Cloud PACS in veterinary digital radiography PART 3: Go Buddah or go home

In part one of this series, the case was made that Cloud PACS had no real place in the veterinary practice. In part two of this series, the case was made that traditional PACS platforms are outdated and the best option for the veterinary practice is a Cloud PACS solution. How can the veterinarians searching for a digital radiography and PACS system reconcile these two extreme viewpoints? Easy. Go Buddah or go home.

The Buddha describes The Middle Way as a path of moderation between the extremes of sensual indulgence and self-mortification. When applied to digital radiography, the middle way is that there is no right solution for every practice and every veterinarian. Traditional systems and cloud based systems both work fine and the one you decide on will depend on you, your practice, your budget, your world view, your tolerance for risk etc.

Like a good therapist, this article will ask you questions to help guide your journey and help you approach your purchasing decision by coming to conclusions on your own. The decision to buy a Cloud vs. Traditional PACS is about you more than anything else.

Before we get started, however, we are going to have to define some terms that you will hear when discussing modern digital radiography and PACS systems. We encourage industry to adopt the following standard definitions so there is no confusion.

• Traditional PACS: with traditional PACS systems, a server houses the images and a standalone (“thick client”) viewer is used to view the images.
  
  
• Web based PACS: Web based PACS systems use a “web server” to run the PACS. A web server, however, does not necessarily mean that these systems use the internet or are even online. Rather, the “web based PACS systems” simply use a web browser (such as Internet Explorer or Safari) to view images. Moreover, if users actually try to use some “web based PACS” over the internet, they will find that they won't work too well. In this configuration, images are stored locally, accessed locally, and use a web viewer to view the images. For the purposes of this article, web based PACS are grouped under traditional PACS as they do not rely on the internet to access your images.
  
  
• Cloud PACS: With Cloud PACS configurations, images are stored remotely and users access the images over the web, using a web browser, to get to their images. In some cases, users will not have a copy of their images stored locally.
  
  
• Remote Archive: The term remote archive should be reserved to refer to a backup of images online. A backup means that you have a local copy in the practice. The Remote Archive is a second copy of your data located outside of the veterinary clinic. The term "remote archive" does not necessarily imply that users can access images online.

Finding your inner Buddha: Cloud PACS vs Traditional PACS

Your first goal is to be sure you really understand what Cloud PACS is and determine your needs to see if cloud based services are right for you and your business. In my discussions with veterinarians, I have found that step one in clearing up confusion about Cloud PACS is to start by forgetting about Cloud PACS altogether. Instead lets focus on other cloud services that you will be familiar with and (hopefully) draw some analogies.

• Service 1: Gmail vs. Outlook: Gmail (Yahoo mail, Hotmail, etc) are cloud based email services. If you cannot get on the Internet, you cannot access old email messages or type a new message to send later. Standalone email applications (such as Outlook or Mac Mail) have more functionality than their web counterparts. Cloud based email works well for hundreds of thousands of users. If you are one of them, great. Personally, I receive hundreds of email messages each day and a disadvantage of Gmail and other web mail services is that there is a significant lag time waiting for web pages to load and this lag time drives me nuts. I am faster at answering email when I use a local mail client. For me, web based email is a nonstarter.
  
  With cloud PACS there will be a lag time before you can view your images around your hospital. This lag time may be perfectly acceptable for you or give you the howling fantods depending on how many people are in your waiting room, how many radiographic studies you do each day, or how much coffee you drank that morning.

• Service 2: Spotify vs. iTunes: Spotify is a streaming music service where the users pay a monthly fee to access music online.  This fee gives the user access to millions of songs. The flip side is that, you do not own any music and if you stop your subscription your entire library of music and all of your playlists are wiped out. Importantly, if you cannot get online, you cannot listen to your tunes. Conversely, with iTunes, you pay a few cents for each song, you own these songs, you pay for them once,  you can do what you want with them, and you do not need to be hooked up to the internet to listen to your music.
  
  If you are like me you see no difference between paying for an online music subscription and paying your cable TV bill. Owning TV shows is just as idiotic as owning music and I would much rather “rent” everything ever made than own less music. Moreover, music is not “mission critical” so if I cannot get online, a little silence is OK for a while.
  
  My friends, conversely, cannot get their heads to stop spinning when I try to get them to sign up for Spotify. They want to own their music. They get twitchy thinking that they will not be able to access their tunes if the internet is down. One big objection is that they worry that they will spend hours to create playlists and curate their online music collection then one day Spotify will go out of business or get purchased and everything will change¹. There is no getting through to these people and the conversation always ends with me feeling like a geek and them continuing their love affair with iTunes.

• Service 3: Flikr vs. iPhoto: Flikr is a cloud based service where users upload their photos. iPhoto is a program that runs locally on your computer. You can use iPhoto to email your friends images but they cannot see them online. Fans of Flikr love the fact that they can get to their images from any computer in the world and they can just give their friends and family a link to get to see the images. Other people, including my family opine “you gotta be nuts if you think I am going to trust my pictures to some company out on the internet. What if they get purchased and the next company changes things, or charges me for access, or just shuts things down on me, or gives out my pictures to the highest bidder and I see pictures of myself in advertisements somewhere? No thank you. I will keep my pictures on my computer where I can back them up myself and only give people access that I want to give access.” Yes – my family gets activated about online image sharing.

As you can see from this discussion, there is no right or wrong when comparing online vs. local software applications. The application you choose (and as a corollary your decision to purchase traditional PACS or Cloud PACS) for you will depend on

1. How much functionality do you need? Online services usually (not always) have somewhat limited functionality relative to local applications. You need to decide if you need these functions. If they are things you won’t need - who cares?  If, however, you are a power user, traditional PACS might be a better fit for your situation².
   
   
2. Can you tolerate not having access to your images or are your images mission critical to your practice? If you are like me, you view the Internet like a highway in a busy city. There are going to be traffic jams and the highway wont work like you want it to. If you are OK waiting in traffic for a while from time to time, perhaps the cloud option would work for you. Conversely, if you are, for example, a surgeon and not having access to your images in the surgery room because of an internet outage will send you over the edge, well, maybe traditional PACS is a better option for you.
   
   
3. Do you have the need for speed?: as a general comment, applications running locally run a bit faster than cloud based solutions. How important is speed to you?
   
   
4. Will the company you choose be around next year? In my experience, veterinarians are a trusting bunch. Many are ready to throw down $80K at a convention to a company with a fancy booth they just heard of. This is mind boggling as none of them would buy an $30K car from a small company out of Somalia that they just met at a meeting but I digress. Remember you are marrying this company and divorce is tough. It is tough for everyone involved. Relationships end abruptly but the pain lingers on for months and sometimes years³.
   
   

Bottom line: Cloud options and traditional PACS both have their place. There is no right or wrong with this decision. Once you have decided, conceptually, if a cloud option is right for your practice, then and only then can you start looking at prices, vendors, determining if your internet speed/bandwidth can even support a cloud PACS, etc. In my experience, I would focus more on the vendor and their reputation than the pro’s and con’s of Cloud vs. traditional PACS or whatever costs or costs savings that you might enconuter with one or another solution. Most vets start with the cost and work backwards. That is…well.. backwards.

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1 Nothing lasts forever on the Internet or the cloud. Companies get bought and sold all the time. You never know who will be next. Never.

2. As we move toward integration between practice management software, teleradiology, and other services, you must be absolutely certain that your cloud provider will be able to integrate everything in your practice with everything online.

3. I talk with a lot of veterinarians who are on their second PACS relationship. Too many times it is because their relationship with their previous vendor did not end on good terms or their previous vendor just evaporated one day. They never make the same mistake twice. Usually, they proceed too cautiously and are not trusting enough. Once bitten twice shy I guess. Please do not let previous bad relationships affect your practice. Learn how to trust again. You will be glad you did.