Although many members of the radiology community have been predicting the imminent arrival of large-scale Picture Archiving and Communications Systems (PACS) for at least ten years, it appears that we will have to wait until well after the year 2000 before more than a mere 1% of healthcare facilities make the transition to a filmless environment. The reasons for this delay are numerous and include the high cost of the technology, uncertainty about system reliability, lack of hospital infrastructure to support PACS requirements across the enterprise, and the inertia that invariably develops in any established system such as a conventional radiology department that has remained unchanged for the past several decades. Perhaps the biggest challenge over the next decade will be to collect and analyze data from early adopters of the technology to help provide the economic and clinical justification for the substantial resources required to make the transition.
A majority of radiology departments have indicated that they currently use or plan to include some form of PACS or teleradiology technology in their short, medium, and long range plans, or are actively shopping for small or large-scale systems. This optimism is probably due to a number of factors, including significant improvements in workstation, network, and storage technology, the increasing need to connect hospitals to outpatient clinics and other medical centers, and perhaps most significantly, the emergence of a tiny but growing number of successful large-scale PACS implementations.
The amount of money required to install PACS in large hospital networks, academic facilities, and community hospitals during the next ten to fifteen years will be many billions of dollars, even with the anticipated decreases in the cost of the technology. With other technologies, an imaging department was able to justify the purchase of a new technology to the hospital by simply demonstrating that the machine would generate a sufficient volume of examinations and revenue to generate a profit given a certain level of reimbursement per study. Since patients and insurance companies cannot be billed directly for the PACS, this justification cannot be used. It seems most likely that the major economic savings, if there are any, will be at the hospital, rather than the departmental level. In order for hospitals to justify a large investment in PACS, they will have to be able to demonstrate two things: that the technology is feasible by observing it in another hospital with a PACS, and also that they can cite data that suggest significant clinical benefits of the technology. There is consequently a critical need to evaluate the quality of care, economic, political, social, and technological impact of small, medium, and large-scale PAC systems. These data should assist radiology and hospital decision makers in deciding if and when to convert to digital imaging, and they should also provide data concerning strategies to optimize the likelihood of success with filmless operation.
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