It is a truth universally acknowledged that the patient archiving and communications systems (PACS) market has progressed through a gradual change from being product based, to being very much solutions-based. An investment in the increasingly common hospital enterprise-wide PACS model necessitates a whole adjunct of services both pre- and post-purchase. The current workflow of the hospital in terms of radiology image management needs to be assessed if a PACS can be designed to best meet its needs, and the traditional break/ fix form of support must be supplemented with intensive implementation, training, and data migration of any images from legacy systems. Meeting these necessities all add to the costs incurred by hospitals and healthcare authorities in making the initial capital investment required. This capital investment can seem particularly daunting in the current European healthcare climate, where budgetary reform has left many regions (such as Italy and Germany) sorely lacking in the requisite funds.
The answer to this problem is seen by some vendors and industry experts to lie in the application service provider (ASP) model. The ASP model relinquishes the burden of upfront capital purchasing by providing an outsourced management of the PACS system, from image capture through to offsite archiving, on a fee-per-service model. At first site, there is much to recommend to this model, and it has indeed made for an accessible and payable model in certain European regions, but upon closer inspection, it becomes clear that problems and industry cynicism persist.
Removing the Burden of Estimation
The immediate advantages offered by ASP are clear. It is a model that has proven its worth in the finance and insurance sectors, but has been a relatively recent option within the typically tardy healthcare industry. The benefits it has brought to these industries in terms of lowering the financial risk of investment in hardware will be keenly felt in a PACS market where the typical replacement rate of 5 years can soon render a system obsolete. The immediate financial risk of investing in PACS is accompanied to a technical risk specific to the archiving side of PACS. It is exceedingly common for hospitals to underestimate the volume of archiving storage they will need for their data sets. This is a trend merely exacerbated by PACS vendors that take radiology department estimates at face value, or just really on historical quotas for hospitals of similar size. The ASP model obviates the difficulties associated with needing to install extra storage capacity retrospectively. This is achieved by the ASP outsourcing archiving to a remote location, that offers far greater storage capacity than is possible onsite in a hospital. This allows for flexibility in terms of archive provision, as the off-site storage has sufficient capacity to cope with the expanding needs of hospital image management. This off-site storage is also of benefit to hospitals that are hard-pressed for storage space in the first instance. The ASP model can also benefit healthcare institutions that are hard pressed in terms of human resources as well as infrastructurally, as outsourcing the management of what can prove a complex IT installation allows those in the radiology department to concentrate on their core competencies, i.e. looking after patients.
Indeed, the perceived advantages of the ASP model have lead to high profile provision of this service within Europe. Finland has a whole national network of hospitals connected to one central, ASP managed PACS archive, and the National Programme for Information Technology (NPfIT) in the United Kingdom has given rise to a trend for a more managed service approach to PACS installations, if not fully following the ASP model completely. Scandinavia is, of course, well suited to this model, as low population density and widespread broadband connectivity create an environment where the transfer of data form remote locations is both necessary and viable. Despite this natural predilection towards the ASP model, certain voices within the medical imaging industry are optimistic that proven savings brought about by shared infrastructure and common components between hospitals will eventually see the ASP model take off among regional hospital consortia in the cash-strapped, yet traditionally more conservative German healthcare market. The sheer size of the German market will drive the growth of this model, should it become widely adopted, despite the current financing issue this market is experiencing.
What ASP Means for the PACS Vendor
Yet a further boon for the end-user is the potential for flexibility and customisation the ASP model provides. Having archiving and image distribution covered as an outsourced service drives down the cost of hardware for the end-user, as they are able to buy OEM workstation components to fit in with their PACS system direct, and therefore at a reduced price. It is in this respect that the traditional PACS vendors and modality / PACS OEMs see themselves as somewhat disadvantaged. Talk to any industry participant about a workflow solution, and they will speak in favour of the "one stop shop" model, whereby the end-user purchases their complete solution from one vendor. ASP threatens this ideal, and will, if consistently successful, necessitate vendors to work with each other’s equipment – something they would rather avoid despite the advances brought in connectivity by the DICOM protocol.
The traditional vendors have responded to this challenge in some instances by signing agreements with online digital imaging storage and archiving providers to offer themselves a greater service delivery model along the lines of that mentioned in the opening paragraph of this article. This model is heavily solution driven, in the true sense of the word solution. This differs to mere product bundling in that every component of the PACS workflow solution is heavily interdependent, and interconnects to form a process optimisation for the radiology department that presents value above and beyond the constituent parts of the product offering. This reinforces the "one stop-shop" ethos so beloved of vendors, as the end-user cannot disaggregate those same constituent parts as they could with a simple product bundle, making near impossible for them to assemble a customised solution.
PACS – A Migratory Species
Despite these perceivably protectionist measures, traditional vendors and end-users alike do raise some other legitimate objections to the ASP model. The greatest question is over ownership of patient data; some of the unanswered legal questions as to whether data is owned by the hospital or the ASP has proven a significant restraint to the adoption of this model. Another vexed question is the provision of data migration from the present ASP to a new set-up should one of the parties decide to terminate a contract for whatever reason. Unless this issue is adequately and transparently addressed at the outset, it can represent a huge potential deterrent to the end user. There is also the argument that outsourcing data in this manner actually engenders further networking costs that are not necessarily beneficial to the hospital or radiology department administration. In the light of this disadvantage, some industry participants are more inclined to view the ASP model as a data security measure, with the remote archive serving as a disaster recovery solution in the event of any failure onsite.
Of course, this last point could be seen as reason enough to subscribe to the ASP model, given that many PACS vendors do not supply a second onsite data storage as standard. Indeed, hospitals that are currently dissatisfied with their service provision in the limited budgetary environment of European healthcare may soon see the non capital-intensive model of ASP as increasingly tempting to switch to.
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