been used to 

expose a radiographic film is digitalised. 

The advantages of digital 

acquisition are that all the data are 

preserved and the images may be 

modified – made lighter or darker, 

given more grey scale or less (1, 2). 

Images on an X-ray film are fixed, 

and the only manipulation possible 

From: 1. Department of Radiology, Ziekenhuisnetwerk Antwerpen, Stuivenberg, 

Antwerpen, Belgium; 2. Department of Radiology, Division of Abdominal Imaging and 

Intervention, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 

02115, USA; 3. Intensive Care Unit, Royal Darwin Hospital, Rocklands, 0810, TIWI, 

Northern Territory, Australia. 

Address for correspondence: Dr A.I. De Backer, M.D., Department of Radiology, 

Ziekenhuisnetwerk Antwerpen, Stuivenberg, Lange Beeldekensstraat 267, B-2060 

Antwerpen, Belgium. 

is to use a brighter light. Once 

images are in digital format they can 

readily be manipulated for better 

viewing quality, but they may also 

be transported electronically, sorted, 

read, saved in an archive, 

retrieved when needed, and called 

to any area within the local or 

extended computer network, within 

the hospital or remotely to other 

hospitals or to general practitioner. 

This approach is called PACS. When 

such a system is installed throughout 

the hospital, a filmless clinical 

environment results. Although there 

are hundreds of PACS installations 

operating throughout the world, 

many are only small, linking, for 

example, the intensive care unit 

with the radiology department, or 

networking a few workstations 

together, and it is questionable 

whether such systems merit being 

described as PACS. There are still 

relatively few truly filmless hospitals 

in existence (3, 4). 

The components of any PACS 

system include the image acquisition 

devices, a system for storage 

and retrieval of data, workstations 

for the display and interpretation of 

images, and a network over which 

to transmit information. 

While digital image capture, distribution, 

presentation and storage 

systems may be configured to support 

virtually any type of application, 

not every configuration is a 

full-fledged PACS. There are roughly 

five classes of digital image systems 

used by radiologist: modality clusters, 

on-call review and teleradiology, 

remote primary diagnosis, mini- 

PACS and PACS.

Modality clusters, whether for 

sonography, nuclear medicine, CT 

or MRI, typically are homogeneous 

groupings of machines connected to 

share printing, soft copy viewing 

and storage resources. 

Teleradiology supports the acquisition, 

transmission and viewing of 

images where the points of acquisition 

and viewing are separated by 

distance. Teleradiology was first 

used for on-call review. Today, the 

technology has matured to the point 

where primary diagnoses may be 

performed remotely. For example, 

teleradiology may be used to send 

images from remote clinics to radiologists 

who are at home or at a 

professional office. While teleradiology 

supports several different types 

of applications, those applications 

all share one characteristic: there is 

little or no image storage. For that 

reason, little image management is 

necessary. 

Mini-PACS is a localized version 

of full PACS. Typically, they let users 

acquire images (as in teleradiology) 

and distribute them quickly. Mini- 

PACS also let users store images for 

a short period of time, usually at the 

point of use. Mini-PACS may be 

used in intensive care units where 

physicians need to keep exam 

images on file for several days. Film, 

however, is still the primary longterm 

storage medium. 

Full-fledged PACS are different 

from teleradiology and mini-PACS 

in two ways. First, full PACS support 

long-term digital image storage – 

the electronic archiving of images. 

Second, PACS support a more flexible 

distribution of images. 

Healthcare facilities may move 

beyond supporting specific departments 

to managing the flow of diagnostic 

images to a wider range of 

physicians. Very often, full-fledged 

PACS will include one or more teleradiology 

subsystems that may 

communicate with central image 

archives. 

PACS hardware 

Digital image acquisition 

PACS must have images in digital 

format, be able to store them, and 

provide access for interpretation by 

radiologists and review by other 

physicians. Images often may be 

directly acquired in a digital format, 

but sometimes they must be converted 

to such a format. Radiographic 

studies already available as 

digital data include CT, MRI, and 

sonography. Recently, some tradi- 

PICTURE ARCHIVING AND COMMUNICATION SYSTEM — DE BACKER et al. 235 

tionally film-based imaging techniques 

(e.g., angiography, fluoroscopy) 

have also moved to digital 

image acquisition. However, the 

main challenge for a digital radiology 

department remains projection 

radiography, such as chest and bone 

films, which still corresponds for at 

least half of the procedures performed 

in radiology. Conversion 

may currently be accomplished 

through one of three technologies – 

use of a film digitiser, CR, or digital 

radiography (DR) (5, 6). 

Digitisation of plain film radiographs 

Conversion of conventional plain 

radiographic film to digital data by 

means of a digitiser is the least efficient 

method. However, it may 

prove useful in radiology departments 

that have a relatively low volume 

of studies. In larger departments, 

it may be useful during the 

transition from a film-based system 

to PACS. Traditional radiographic 

studies may be digitalised so they 

may be easily compared with the 

newer digital images. 

Computed radiography 

CR is a technique that uses conventional 

radiographic imaging 

equipment to obtain digital data. CR 

uses cassettes, which contain, 

instead of film, a re-usable plate 

with photo-stimulable phosphors to 

store the latent image. When an Xray 

photon hits a phosphor crystal 

its electrons are excited to a higher 

energy level where they become 

trapped producing a latent image. 

The image is digitally processed, 

and the digital image is transmitted 

to a processing station for further 

interactive image manipulation and 

to a PACS reporting or viewing station. 

Digital images may then be 

accessed by radiologists, referring 

physicians and other departments 

within the facility. They may also be 

combined with the patient demographic 

data from the HIS/RIS systems. 

The image may also be available 

as a hardcopy via a laser camera. 

Most current PACS systems rely 

on digital storage phosphor radiography 

to provide digital projection 

radiographs (7). However, storage 

phosphor radiography is associated 

with some disadvantages including 

a limited spatial resolution and a 

low-detective-quantum efficiency 

(5). There is still the need for cassette 

handling, and the life 

expectancy of the expensive storage 

plates is shorter than that of con- 

ventional film-screen cassettes, due 

to mechanical strain during storage 

plate readout. Due to its flexible 

handling, storage phosphor radiography 

probably will remain the digital 

modality of choice for bedside 

and intensive care imaging. 

Digital radiography 

DR uses electronic detectors to 

convert radiation that passes 

through the patient directly to a digital 

image without the need for cassette 

handling. The future of digital 

projection radiography will depend 

on new digital receptors based on 

amorphous silicon or selenium (8). 

Dedicated chest imaging systems 

based on amorphous selenium are 

currently available with an excellent 

image quality and signal-to-noise 

ratio (5, 10). Direct digital radiography 

system for general radiology 

based on thin-film transistor technique 

is now also available (5). 

Although DR is the most expensive 

of the three methods, it is also the 

most practical way to obtain digital 

data for plain radiographic studies 

in high-volume departments. A 

major drawback is the solely stationary 

use. Digital receptors based on 

amorphous silicon or selenium may 

also be expected to provide an adequate 

solution for digital mammography, 

which, due to its high spatial 

resolution requirements and 

difficult handling (related to the 

large size of image files) has usually 

remained film based, even in otherwise 

fully digital departments (9, 

11). 

Image archiving 

A typical radiology department 

creates many gigabytes of image 

data per day and several terra-bytes 

(TB, 1012 Byte) of data per annum 

(12). The volume of archived images 

is increasing and will continue to 

rise at a steeper incline than filmbased 

storage of the past (13). Many 

filmless facilities have been caught 

off guard by this increase, which has 

been stimulated by many factors: 

investment in new digital and 

DICOM-compliant modalities will 

result in more images to be 

“brought into” the filmless network; 

CR and DR is becoming more affordable 

resulting in digital plain film 

studies; and multi-slice CT technology 

results in an increasing number 

of images per study. New multi-slice 

CT scanners, for example, may generate 

as many as 800 to 1,000 

images per exam.

236 JBR–BTR, 2004, 87 (5) 

Storage requirements also are 

affected by disaster recovery initiatives 

and state retention mandates. 

Disaster recovery and data storage 

require a backup of imaging data 

that may be quickly recovered in 

case of disaster. This means that a 

second copy of the data must be 

stored, which is most easily accomplished 

electronically. Retention 

requirements vary by nations; 

Belgium, for example, mandates up 

to a 30-year retention for certain 

types of data. 

There are two basic approaches 

to archiving – single tear and multitier 

(13). Each has benefits. With a 

single tear approach, all the data are 

stored on a single media that may 

be accessed very quickly. A redundant 

copy of the data is then stored 

onto another less expensive media. 

This is usually a removable media. 

In this approach, the on-line storage 

is increased incrementally as volume 

grows. In a multi-tier approach, 

a hierarchical architecture, based on 

access speed and cost, is set up in 

three stages with different storage 

media depending on the amount 

and duration of storage and the 

expected retrieval frequency. The 

first stage is on-line storage, where 

information stored is available to 

the user immediately. This is typically 

reserved for data needed during a 

single episode of patient care and is 

readily accessible to radiologists 

and clinicians. The second stage is 

short-term storage intended to provide 

rapid access to studies for comparison 

with current studies, and the 

third stage is deep archival storage 

intended for long-term storage of 

prior images. 

The traditional approach to medical 

image archiving was tiered. This 

means that images accessed most 

frequently were stored on high-cost 

fast-access media, and those less 

frequently accessed were shifted to 

lower-cost slower-retrieval media (5, 

13). Fast but expensive redundant 

array of inexpensive disks (RAID) 

systems are appropriate for shortterm 

storage of up to several days 

or weeks. For inpatients, the RAID 

should ideally be large enough to 

hold all current and relevant previous 

films for the entire hospital stay 

(14). A RAID is a multitude of hard 

disk drives where the information is 

written to all the disks so that it is 

distributed over the entire RAID. This 

means that if any of the disks were 

to fail, only a small proportion of the 

data would be lost. In addition, the 

RAID management software has an 

error-correcting algorithm, which is 

able to rewrite any lost data with a 

high degree of accuracy, so that 

data loss is very unlikely. 

Optical disk jukeboxes, with a 

storage capacity of a single jukebox 

typically between 0.5 and 1 TB, usually 

provide uncompressed on-line 

storage only for a maximum of 1 or 

2 years. Thereafter, many current 

PACS concepts still rely on off-line 

long-term storage of optical disks 

with the necessity to manually reenter 

older disks into the system 

when necessary. With a capacity of 

20 TB or more, tape-based storage 

systems provide an easy, cost-effective, 

and safe way of long-term storage 

even for a large radiology 

department (15, 16). Tape is still the 

top performer in terms of cost and 

capacity for data storage. Data security 

of modern data tapes, with a bit 

loss rate of less than one unrecoverable 

hard error for every 1017 bits 

and an expected data life of 

30 years, is now comparable to optical 

technology (7). However, tape 

still has one of the slowest data 

access times making it more appropriate 

for deep archiving and redundancy. 

Reliability is also of concern 

with tape media, as it is sensitive to 

data loss when exposed to magnets. 

Based on data safety considerations, 

optical write-once read-multiple 

(WORM) technology over rewritable 

magneto-optical (MO) disks 

and tapes has been proposed for 

storage of radiological images (15). 

However, regardless of whether 

write-once or rewritable media are 

used for storage of medical data, the 

archive setup and software must 

ensure data integrity and as far as 

possible prevent fraudulent manipulation 

of imaging data. Moreover, 

data integrity must be protected not 

only during long-term storage, but 

also during the entire chain from 

data acquisition to the long-term 

archive (17, 18). 

As more historical imaging data 

will become filmless, there may be a 

trend toward on-line RAID storage 

of all images as the long-term or primary 

archive. This trend toward online 

storage may be facilitated by a 

predicted continuous, even dramatic 

decrease in hard disk cost-permegabyte. 

For that reason, on-line 

hard disk archiving may become a 

viable storage solution for the primary 

archiving of images. 

Redundant storage and disaster 

recovery may then be addressed 

with a back-up archive on a jukebox 

or shelf-managed media (13). 

Once an image has been 

acquired onto the PACS archive, it 

can never be lost and is always 

accessible. Even if the image is not 

on the short-term archive, it will still 

be accessible when fetched from the 

long-term archive within minutes, 

and available for viewing on the 

ward workstation. Pre-fetching is the 

process whereby previous images 

on a patient are automatically 

retrieved from the long term archive 

onto the short term server, prior to 

the acquisition and viewing of the 

current imaging examination on 

that patient. This software is commonly 

sufficiently sophisticated to 

take the form of an “intelligent prefetch”. 

This means that only a configurable 

number of examinations 

from the same modality and the 

same body part as that currently 

being imaged are pre-fetched from 

the long term archive; it is usually 

only these that will be of relevance 

in making a diagnostic comparison, 

and there is no point in unnecessarily 

overloading the PACS network 

and short term server with data irrelevant 

to the current clinical problem. 

The efficiency of a PACS archive 

also strongly depends on the way 

permanent storage is organized. If 

images are written chronologically 

on a first-in-first-out basis to WORM 

media, later image retrieval will be 

tedious, since images of a single 

patient will be spread over several 

disks. Long term archive will be 

organized more efficiently if images 

of a single patient are first kept in 

temporary storage and are later 

written conjointly to the long-term 

archive, e.g. after the patient has 

been dismissed from hospital. With 

rewritable media, such as MO or 

tape, it is possible to regularly reorganise 

storage to keep all imaging 

data of a patient together (5, 19). 

The amount of data to be stored 

may be reduced substantially by 

using appropriate compression 

techniques. Image compression 

also has the potential of drastically 

reducing network performance 

requirements. Reversible and lossless 

compression is often used in 

long-term storage and allows from 

2:1 tot 5:1 compression rates. About 

15:1 compression for X-ray images, 

and 10:1 for MR and CT images, may 

be obtained with some data loss but 

with essentially no visible change in 

image quality. Irreversible compression 

ratios of up to 40:1 without clinically 

relevant image degradation 

have been reported (20-23). 

However, with any kind of irreversible 

compression, there is at 

least the theoretical risk of losing 

important image information, and

this risk increases with the degree of 

compression. Irreversible compression 

is, therefore, usually not used 

prior to primary reading. 

Network technology 

Efficient PACS operation relies 

heavily on the performance of communication 

infrastructure and networks 

to provide adequate and 

timely delivery of the image data. 

The network and data communication 

components of PACS are probably 

the most technically challenging 

components, and are also closely 

related to the equally challenging 

tasks of image archiving and data 

repository. The success of these 

components relies not only on stateof-the-art 

technology, but also on 

innovative and complex system 

architecture, where both the software 

and hardware components are 

critical (24, 25). 

One can distinguish between two 

basically different network technologies: 

shared medium technologies 

(Ethernet, 10 M-bit/s; fast Ethernet, 

100 M-bit/s, Fibre Distributed Data 

Interface (FDDI), 100 M-bit/s) and 

switching technologies (switched 

Ethernet, 10 M-bit/s per channel; 

Asynchronous Transfer Mode (ATM), 

155 up to 622 M-bit/s per channel) 

(24). In shared medium technologies 

(broadcast networking), the bandwidth 

of the communication medium 

is shared between all instances 

exchanging messages and the bottleneck 

in terms of throughput is the 

bandwidth of the communication 

medium. In switching technologies, 

a switch establishes a point-to-point 

communication (channel) between 

two instances every time it is necessary. 

Each channel has access to the 

full bandwidth of the transport 

medium, the limiting factor being 

the bandwidth of the switch. Image 

transmission time depends on the 

speed of individual connections in 

the network, the overall network 

topology and the number of concurrent 

image transfers that compete 

for the same connections. To enable 

efficient soft-copy reading, image 

retrieval during interactive operation 

should not take more than a 

few seconds (26). It has been shown 

that the average throughput with 

standard Ethernet is only around 3 

M-bit/s despite the theoretical maximum 

bandwidth of 10 M-bit/s (27). 

This translates into a transfer time 

for an uncompressed 10 M-byte (=80 

M-bit) digital image of more than 25 

s, which is not acceptable during 

clinical routine. Connections from 


workstations to the network backbone 

should, therefore, probably 

have a bandwidth of at least 100 Mbit/s 

(27). Among the standard network 

protocols fulfilling these 

requirements are FDDI and fast 

Ethernet, and ATM. Recently, ATM 

has been considered by many 

authors as the networking technology 

best adapted to image communication 

in medicine (28, 29). With 

ATM, a memory-to-memory transmission 

rate of up to 80 M-bit/s may 

be achieved, which reduces the 

transfer time for a 10 M-byte image 

to around 1 s. An ATM network provides 

an aggregate bandwidth and 

throughput that seems sufficient to 

satisfy the needs of image communication 

in radiology. The use of an 

ATM network allows the use of up to 

90% of the channel bandwidth (usually 

155 M-bit/s). The switches in an 

ATM network establish point-topoint 

communications. Up to the 

maximum bandwidth of the switches 

(aggregate bandwidth), the 

throughput of an ATM network does 

not decrease with the number of 

communicating instances. In contrast 

to Ethernet Local Area 

Networks (LAN), ATM networks also 

may operate as wide area networks 

(WAN), allowing communication 

over greater distances (for teleradiology 

purposes). The speed of ATM 

networks allows access to images 

stored on an image server even 

faster than images stored locally on 

the hard disk of a standard workstation 

(24). This enhanced network 

speed, together with an intelligent 

and powerful image server architecture, 

may simplify the architecture 

of future PAC systems because the 

complex and time-consuming 

strategies of preloading (pre-fetching 

at times of low network travel) 

and auto-routing (newly acquired 

images automatically transferred to 

the appropriate reading workstation) 

are no longer necessary. The 

ATM networks may be combined 

with switching Ethernet technology, 

reserving the more expensive ATM 

links for high-throughput workstations 

and servers (image and database 

servers, workstations in the 

radiology department, intensive 

care units and the operating room) 

and using cheaper Ethernet links for 

simple viewing stations on wards. 

Viewing stations 

A viewing station gives access to 

all stored images in a PACS environment. 

Ideally it also integrates 

access to other information stored 

in the RIS and the HIS. Many different 

viewing station designs have 

been implemented over the past 

years. With respect to their main 

function, different types of viewing 

stations may be distinguished (24). 

The diagnostic viewing station 

(DVS) is used in radiology department 

for primary diagnosis. It consists 

of expensive, high-resolution, 

high-luminance monitors. The result 

viewing station (RVS) gives access 

to images and reports outside the 

radiology department, possibly 

from outside the hospital. Usually, it 

is a low-cost system with standard 

hardware, using graphic hardware 

of good quality. The http viewer is 

used for access of images and 

reports from outside the radiology 

department, sometimes even outside 

the hospital, runs on all computer 

systems equipped with a 

WWW browser and is soft- and 

hardware independent. The presentation 

viewer allows presentation of 

radiological images to a large audience 

during case conferences and 

consists of a fast and easy-to use 

system connected to a video beamer 

for better visibility to large audiences. 

As they constitute the interface 

to the system, all of these viewing 

stations are critical factors for 

the success of PACS in the hospital. 

Due to the high costs of a DVS, most 

PACS installations distinguish 

between two or three different types 

of viewing stations. 

Diagnostic viewing station 

The DVS will be the routine workplace 

of the radiologist. The DVS 

must be able to display examinations 

from all modalities (multimodality 

viewing station) in a diagnostic 

image quality. Easy access to 

historical examinations and reports 

must to be guaranteed. Spatial resolution 

requirements strongly 

depend on the type of image material 

viewed (5). Whereas 1-k monitors 

are sufficient for viewing of fluoroscopic 

or angiographic images, only 

modern 2 x 2.5-k high-resolution 

monitors are able to display the full 

resolution of large-format digital 

projection images, notably chest 

radiographs. In terms of graphic 

hardware, the minimum configuration 

required by most authors is a 

solution with two cathode-ray-tube 

(CRT) monitors of 2000 x 2000-pixel 

resolution and high luminance (> 

500 lumen) with a high dynamic 

range (30). The CRT units must guarantee 

sufficient image geometry. As 

individual differences between CRTs

238 JBR–BTR, 2004, 87 (5) 

are often encountered, the monitors 

should be selected in pairs with the 

same image characteristics (same 

brightness, same phosphor colour). 

More than two monitors may be 

useful for comparison to previous 

examinations but require more 

space. 

Ageing of CRTs with subsequently 

decreasing luminance and resolvable 

spatial resolution is a potential 

problem and appropriate quality 

monitoring of soft-copy displays are 

necessary in a PACS environment 

(31). 

Result viewing station 

The RVS are mainly intended for 

access to radiological images and 

reports on the clinical wards and at 

outpatient clinics. For economic reasons, 

the hardware is less powerful 

than the DVS hardware. The use of 

standard PCs allows use of the same 

hardware for purposes other than 

PACS purposes. For the acceptance 

of PACS by non-radiologists, the 

RVS should be very simple to use in 

order to avoid extensive user training. 

The RVS should be able to present 

the radiological image together 

with the radiological report because 

of the non-diagnostic quality of the 

graphic hardware. However, there 

are some areas in the hospital 

where higher quality two screen 

diagnostic workstations may still be 

necessary. These should probably 

be located in the intensive care 

units, emergency department, and 

within a communal area accessible 

to the outpatient consulting rooms. 

Http viewer 

One of the most significant developments 

in PACS over the last years 

has been the exploitation of conventional 

web browser technology to 

access images from a short term 

PACS server and display them on 

ordinary desktop personal computers 

(PC). This has provided a cheap 

and easy means of reviewing 

images and has facilitated the development 

of teleradiology whereby 

doctors may review emergency 

images from their homes at night. 

This would be expected to be a beneficial 

development if it means that 

there will be greater recourse to 

senior medical opinion for difficult 

emergency cases (32). 

Ergonomics 

Initially, the ergonomics of the 

PACS work environment have 

severely been neglected. Workstations 

were placed in radiologists’ 

individual offices, which had not 

been prepared for softcopy reporting. 

The office windows were 

already shuttered to allow conventional 

reporting, but no alterations 

were made to the fluorescent lighting. 

Monitor placement was critical 

to avoid ambient light reflections 

from screen. In most present PACS 

installations noisy computer workstations 

and hard disks are situated 

right next to the reading area, where 

radiologists are expected to work 

with concentration for long hours. 

Air conditioning is often insufficient 

to cope with the additional heat 

from the computer workstations 

and monitors. In most cases an 

additional computer with a second 

monitor, keyboard and mouse is 

necessary to provide RIS functionality 

for a PACS view-station, e.g. to 

create or look up a report. 

Planning special reporting areas 

or creating new radiologists offices 

during departmental extensions 

may improve performance of the 

user in a PACS environment (5, 33). 

These have computer-type benching, 

mid-wall height trunking for 

electricity sockets, computer network 

outlets and telecoms, special 

light fittings and vertical variable 

window blinds, separate computer 

rooms with noise shielding and air 

conditioning. In particular, lighting 

must give no reflections from monitor 

screens and should be of the 

order 500 lx maximum and dimmable. 

Seating distance from the monitor 

will depend partly on its size to 

avoid excessive neck and eye movements. 

This is another reason to 

choose smaller monitors – apart 

from their cost. It must be possible 

to be able to look away from screens 

towards distant objects at 20-min 

intervals to rest eye muscles and in 

order to minimise eyestrain. Noise 

reduction will also be important 

with implementation of voice recognition. 

Furniture should be comfortable 

and supportive. Decor should 

consist of restful colors. The PACS 

and RIS functions should be integrated 

into a single workstation 

obviating the need for multiple separate 

computers. 

PACS software 

Interfacing of digital image generation 

systems 

Any digital imaging equipment 

has at least two inputs and one output. 

The image data are generated 

by the imaging device itself (CT, 

MRI) or introduced via an imaging 

plate (CR). The patient data are usually 

entered manually via keyboard. 

The image data leave the system 

together with patient and examination 

data to be printed or stored in a 

digital archive. 

Until recently, the connection of 

an imaging device to film printers 

relied on industry standards or proprietary 

protocols; the connection to 

an archive was entirely based on 

proprietary, vendor-specific design 

of image and data communication 

between individual PACS components. 

Through the effort of the 

American College of Radiology and 

the National Electronic Manufacturers’ 

Association, who established 

a joint committee to develop a standard 

for medical image communication, 

a more open, vendor-independent 

PACS architecture has been 

developed. The Digital Imaging and 

Communications in Medicine 

(DICOM) standard with its 3.0 version 

release in 1993 has finally made 

standardized image communication 

between PACS components of different 

vendors a reality. The adoption 

of the DICOM standard presently 

allows the connection of most 

recent imaging devices to a DICOMcompatible 

archive and printers (34, 

35). Older modalities have to be 

connected to the archive using socalled 

gateways, which translate the 

proprietary image format into a 

DICOM-compatible format. DICOM 

defines a network protocol that 

allows devices on the network to 

negotiate services to be performed 

(e.g., store, query, retrieve, print). 

Manufacturers must provide a “conformance 

statement” that describes 

how DICOM has been implemented 

for a given device and what services 

the device supports. 

The use of DICOM externally is a 

critical component of PACS architecture. 

For various reasons, such 

as achieving better image transfer 

efficiency, many modalities and 

PACS do not maintain strict DICOM 

representation internally for storage 

or communication (36). Most 

remaining problems in DICOM 

communication are caused by the 

so-called shadow groups in DICOM, 

which may be used by the manufacturers 

to store proprietary information 

(27). If information relevant 

for further processing (e.g. slice 

position of CT or MR images) is 

stored in undocumented shadow 

groups, this information may no 

longer be available after transfer of 

images to a DICOM device from a 

different manufacturer. Some manufacturers 

even continue to use

non- or pre-DICOM communication 

standards between their modalities 

and workstations with a special 

gateway to the outside DICOM 

world (5). 

PACS-RIS-HIS integration 

A fundamental tenet of current 

PACS implementations is that 

images should not be available 

without information. Therefore, each 

PACS has a mechanism for linking 

the pertinent patient information 

(e.g. demographics, clinical history, 

allergies) with the image. Each 

image data set must be “labelled” 

or identified with a specific patient 

and linked to a patient folder or 

some other useful construct within 

PACS. Therefore, there are two components 

to a PACS archive. One 

component is the database that 

maintains patient metadata information 

and the other component is 

the file server that actually stores 

the image data sets (37). 

Current PACS with secure 

Internet or Intranet web techniques, 

enables rapid and simultaneous 

access to images in different physical 

locations. With prompt interpretation 

and voice recognition technology, 

reports should be available 

rapidly and may automatically be 

associated and delivered with the 

images (36). However, such successful 

PACS implementation requires 

RIS and HIS integration. 

Many institutions already have a 

HIS or RIS in place in addition to the 

PACS information system. Ideally, 

these systems should be integrated 

for image management. The most 

important roles of HIS related to 

PACS are to provide a “clean” master 

patient index that identifies 

every patient uniquely on a one-toone 

basis, as well as to provide 

admission, transfer, and discharge 

information. The RIS provides notification 

of events – particularly the 

scheduling of an imaging procedure, 

with relevant clinical information. 

The RIS provides unique identification 

of the imaging procedures 

requested and performed, allowing 

PACS to handle and archive them 

unambiguously, and to associate a 

diagnostic report with each 

study (36). 

Problems may occur even with 

highly integrated PACS-RIS-HIS. 

One of the most bothersome is that 

the PACS database, even with the 

best pre-fetching, usually is 

unaware of prior studies existing 

only on film. In addition, the present 

RIS database usually does not dis- 


tinguish between studies on film 

and those archived digitally, without 

film (36). 

For most cross-sectional examinations, 

such as CT and MRI, the 

technologist manually enters 

patient demographic information 

into the acquisition device. The 

study and associated information 

are then “pushed” into PACS via a 

gateway (preferable using the 

DICOM standard). PACS then needs 

to handle or deal with both the 

image data set and associated information. 

If a HIS/RIS/PACS communication 

link is in place, then PACS 

attempts to match the incoming 

study with what exists on its database. 

If a discrepancy occurs, PACS 

may reject the study (i.e., not allow 

into the system), place it on the special 

list (e.g., “unspecified folder”, 

“exceptions list”, or “penalty box”), 

or create a new patient folder (i.e., 

new study) with the erroneous data. 

This scenario is not uncommon 

because dual entry of patient information 

is fraught with problems, 

including a substantial potential for 

misspelling and other alphanumeric 

data errors (e.g., transpositions). 

Another problem that is not specific 

to digital image storage but in a full 

PACS environment occurs when a 

patient has been assigned a new 

patient identification number in the 

HIS or RIS on a repeat visit to the 

hospital. This results in previous 

images not being found in the PACS 

archive. In both situations operator 

intervention is required to rectify the 

situation. An operator must then 

have access to a PACS workstation 

to identify the problem and accomplish 

a solution “after the fact” (5, 

38). 

PACS should be considered part 

of the hospital infrastructure with 

distribution of radiological images 

throughout the hospital. Through an 

appropriate HIS/RIS/PACS interface, 

the current location of a patient in 

the hospital is made known to PACS 

to enable the correct distribution of 

images to the clinics and wards. In 

the future, viewing of radiological 

images should become an integrated 

part of the HIS. Both to assure 

data security of the PACS archive 

and to provide fast access to the 

users, image distribution throughout 

the hospital should be accomplished 

by using one or more separate 

image servers (5). 

PACS workflow 

Early PACS installations focused 

on just providing the most basic 

PACS functions, image retrieval and 

viewing. Workstations were rather 

clumsy and tended to reflect a lack 

of experience and understanding of 

radiologists’ work habits. Continuous 

technological improvement and 

better understanding of workflow 

within PACS resulted in a broader 

level of acceptance by radiologists. 

Workstation design and system 

architecture have improved as many 

institutions and manufacturers 

actively involved radiologists in the 

design process, resulting in the 

development of user-friendly workstations 

that are more suitable for 

the radiologists’ task. 

The smooth flow of images to the 

location at which they are needed, at 

the time they are needed, and displayed 

in the preferred manner as 

required by the radiologist to 

achieve both with efficiency and 

high diagnostic accuracy, requires 

management of the studies. This 

study management, often referred 

to as folder management, provides 

PACS with intelligent functionality 

for image acquisition, routing, storage, 

presentation, and retrieval 

functions (36,39). For example, 

when a patient is scheduled for a 

given type of procedure, the workflow 

manager will know where the 

images are likely to be viewed, what 

prior studies are relevant and prefetch 

these studies from the longterm 

archive and then to the workstation 

before the arrival of the 

images from the current study. 

Reports from prior procedures will 

be available at the workstation. 

When the study is completed the 

images are automatically sent to 

PACS and routed to the appropriate 

workstation. When the new study is 

called up for review, images appear 

in the correct sequence and at the 

appropriate window width and 

level. Prior images are available 

immediately for display. 

To ensure an ergonomic interface, 

an operating system based on 

the windows metaphor may be used 

for the viewing station. Image preprocessing 

with its potential to 

improve visualization of certain radiographic 

findings may often be very 

time-consuming with current workstations 

and, therefore, is rarely 

used in clinical routine. However, 

many preprocessing tasks could be 

automated by appropriate software. 

Automatic arrangement of images 

in pre-set orders and managed by a 

rule-based system may be provided. 

In soft-copy viewing of radiological 

images, it is often desirable to block 

out white, unexposed image areas.

240 JBR–BTR, 2004, 87 (5) 

Current workstations may provide 

dark shutters to manually exclude 

peripheral white image areas from 

being displayed. With appropriate 

segmentation software, this task 

may be automated. Automatic 

optimisation of window settings, 

image enlargement (zoom) and 

translation (pan) are other examples. 

In addition to conventional 

viewing of CT and MRI examinations, 

the DVS may provide the possibility 

to scan through virtual stacks 

of images (stack or cine-mode) or 

may allow stepping parallelly 

through two or more stacks of 

images (actual and previous examination, 

examination without and 

with contrast medium, different MR 

sequences) resulting in faster interpretation 

and reporting time. Finally, 

some calibrated quantification functions 

are needed: spatial measurements 

(length, surface, volume) and 

density measurements (in Hounsfield 

units for CT). 

For the acceptance of PACS by 

non-radiologists, the RVS should be 

very simple to use in order to avoid 

extensive user training. The RVS 

should be able to present the radiological 

image together with the radiological 

report because of the nondiagnostic 

quality of the graphic 

hardware. Image manipulation function 

may be limited to image rotation 

and centre-window adjustment; 

the images should be presented in a 

way that demonstrates the radiological 

findings. Specialized RVS may 

integrate programs for planning of 

surgical interventions such as the 

measurements of the dimensions of 

a total hip prosthesis. 

Conclusion 

Information technology has 

become a vital component of all 

health care enterprises and large 

hospital networks provide the basis 

of hospital-wide information. The 

technologic imperative that has 

been the driving force advancing 

radiology over the past 20 years has 

produced new approaches to the 

acquisition of medical images and 

placed radiology at the leading edge 

of the computer-technology era of 

modern medicine. Ever-increasing 

computer performance in combination 

with the advent of the communication 

standard DICOM makes 

PACS a reality with numerous small 

and middle-scale installations, but 

also with several truly filmless hospitals 

in operation all over the world 

(3). PACS is responsible for solving 

the problem of acquiring, transmitting, 

and displaying radiological 

images. Integration of PACS with 

the HIS and RIS facilitates more 

informed and presumably more 

accurate interpretations (40). 

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CONSIDERATIONS FOR PLANNING AND IMPLEMENTATION 

A.I. De Backer 1 , K.J. Mortelé 2 , B.L. De Keulenaer 3 

38. Andriole K.P., Avrin D.E., Yin L., et al.: 

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the folder manager concept. J Digit 

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Installing Picture Archiving and Communication System (PACS) has very wide implications on the radiology department 

and the hospital as a whole. PACS is an entire hospital investment, which will change many professionals’ 

working practices. Its selection and implementation must involve all the groups it will affect and this demands an 

appropriate approach. Developing processes that establish the needs of the users, support strategic initiatives, and 

address risk management is not a minor undertaking.The development of a plan that provides PACS selection committees 

with a step-by-step roadmap to seek and procure PACS best suited to their workflow is a valuable tool.This 

review considers the process of planning and implementation for PACS. 

Key-word: Picture archiving and communication system (PACS). 

Over the last 10 years, PACS has 

become established as a credible 

alternative to the traditional filmbased 

radiology service (1-5). To 

integrate PACS into the radiology 

department and hospital it is critical 

to follow a standard plan, or 

sequence of planning elements, to 

lay a solid foundation for each project. 

Therefore, planning and implementation 

of PACS must begin with 

a clearly stated mission, a leadership 

statement and financial 

accountability. Distinct phases may 

be identified in the planning process 

in which critical questions must be 

formulated and answered. A strategic 

and financial plan must be established, 

a timeline created, marked 

research performed, program 

design developed, and training programs 

designed before implementation 

may be performed. 

Dreaming about PACS 

Dreaming about the purchase of 

PACS will start by identifying the 

significant operational issues and 

the stakeholders, and by considering 

how PACS will help resolve 

problems. Issues that may be associated 

with enterprise risks, operational 

expenses, service delivery, 

and that impact many stakeholders 

are more likely to gain senior 

administration attention and financial 

support. Furthermore, the enterprise’s 

other major strategic initiatives 

should be considered in relation 

to the PACS initiatives (6). As a 

consequence, many questions must 

be answered right from the start to 

ensure that the planning, development, 

and implementation phases 

will move smoothly; for example, 

What is PACS and what are its pro- 

From: 1. Department of Radiology, Ziekenhuisnetwerk Antwerpen, Stuivenberg, 

Antwerpen, Belgium; 2. Department of Radiology, Division of Abdominal Imaging and 

Intervention, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 

02115, USA; 3. Intensive Care Unit, Royal Darwin Hospital, Rocklands, 0810, TIWI, 

Northern Territory, Australia. 

Address for correspondence: Dr A.I. De Backer, M.D., Department of Radiology, 

Ziekenhuisnetwerk Antwerpen, Stuivenberg, Lange Beeldekensstraat 267, B-2060 

Antwerpen, Belgium. 

posed services? Is there a true need 

for the new technology? Who are the 

stakeholders? How will the organization’s 

shareholders benefit from 

this technology? Does PACS align 

itself with the company’s overall philosophy? 

Are the cost-benefits of 

PACS real or imagined? What does it 

take to prove cost-effectiveness? 

What is the lifecycle of PACS? What 

are the financial and managerial 

demands of implementation? May 

existing staff or equipment 

resources be reallocated to support 

the new program? If not, what is the 

availability of staffing resources? 

Can funding be reallocated from the 

existing budget? Does the company 

have the resources to research the 

market’s need for PACS? What type 

of managerial and operational structure 

will the PACS program require? 

Are there any legal or regulatory 

issues surrounding PACS? What are 

the company’s strengths and weaknesses 

with regard to PACS? 

Issues and concerns 

The introduction of PACS technology 

may creates several issues and 

concerns related to physician acceptance, 

confidentiality, security and 

reliability (7).

242 JBR–BTR, 2004, 87 (5) 

Physician acceptance 

Physician acceptance may be hindered 

by the following factors: computer; 

unfamiliar working environment; 

softcopy reading; query/ 

retrieval by oneself rather than 

having the films hung by a technician; 

voice recognition instead of 

dictation/transcription; signing of 

reports electronically. 

Confidentiality 

Traditionally, doctors have maintained 

patient information confidentiality. 

As health care organizations 

handle the same information electronically 

for doctors, confidentiality 

must be maintained. 

Security 

Software lock/key protection is 

more vulnerable than physical locks. 

It is easier to copy or modify an electronic 

medical record than a hard 

copy, and at the same time, it is 

harder to detect the occurrence of 

any illegal break-in. Better products 

to implement flexible encryption 

setting, log incoming/outgoing communication 

and auditing/reporting 

tools are needed. 

Reliability 

In general when networks suffer 

downtime, you get the service you 

pay for. If you need 24-hour, sevenday-a-week 

coverage with one-hour 

response time, you’ll have to pay for 

it. 

Redefining the vendor-customer 

relationship 

The traditional relationship 

between vendor (as equipment supplier) 

and customer (as end-user of 

the technology) undergoes a major 

change with PACS (8). With CT or 

MRI, one purchases or leases the 

equipment and has it installed; this 

is followed by clinical applications 

and subsequent long-term use of 

the technology. With the exception 

of maintenance/service the relationship 

between vendor and customer 

essentially ends, until the next 

equipment purchase is anticipated. 

For PACS implementation to be 

successful, a different relationship 

exists between vendor and user. 

This takes the form of a long-term 

partnership, which does not simply 

end after delivery and installation of 

the equipment. Because PACS is not 

a “plug and play” technology, myriad 

technical, clinical, workflow and 

political issues arise after delivery 

and installation. To successfully 

resolve these matters, ongoing collaboration 

between multiple parties 

is required. On the user side (hospital), 

the collaboration involves radiologists, 

technologists, clerical staff, 

administrators (in and outside of 

radiology), information technology 

specialists, engineering, referring 

clinicians (and their staff), and nursing. 

On the manufacturer side, collaboration 

requires participation by 

all vendors involved in the entire 

PACS/HIS network. To date, no single 

vendor offers a true “turnkey” 

approach. 

The end result is that, upon delivery 

of the equipment, the challenge 

escalates. It is in the best interest of 

all involved parties to forge an honest, 

open, long-term relationship of 

the transition to PACS if it is to be a 

success. 

Planning stage 

Planning steps are relatively simple. 

However, if planning is skipped, 

it may create serious blocks on the 

path to implementation of PACS and 

may deliver less than desirable outcomes. 

Successful planning for PACS 

requires an enterprise wide 

approach. This involves identifying 

key players to develop a plan and to 

implement a decision structure that 

is both consultative and efficient. 

Composition of the selection committee 

(SC) is vital and should 

include both a project leader and 

stakeholders. A project leader, who 

has both the authority to support 

the project and a commitment to the 

project’s success, should be identified 

to lead the project. In the past, 

the radiology manager or the 

department chairman typically was 

identified as the project leader, but 

this role may be delegated to someone 

else within or outside the 

department (e.g., administrative 

director of information technology 

systems (ITS)). Key personnel must 

be selected from all aspects of the 

operation to form a core project 

team. Stakeholders in planning 

PACS are senior administration, 

radiologists, diagnostic imaging 

staff and administration, information 

technology services, referring 

clinicians (e.g., from the following 

departments: emergency room, 

surgery, orthopaedics, intensive 

care unit, obstetrical/gynaecology), 

ward and clinic staff, and other speciality 

disciplines reliant on diagnostic 

imaging and reports. 

Creation of vision and mission statements 

The first objective of the SC is to 

create vision and mission statements. 

Each member of the SC may 

have a different idea of what PACS 

means, with individual definitions 

related to their job titles (3). 

Technical and clerical staff may see 

PACS as the elimination of their 

work involving the handling of film – 

processing it, hanging and filing 

films, and looking for, delivering 

and retrieving films. The RIS manager 

may see PACS as an extension of 

the information system with a problem 

to integrate the RIS and PACS. 

The ITS representative may see 

PACS as key to acquiring medical 

images for the computed patient 

record system and may consider the 

power of distributing images and 

information throughout the enterprise. 

The radiologists may foresee 

changes on everyone’s workflow. 

Referring physicians may have 

questions about the change to electronic 

imaging and what soft-copy 

display might mean for them. 

One must have a clear idea of 

why to introduce PACS. The challenges 

facing each department will 

be different but the goals must be 

articulated and honest (9,10). Going 

into a new hospital may offer the 

opportunity to dispense with a film 

filing room, film-handling areas, 

film storage at ward and department 

level and to opt for integration of 

images into an electronic patient 

record system. A common entry 

point into PACS is the urgent need 

to develop teleradiology. 

Redeveloping the radiology department 

may give the opportunity to 

introduce a filmless environment 

gradually extending out to the ward 

as money and opportunity allow. All 

CT and MRI examinations may be 

put onto a single network as a starting 

point. There have been some 

intentions to implement PACS in a 

‘big bang’ (i.e., all at once) throughout 

a hospital, but they are in the 

minority, and generally are only feasible 

in a new institution (10). 

The ideas from dreaming about 

PACS, together with a list of primary 

needs identified by key stakeholders 

(e.g., obtained during an interview 

process), will be valuable for the SC 

to create Vision and Mission 

Statements. A detailed SWOT 

(strengths, weaknesses, opportunities 

and threats) analysis, with a 

focus on the status of “electronic 

preparedness”, ensues (11). With 

respect to internal strengths and

weaknesses, an inventory of technologic 

requirements must be made. 

This inventory of technologic 

requirements must include modalities 

and DICOM readiness, hardware 

requirements (workstations, 

servers, archives), network status, 

implementation timelines, maintenance 

requirements and upgrade 

issues. Certainly, these requirements 

are associated with costs, 

and these costs must be factored 

into the project analysis. Equally 

important are the human resources 

that are required to implement, 

maintain and support the project; 

they will determine its success. 

The role of the parent organization 

is important and must be 

analysed. Is the culture conservative 

or progressive? What is the current 

level of technologic sophistication 

within the organization? What is the 

organization’s track record with prior 

information technology projects? 

External opportunities and threats 

must also be factored into the analysis 

and the status of the electronic 

imaging market must be considered. 

With respect to environmental 

issues, project planners must maintain 

an awareness of increased government 

scrutiny and regulations. 

A dedicated vision and mission 

statement establishes a direction 

the enterprise will move toward, 

adequately represents the need of 

users, and supports enterprise-wide 

strategic initiatives such as the electronic 

medical record. A mission 

statement demonstrates its value by 

providing the SC with high-level 

objectives that support the vision 

statement. A vision and mission 

statement concerning PACS may 

include primary goals and longer 

term goals. The primary goals for 

PACS implementation are: make 

images available to any physician 

who needs to see them, with images 

and reports to be combined in an 

integrated solution; increase the volume 

and decrease the backlog of 

scheduled exams in the radiology 

department; increase productivity of 

physicians and radiologists while 

retaining the same sized staff to 

handle a larger volume of exams; 

increase the reliability of locating 

exams in archives. Longer-term 

goals are to reduce, redirect or reeducate 

staff to work smarter; 

reduce storage costs of purging 

records; and eventually, reutilize the 

space used to store films. 

Development of strategic plan 

The extent of PACS implementation 

or scope must be established as 


early as possible and maintained. 

Project add-ons that result from new 

objectives or new programs are best 

left as complementary implementation 

phases for new funding allotments 

(12). The strategic plan 

becomes the roadmap for the PACS 

initiative and describes problems, 

defines needs, and proposes solutions. 

Key elements in the strategic 

plan include objective and desired 

outcome, description of issues, definition 

of needs, proposed solution, 

scope of project, resources required 

( financial, human, and physical), 

roles and responsibilities of SC, 

due-diligence process including 

time lines, policies, procedures, and 

strategic guidelines, quality of 

implementation, Strengths, Weaknesses, 

Opportunities, Threats 

(SWOT) relative to PACS, and proposed 

configuration scheme 

Collection stage 

The collection stage documents 

the current environment and provides 

the baseline for change. 

Required-skill sets 

To successfully complete the collection 

of data the SC requires diagnostic 

imaging experience, computer 

hardware and network knowledge, 

and expertise with clinical, 

financial, and hospital systems. 

External resources, such as new 

employees or consultants, may be 

required in situations where the SC 

is deficient. 

Workflow analysis 

PACS may not provide the 

expected advantages if changes are 

not instituted in the different 

processes and workflow of the 

department at all levels. An exhaustive 

workflow analysis must be carried 

out and this may allow the reorganization 

of a number of processes 

in the department at the clerical, 

technical, and medical levels (6). 

The workflow analysis must provide 

current and projected examination 

volumes (e.g., volume of studies 

per day, peak volume per hour, 

distance from imaging suites), 

workflow strengths and weaknesses, 

and staffing levels. Other important 

subjects are the cost per examination 

by modality, the overall 

operating expenses with film including 

staff, supplies, and equipment 

service cost. The current demand to 

view films (e.g., over the counter, at 

clinics, external requests); the critical 

response times (e.g., exam com- 

pletion to being reported, being 

reported to being transcribed); the 

percentage of pull requests filled 

and unfilled in the film library and 

the percentage of lost films are evaluated. 

Special needs obtained from 

exhaustive workflow analysis will 

establish unique workflow requirements 

for each stakeholder. For 

example, the emergency department 

setting and intensive care unit 

probably will instantly have access 

to the images as they are acquired. 

The flow of images to the location at 

which they are needed, at the time 

they are needed, and displayed in 

the preferred manner as required by 

the radiologist to achieve both with 

efficiency and high diagnostic accuracy 

requires management of the 

studies. An intimate understanding 

of existing workflow patterns will 

significantly aid in the selection of 

PACS that will provide workflow that 

meets today’s requirements and has 

flexibility for reconfiguration in the 

future. 

Training requirements 

Not only is there a challenge to 

inform clinicians about the radical 

changes in practice which PACS 

brings (no more looking at films 

against the nearest window) but the 

impact of training on the hospital, 

especially if PACS is hospital-wide, 

should be considered carefully. Not 

only will all the radiographers and 

radiologists require several hours of 

training to use the system at maximum 

efficiency, but every other user 

of images will need training, including 

referring physicians, nurses, 

physical therapists, etc. Many junior 

medical staff change appointments 

at one-year intervals. The minimum 

PACS training, however computer 

literature, both hospital-wide and in 

the radiology department, is provided 

to produce adept users whilst 

appreciating that hospital staff, 

especially busy junior doctors, are 

loathe to sacrificing time to a training 

program (13). If PACS is hospital-wide, 

setting up and maintaining 

a training program may be advocated. 

Vendors offer a wide variety of 

training packages. Some have a service 

engineer who trains new users 

for a few hours and then leaves 

them on their own. Other vendors 

have a staff of dedicated training 

specialists who roam the country 

and provide training wherever they 

are needed. More and more, vendors 

are advocating the train-thetrainer 

concept, where the vendor

244 JBR–BTR, 2004, 87 (5) 

trains an in-house resource, who 

then is responsible for training inhouse 

staff (14). 

Information system integration 

It is necessary to determine the 

requirements and costs of interfacing 

PACS with existing applications 

on the current network. Specification 

of the network communication 

infrastructure, either existing or 

new, and inclusion of wide-area network 

connectivity to clinics and 

physician offices or homes, based 

on required transfer times, availability, 

reliability and cost are other 

important issues. Furthermore, the 

make and versions of HIS and RIS 

and current enterprise security protocols 

must be known. 

PACS component requirements 

report 

A PACS component requirements 

report lists the PACS equipment by 

component and the integration 

requirements to meet a desired 

quality of implementation. What are 

the requirements for each major 

function? For example, what are the 

important functions for a workstation: 

image manipulation and processing, 

supported “hanging” protocols 

depending on the application, 

image quality, number of screens, 

performance? The same applies for 

the archive and database management 

system – what is the required 

capacity, the access time, workflow 

support (pre-fetching), and performance 

standards? Surveying the 

marketplace will provide current 

trends and changes in technology 

that should be included, such as 

changes in archive long-term storage 

media. The report outlines the 

required storage, network, functionality, 

integration, and network 

performance requirements and provides 

the requirements needed to 

write the request for information 

(RFI) and request for proposal (RFP). 

Physical needs 

Physical layout is often an overlooked 

aspect of PACS projects. 

Details of room design, storage, 

lighting and communications needs 

have a tremendous impact on effective 

utilization. A functional analysis 

of the PACS project with evaluation 

of the actual layout may help for 

finalizing design details. Having the 

proper room design and comparing 

it to the required functions and work 

flow will be crucial in enabling the 

equipment to be properly utilized. 

Outline business case 

PACS systems can range from 

hundreds of thousands to millions 

of Euros. Developing a realistic budget 

that is adequate, not only to 

cover initial installation and start-up 

costs, but for the life of the system is 

necessary for successful PACS 

implementation (5,6,11,15). A successful 

business case compares the 

cost of operations in a film environment 

with the projected costs in a 

PACS environment. It is important to 

create a budget based on what is 

currently spend on film, film processing 

and handling, full-time 

equivalents, capital equipment that 

will need to be replaced if not buying 

PACS, storage costs/restraints, 

as well as growth of the department 

and available capital. Projections 

should also include all hidden costs, 

such as facilities remodelling, telephone 

and modem capability. The 

costs of capital equipment 

upgrades, to meet DICOM compliance 

standards or to enable the creation 

of modality work lists, must be 

accounted for. The equipment costs 

for workstations, servers, brokers, 

archives, digitizers and viewing stations 

must be calculated. Network 

creation and maintenance will also 

have assigned costs. An oftenignored 

issue is the human resource 

allocation that is required to implement, 

maintain and upgrade the 

system. Who will cover cost overruns 

for installation, service or 

upgrades, if they occur? Three prime 

areas need to be investigated: cost 

avoidance, productivity gains, and 

revenue-generation opportunities. 

The cost per examination is calculated 

with the supplies, staff, and service 

costs in both environments. 

Unrealistic claims must be avoided 

regarding improved throughput and 

reductions in staffing and expenses. 

Perhaps those could be achieved 

under ideal conditions elsewhere, 

but whether or not they can be 

achieved at your institution is key. 

Attempt to undersell, or at least conservatively 

sell, what will be 

achieved so expectations can be 

met or exceeded. Overselling has 

two very serious results. One is that 

you have doomed the project to failure. 

The second is that it will be 

much more difficult for you to gain 

approval for future requests (15). 

The scope of the project and capital-financing 

plan will impact the 

business case outcome. Consider 

the following three payment methods: 

a capital purchase, an operating 

lease, and an application service 

provider. The method of payment 

chosen affects the business plan significantly 

(6). 

The business case is critical for 

senior administration approval to 

implement PACS. 

Investigation stage 

Share information 

The more information shared 

between the institution and the 

potential vendors, the better off 

everyone will be (14). If a vendor 

does not know exactly what the 

objectives are – what the new acquisition 

needs to achieve and the characteristics 

of the institution – the 

proposed system cannot be expected 

to meet the specified needs. It is 

essential to share as much information 

as possible. 

What is the problem to be 

solved? The introduction of any RFP 

should state objectives, such as 

eliminating film loss, increasing 

turnaround time, simultaneous 

access in the intensive care unit, 

emergency radiology or radiology 

department to increase efficiency, 

etc. In addition, one should list hospital 

characteristics, such as the 

number of its procedures, 

images/exams, a complete list of 

acquisition modalities and its 

expected growth rate. Further, clinical 

scenarios, from patient entry 

through discharge within radiology, 

are important so that a vendor can 

match the workflow. 

The investigation of options is 

probably the most time-consuming 

portion of the analysis. It is in this 

stage that the system architecture is 

drafted. This draft is both determined 

and refined by input from 

multiple individuals and groups. 

Important contributions must be 

solicited from the information technology 

division, radiologists and 

other physicians, hospital administration 

and any other service where 

the use of imaging technology information 

is required and beneficial. 

Vendors and consultants may be 

extremely valuable in generating 

workflow diagrams, which include 

imaging acquisition components 

and imaging display components 

(11). 

Request for information 

A well-designed RFI may be a 

means to meeting the various needs 

for successful PACS implementation. 

A detailed inventory of imaging 

equipment, imaging equipment

locations and use, imaging equipment 

DICOM compatibility, imaging 

equipment upgrade requirements, 

reading locations and user locations 

must be obtained and confirmed. 

The extent and requirements, reading 

locations and user locations 

must be obtained and confirmed. 

The extent and requirements for 

both the local and wide-area networks 

must be clearly defined by 

qualified personnel. Of critical 

importance are the allocations for 

growth in imaging information volumes. 

These are associated with 

increased efficiency and economies 

of scale and are also a by-product of 

increases in data sets related to 

technologic innovations (for example, 

multi-slice CT). Imaging volumes 

must be estimated for each 

modality in order to determine the 

most appropriate archiving strategies 

(11, 16). 

Implementation alternatives 

must be factored into the analysis. 

Will the implementation of the system 

occur as a single event or will 

the implementation require multiple 

phases? Alternatively, should the 

radiology department outsource its 

PACS, partially or completely? 

Finally, financing options must be 

assessed and factored into the 

analysis. 

A RFI proved to be a learning 

opportunity for the development of 

questions for the RFP along with 

knowledge of how vendors respond 

to various types of questions. It 

allows the SC to learn how to evaluate 

proposals and refine their evaluation 

process prior to evaluating the 

RFP. Furthermore, it offers the SC 

the opportunity to increase their 

understanding of PACS and the 

offerings of vendors. A RFI may be 

used to narrow the list of vendors 

who will receive the RFP, thereby 

reducing the evaluation costs for 

both the hospital and vendors (6). 

With the budgetary costs and 

information gained from the RFI, the 

business case may require modifications 

and an alternative configuration 

in order to make PACS viable. 

Request for proposal 

The strategic plan, business case, 

and reference documents created in 

previous stages can be used to 

obtain the approval of senior administration 

to proceed to the RFP. 

Agreeing to proceed with the RFP 

commits senior administration to 

fund the PACS initiative once a vendor 

of choice has been selected. 

A well-designed RFP becomes 

the basis for the purchase agree- 


ment. The RFP requests the information 

required to make an informed 

decision and can be a refinement of 

the RFI. It also provides an accurate 

method for evaluating many proposal 

responses. Specific objectives 

defined in the strategic plan should 

serve as the basis for evaluation criteria 

in the RFP. A poor or incomplete 

RFP will end up with much 

time wasted and inadequate 

responses from suppliers. Not only 

at this stage, but also throughout 

the procurement, the most involved 

members of the SC have to invest 

considerable time in the project. 

An RFP with requirements that 

are impossible for any vendor to 

meet, particularly for the price the 

users are willing or can afford to 

pay, must be avoided. For vendors, 

this attitude may be so discouraging 

they may opt not to bid at all. It is, 

therefore, important to agree in 

advance which requirements are 

true needs, wants or ‘nice-to-have’. 

It may also help in evaluating 

responses because a relative rating 

may be applied to each requirement; 

for example, using these 

weighted factors, a matrix may be 

applied objectively to come up with 

the proposal that best meets the 

requirement. 

Evaluation of proposals 

Evaluation criteria need to be 

developed and agreed upon prior to 

release of the RFP. The criteria must 

emphasize the primary objectives of 

the strategic plan. Methodologies 

and processes for the numerical 

evaluation of different vendors’ 

systems, based on measurable 

specifications and subjective input, 

must be established. Different vendor 

response styles and personal 

preferences or interpretation of 

information may offer some problems 

to fairly evaluate all vendors 

(6, 14). 

It may be important to get as 

many references about comparable 

sites as possible. There are many 

small things that one will learn only 

from other users who recently 

implemented a system. Site visits 

are important, but be aware that a 

vendor typically has several “showcase 

sites” that display the good 

side of a system, or sites where one 

will speak only with a satisfied user. 

Try to speak with users who are 

unhappy with a system or who have 

had a hard time adjusting to implementation. 

There is nothing wrong 

with asking to speak with dissatisfied 

users because, typically, these 

people will teach you the most. 

Negotiation stage 

Once a vendor of choice and a 

decision to purchase is established 

the negotiating team begins negotiations 

with final objectives related 

to operating and capital costs. The 

negotiation stage is critical to the 

long-term success of the project. 

Negotiations will determine the purchase 

price, as well as other critical 

ownership details (6, 8). 

A technical review of the final 

configuration should confirm all 

PACS components, functionality, 

integration requirements, and the 

resulting workflow. When the RFP is 

used as the technical specification 

for functionality and performance, 

reference to the RFP must be included 

in the final agreement. Furthermore, 

ensure that the vendor 

updates the RFP responses with current 

deliverable specifications prior 

to the negotiations. 

The optimal financing strategy 

(e.g., purchase versus lease) must 

be determined during financial 

negotiations. The optimal financing 

strategy is based on the intended 

use of the equipment, the planning 

horizon of the technology, annual 

service plan options, the expected 

lifetime of the equipment, potential 

changes during the intended lifetime 

(in the form of upgrade path 

options or replacements), network 

upgrades, type and quantity of 

workstations, furniture requirements, 

CR versus DR options, 

archive options and special software 

packages (e.g., cardiac, etc.). 

Furthermore, other critical details 

consisting of penalty clauses, delivery, 

installation, and implementation 

timelines, acceptance test plan, 

application and system administration 

training, current and future 

interface and integration costs and 

performance guarantees must be 

discussed (12). 

A managed service may allow for 

the application of penalties if the 

supplier fails to provide the service 

for which they have contracted. The 

specification should include the 

standards expected of the service 

for uptime, system response times 

(for image transfer to the workstation, 

for instance), service response 

times (how quickly an engineer may 

be expected to respond to a service 

call, and how long before the acute 

problem is rectified to re-establish 

the previous level of functionality 

extant before the fault developed)(12). 

If delays in implementation 

occur there must be some 

agreed escape route at no cost to

246 JBR–BTR, 2004, 87 (5) 

the purchaser. Some formula for liquidated 

damages may be included 

in the contract. Upgrades and 

enhancements should be included 

in the contract to avoid the risk of 

obsolescence. A hardware refresh at 

regular agreed intervals may be 

mandatory for lengthy contracts. It 

would be unreasonable to expect 

new hardware to be installed every 

time that a new computer came on 

the market, but a replacement of 

computers and monitors may be 

expected after 5 years. All training 

and management costs may be 

included in the proposed contract 

reducing the risk of additional costs 

over time as the system requires 

modification with further training 

implications. It is mandatory to 

agree with the supplier to maintain 

the system in line with the latest 

DICOM attributes, which become 

available during the course of the 

contract. However, it must be 

acknowledged that some DICOM 

developments will have to be 

matched by software upgrades on 

modalities or the departmental RIS 

in order to take advantage of the 

new DICOM attribute and this may 

be costly. The risk of cost overruns 

should be discussed and may be 

transferred to the supplier in a managed 

service because a fixed price 

will be agreed for a clearly defined 

specification. Performance guarantees 

must be established. An uptime 

of 98% is certainly a standard which 

modern information technology systems 

should be able to achieve. This 

is a generous allowance since it 

equates to 13 hours of downtime in 

any month. Downtime may be 

defined as the failure of any component 

of the core system or the simultaneous 

failure of three or more 

workstations (12). The event of any 

complete system failure and disaster 

recovery should be discussed 

and will have to be overcome without 

financial implication for the purchaser. 

Contract 

‘Get a good lawyer’ was the 

advice given at one PACS confer- 

ence (6). Your Trust needs expert 

legal advice in order to avoid later 

pitfalls. However, smaller PACS 

implementations require less supporting 

documentation. The scope 

of the project determines if a purchase 

order or contract finalizes the 

agreement. Once the terms of an 

agreement are established, a legal 

review by attorneys with experience 

in high-technology system purchase 

agreements is recommended (6). 

For example, the contract needs to 

review definitions of terms, performance, 

penalties (or lack of) for failure, 

dispute resolution mechanisms, 

acceptance test plans with redress 

for any failure, and software licensing 

agreements. One of the major 

costs that incurs after a PACS implementation 

is that of service and 

maintenance (9). At the contracting 

stage it is essential to ensure that 

adequate service is available. Many 

suppliers think that 8 h/day 250 

days/year is sufficient. They may 

charge exorbitant sums for more 

comprehensive cover. This is the 

time to sort it out. They may provide 

the cheapest system to install but 

you may not be able to afford to run 

it. 

Conclusion 

It takes a certain dogged persistence 

to see a PACS procurement 

through to a successful conclusion. 

To successfully integrate PACS into 

the radiology department or hospital 

it is critical to outline different 

stages for a PACS procurement in 

which critical questions must be formulated 

and answered, a strategic 

and financial plan must be established, 

a timeline created, marked 

research performed, program 

design developed, and training programs 

designed before implementation 

may be performed of the best 

PACS solution. 

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