As health systems have matured their EHR implementations, many are now focusing on updating key supporting IT infrastructure, such as picture archiving and communications systems (PACS). However, modernizing your imaging system isn’t just an upgrade; it must be approached strategically to ensure success.

“PACS is at an inflection point, with many factors coming together to influence the imaging system selection process,” said healthcare consultant and Healthlink Advisors Brian Cornell. “As a result, making the right choice for your PACS needs is about more than just signing a contract.”

According to Cornell, several major factors are influencing the PACS environment, including:

  • Broader, more complex imaging systems — and needs.

Imaging technology has advanced rapidly. These advancements have also ushered in new needs related to imaging preprocessing and enhancement, bedside imaging & interpretation, such as point of care ultrasonography (POCUS), and the emergence of visible light imaging across specialty areas from wound care to endoscopy.

  • Higher resolution and bigger files.

The use of complex, high-resolution modalities such as MRI, CT, PET, and SPECT continues to grow as a proportion of the total diagnostic imaging volume. As the resolution increases, so does file size — creating new considerations for imaging access and storage.

  • Decreasing reimbursements and increasing workloads.

Downward pressure on reimbursement continues. The Protecting Access to Medicare Act of 2014 (PAMA), while delayed again by CMS for 2024, remains a threat. Hence, radiologists are pressured to read more studies for less reimbursement as demand for imaging continues to grow.

  • Radiologist shortages.

There are not enough radiologists. A perfect storm of an aging population and federal funding for graduate medical education that has not kept pace has resulted in too few graduating radiologists. To meet the increased demand, radiologists need flexibility in where they read, along with productivity enhancements such as computer assisted diagnosis (CAD) and AI-enhanced impression generation & worklist managers.

A shifting PACS paradigm

Historically, imaging modalities — along with the reading radiologists and image storage systems — were located onsite. However, today’s circumstances dictate a paradigm shift for the architecture and performance of PACS systems. 

“Since the pandemic, we’ve seen small radiology groups merging to create larger groups — and those groups aren’t just reading locally,” said Cornell. “You may have radiologists working from home and reading for hospitals across the nation — which means they need to access files many times the size of a Netflix movie using their home internet while managing expediency needs across multiple time zones.”

And, while the Vendor Neutral Archive (VNA) is standard in all modern PACS systems, most vendors favor the cloud as the primary location for the VNA.

A cloud-hosted VNA may be financially advantageous on paper because it eliminates the capital-intensive outlay for storage and allows for more predictable cash flow. It also facilitates Disaster Recovery (DR) since hosted solutions will include backups, secondary storage locations, and perhaps options for immutable storage for cybersecurity.

However, many organizations make the mistake of focusing too much on functionality and assume that the underlying architecture will meet the performance requirements. This is a mistake because of the volume of data that must be moved – in milliseconds – to maintain the productivity of the radiologist.

“Your technical team should spend as much time scrutinizing the architecture and topology of the VNA as is spent on features and functions,” said Cornell. 

Four Key Factors to Consider for PACS Selection

As the changing PACS environment becomes more complex, health systems face unique challenges when selecting an image storage option. Cornell said organizations should consider several interdependencies when evaluating PACS storage options:

  1. Geography. 

Where are your modalities and radiologists located? This will define bandwidth and latency requirements. Although many vendors are trying to simplify their architectures, serious consideration should be given to local cache and DICOM routers.

  1. Viewer. 

What kind of latency can the viewer handle? Does it cache images locally, stream, or something in between? You must “lift the hood” to understand how the viewer retrieves images.

  1. Prefetch. 

Where and how are related studies cached? In large, geographically diverse organizations, intermediate cache may need to be placed at strategic locations to ensure a timely response. But don’t overlook this in small organizations because it will also depend on where your radiologists are located and your disaster recovery/business continuity plans.

  1. Business continuity. 

How will radiologists read in the event of a disaster? Worst case, can they be at the locations where modalities are located?

“As you can see, these requirements are intertwined and must be approached holistically, considering the realities of your radiology groups along with functional requirements and performance considerations,” said Cornell. “That’s why it’s critical to use a structured process to assess how different vendor offerings can fulfill your requirements — including the requirements your organization has today and the requirements you anticipate for the next 10 years.”

Brian Cornell is Vice President of Digital Strategy at Healthlink Advisors, a healthcare consulting firm committed to improving clinical innovation, business systems, and healthcare IT strategy, delivery and operations. Our team has extensive experience in assisting healthcare organizations with imaging strategy, including selecting and implementing imaging solutions. To learn about how we can assist your organization, contact us at (888) 412-8686 or