HIStalk Interviews Mike “The PACSman” Cannavo

Mike Cannavo, aka “The PACSMan,” is founder and president of Image Management Consultants.

You recently spent time working for a major vendor after years of solo consulting, but now you’re back on your own again. What was it like on the dark side?

I was always curious on what it would be like to work for a vendor again, but I didn’t want a job that required me to be away from my kids while they were growing up. My father worked three jobs during my own youth and I really didn’t get to know him until after my mom passed away in my mid-30s. As tempting as some of the offers I had from major companies were, I swore there would not be another “Cat’s in the Cradle” scenario in my own life, so I chose instead to balance my own work life with fatherhood. My youngest son graduated high school in May 2011 and I accepted a position with a major vendor in July 2011.

The market had changed a lot since I last had a real job with a steady paycheck. Some things, like corporate politics, remained the same. I stuck it out almost 2.5 years until I looked in the mirror, didn’t like what I saw, and then played Roberto Duran and finally said “No Mas.” Besides, I had at least 50 bets out there that I wouldn’t last more than two days in a big company setting.

On the positive side, I learned the value of service, how important having a good project manager really is, why managing expectations is key, why you need to get everything in writing, and the importance of a strong IT department. On the minus side, I learned that simply doing your job often isn’t enough. The blame game is alive and well and people often rise to the level of their incompetence.

How has PACS changed in the last four years since we last spoke in an interview?

PACs is no longer an independent system, but is instead looked at as a crucial part of the EHR. Vendor neutral archives, once considered a central data repository for radiology images only, have been expanded out to included cardiology, medical records, and numerous other ‘ologies. Large healthcare systems are either planning or implementing the sharing of images and images locally as well, both on a regional and even national basis with establishment of HIEs. Interestingly, private HIEs are growing at the rate of three to one over public ones, with over one-third of all hospitals and about 10 percent of all private practices sharing data.

We still have a very long way to go, but as we both know, all progress in healthcare is slow.

You mentioned in an article I read that the PACS sales process has changed as well.

For all intents and purposes, large-scale capital doesn’t exist. What little does exist is being used to replace things that should have been replaced years ago. The name of the game is finding ways to implement new technologies by either offsetting costs from operating budget or showing a return on investment out of the box by obtaining either increased reimbursement or decreased costs.

As controversial and possibly upsetting as this statement might be, improving patient care, while important, can’t be done at increased cost. You have to somehow show an ROI for the facility or it’s usually a no-go.

Healthcare profits are getting eaten alive by the need to implement federally mandated programs, from MU to shoring up internal security. Nearly all of these involve IT departments that have their own staffing and budget cuts to deal with.

What’s funny in a not so funny way is that MU encourages hospitals to share data with a laundry list of people, yet it also needs to be secure enough that no unauthorized access happens lest you incur a $10,000 per event HIPAA penalty. Look at the Community Health Systems breach. This will cost them a fortune if the feds don’t take into account they did all they could from a security standpoint, assuming they really did do all they could to prevent the breach. This will take years to sort out, all the while with the organization having the sword of Damocles dangling over their heads.

What would you do differently as a health system?

Implement solutions that make sense, recognizing that many solutions don’t have to involve technology at all, but instead require workflow or process changes. I can’t begin to tell you how much trouble employing a common sense approach to problem solving has gotten me into over the years working for companies that sell technology-based solutions. Sometimes you just need to step back though and examine the problem before throwing hardware and software at it in the hope that solves the problem.

Companies typically sell products instead of solutions. End users buy products they hope provide solutions. Never the twain shall meet. End users need to be more educated before they make decisions because those decisions will last a lot longer than expected. For the most part, companies sell products and services and do not necessarily ensure that what you are buying or have already bought is what you need or is being properly used.

What’s the status of the PACS marketplace?

There is lots of interest in VNAs, especially those that can be used as an enterprise solution that takes images from all the ‘ologies as well as the EMR. Medical image sharing, where images are securely transferred between sites and patients as a cost-effective alternative to CDs, is also hot, especially after Nuance’s purchase of Accelarad.

Software add-ons such as radiation dose management, peer review, critical results reporting, and ED discrepancy are also hot. So are PACS dashboards, although most sites want the dashboards for free stating it’s like a speedometer in the car. For that matter. most sites want everything nearly for free, but it’s simply not going to happen. Data analysis is smoking hot right now, but finding time to review the analysis remains to be seen.

What’s not hot are upgrades for the sake of upgrading without a distinct advantage or improved feature/functionality. All the big companies want you to do this. Solutions that have anything proprietary in nature. Solutions that doesn’t interface easily with the other clinical systems in use. Anything that doesn’t show a value or ROI out of the box.

What about the cloud?

Depending on whose survey you believe, up to 80 percent of all hospitals have at least a few cloud-based applications running. Adoption is much slower than expected, but that is because there are so many unknowns, including security.

As was pointed out in a recent HIStalk article, running a data center isn’t the strength most providers have. Cloud providers can offer higher reliability and redundancy at a better price point than a facility maintaining its own hardware. Cost-effective high-bandwidth networks have also eliminated most of the barriers to using the cloud as well.

Once we are comfortable with the security aspect of having images and information stored in the cloud, usage should take off. Sadly, HIPAA penalties and the limits of business associate agreements in protecting the end user have made providers gun shy.

Has radiology embraced Meaningful Use?

With few exceptions, not at all. The vast majority of clients I am dealing with are taking a wait-and-see approach to MU before investing money due to the never-ending changes in the rules. This reflects the general population as well, where only 4 percent or so of all eligible providers have attested to Stage 2 so far.

The cost to implement MU has, in many cases, exceeded any return on investment that a group or imaging center will see. When you add the aggravation factor, you are definitely in the red.

What will we see in the future?

No one really knows what is going to happen with Meaningful Use, ACA, HIEs, and a whole lot more. Vendors are pulling their hair out trying to get any decisions from end users — positive or negative — while end users take the Holiday Inn approach — where the best surprise is no surprise — and choose to remain in limbo doing nothing. In the mean time, IT stands at attention waiting for something to happen so it knows what resources need to be dedicated when and where.

What is frustrating is that even if something shows a ROI right out of the box, a lot of end users are still afraid to pull the trigger. If we can’t overcome the paralysis by analysis, you are going to see a lot of companies go belly up, and soon. Add to this the market consolidation that is going to happen in the next few years with at best a few dozen companies left to provide PACS solutions and it’s a scary time, especially since all of those will need to be integrated into the EHR as well.