Download RIS/PACS THIN CLIENT VS. SMART CLIENT FACTS AND FADS

RIS/PACS THIN CLIENT
VS. SMART CLIENT
FACTS AND FADS:
Understanding RIS/PACS Past,
Current, and Future Trends
By Murray A. Reicher, M.D.
DR Systems Chairman and Co-founder
RIS/PACS Thin Client vs. Smart Client facts and fads: 2
Understanding RIS/PACS Past, Current, and Future Trends
Contents
Introduction............................................................................................. 3
False Fad #1 (1992) ................................................................................... 3
PACS requires a high-end workstation and will never work on a PC ................3
False Fad #2 (1992-1998)............................................................................ 3
A distributed architecture (“store and forward”) is the only feasible way of
moving large imaging cases around a network..........................................3
False Fad #3 (1996-1998)............................................................................ 4
The network computer will replace the PC as a thin client ..........................4
False Fad #4 (1997-2005)............................................................................ 4
Customers aren’t smart enough to manage their own file servers and budgets ..4
False Fad #5 (1992-2005)............................................................................ 5
Technologist workstations are a waste of money and create work .................5
The Latest False Fad—Thinner is Inherently Better............................................ 6
How about price?
8
Safety Considerations
9
The Next Lasting Trend—Unified Systems........................................................ 9
Conclusion..............................................................................................10
About the Author and Company...................................................................10
About Murray A. Reicher, M.D. .......................................................... 10
About DR Systems, Inc. ................................................................... 10
RIS/PACS Thin Client vs. Smart Client facts and fads: 3
Understanding RIS/PACS Past, Current, and Future Trends
Introduction
DR Systems is the leading independent provider of medical image and information
management solutions for hospitals and imaging centers. Since 1992, we have
pioneered many of the most significant and long-lasting trends in our industry, while
observing the emergence and passage of many fads.
Why do some trends persist and gain momentum over time, while others disappear?
The determining factor is whether a technology trend provides true value: trends don't
last if they fail to provide true value.
With this in mind, let’s review a brief history of some RIS/PACS fads that were once
conventional wisdom, but later disappeared. The goal of this history lesson is to better
understand the factors that lead to false fads, so that you can avoid being trapped in
the next latest style of the “emperor’s new clothes.”
False Fad #1 (1992)
PACS requires a high-end workstation and will never work on a
personal computer
This was industry conventional wisdom when DR Systems built the first successful
PC-based PACS system. Other companies in that era based their PACS on “higherend” proprietary computer workstations. Instead, DR Systems chose the personal
computer because of one of our basic tenets, a principle we call “ride the big wave.”
This principle guides us to standardize on the world’s most popular technologies and
standards, because popularity breeds competition, which in turn results in faster
product development cycles and better pricing.
Simply stated, we bet that the PC would get faster, better, and cheaper - and we were
right. The PC became standard in PACS, and the high-end workstation slipped away
as a fad.
Today, do you know anyone with a PACS that is operated by a
mainframe computer?
False Fad #2 (1992-1998)
A distributed architecture (“store and forward”) is the only feasible
way of moving large imaging cases around a network
Believe it or not, as late as 1997, DR Systems was one of only a few vendors that
challenged the conventional wisdom that required a “store and forward” approach to
image management, Instead, DR Systems pioneered the central client-server
architecture in medical imaging. Nearly all of our competitors preached that images
needed to be pre-routed to workstations prior to reading.
RIS/PACS Thin Client vs. Smart Client facts and fads: 4
Understanding RIS/PACS Past, Current, and Future Trends
DR Systems showed not only that a central server architecture is sufficiently fast, but
that it provides a clinical environment that far better meets the needs of radiologists,
referring doctors, technologists, and administrators. This environment enables
availability of any case, anywhere, any time. Today, nearly all vendors support the
central client-server architecture that DR Systems pioneered.
Today, who do you know with a successful “store and forward” PACS
or RIS?
False Fad #3 (1996-1998)
The network computer will replace the PC as a thin client
It’s hard to remember that just a few years ago large companies like Oracle were
convinced (and tried to convince the rest of us) that the PC would be replaced by a thin
client, the so-called network computer. The argument was convincing—since you don’t
use most programs that are resident on your computer most of the time, why not
download the programs only when you need them? Why pay for a PC, when you can
buy a less powerful, but less costly alternative?
Well, the network computer never caught hold, in part because of the tremendous
popularity of programs like Microsoft® Word, Microsoft® Power Point,
Microsoft® Excel® and many others—programs that continue to grow in size and
functionality and that people want resident on their computers. No one wants to
download Microsoft Word every time they use it. And at the same time, the PC grew
in power, speed, and popularity, in part because of the many advantages of having a
local disk, such as private storage, performance related to caching, and ability to run
independent of a live network connection.
Today, who do you know anyone running a hospital or imaging
center information system based on network computers?
False Fad #4 (1997-2005)
Customers aren’t smart enough to manage their own file servers and
budgets
Instead, customers will opt for the expertise provided by companies that offer off-site
file servers and applications - also known as ASP model PACS.
This model has largely failed for the same reason most fads fail: for the most part, it
doesn’t make logical, clinical, or financial sense. Take a look at most PACS and one
can quickly see that most of the applications and devices must work at the local site,
not off-site.
Radiologist reading stations, review stations in the ER, ICU, and other hospital
locations, technologist workstations, and a local server are all essential local
RIS/PACS Thin Client vs. Smart Client facts and fads: 5
Understanding RIS/PACS Past, Current, and Future Trends
components, independent of the software architecture. So what hardware investment
does the ASP model really save—the archival device?
Off-site deep archive and back-up may make sense from an architectural viewpoint,
especially when shared between multiple institutions, BUT only under the following
circumstances:
ƒ
Telecommunications to the off-site storage must be extremely reliable.
ƒ
The remote ASP provider must be financially stable and secure. That vendor holds
your family jewels.
ƒ
The per-click cost paid to the ASP has to make financial sense. Some customers
may feel that they don’t have the capital to purchase RIS/PACS, so instead they
arrange for a per-click fee, which almost always costs much more in the near and
long-term. Or as a wise man once taught me, if you don’t want to get “conned”,
never want something for nothing. If you can’t afford to purchase a PACS or RIS,
don’t fall into the trap of believing that a third party is going to give you one for
nothing.
So, for the most part, ASP model PACS/RIS is becoming another passing fad that DR
Systems and our customers appropriately avoided.
Today, do you know anyone with an ASP model that is paying a feeper-click for medical imaging technology - that wouldn’t be better off
financially if they had purchased the technology outright?
False Fad #5 (1992-2005)
Technologist workstations are a waste of money and create work
Vendors that did not provide technologist workstation capability were of course the
most vocal proponents of the false contention that technologists workstations are a
waste of money, and somehow create more work for technologists.
As PACS and RIS combine, it is now clear that technologists must have access to
computing devices, not only for image management, but also to record notes, modify
histories, view old exams, view and scan documents, receive notification of patient
arrival, receive allergy alerts, edit exam information, and much more.
The vast majority of vendors now support provide some form of technologist
workstation, even those who argued against this need. Somehow, while arguing
against technologist-centered applications, vendors managed to simultaneously
develop these products. Many vendors still provide limited technologist workstation
capabilities, claiming this saves money, but still charge a “connection fee” per imaging
device that equals or exceeds DR Systems’ fee for a fully functional technologist
RIS/PACS computer.
As in any business, human resource costs comprise the single largest expense in
running a medical imaging department or imaging center. So providing technologists
with tools that enable them to work more efficiently while remaining at the patient’s
side results in lower operating expenses and greater patient satisfaction.
RIS/PACS Thin Client vs. Smart Client facts and fads: 6
Understanding RIS/PACS Past, Current, and Future Trends
Today, do you know anyone who is operating a RIS/PACS without
technologist computing terminals?
Do you know any technologist forced to use separate RIS and PACS
devices who wouldn’t prefer to use a unified system that provides all
functionality in one package?
The Latest False Fad—Thinner is Inherently Better
Defining Terms
First, let’s address the ambiguous definition of “thin client.” The term has been
variously applied to refer to both hardware and software.
Thin Client - Hardware Definition
In terms of hardware, a thin client was initially defined as a network computer
without a hard disk drive, whereas a fat client includes a disk drive. But as discussed
previously, the network computer never really caught on, because the PC offers more
functionality at a competitive price.
In reality, for hospitals and imaging centers, the feature-rich desktop of the modern PC
is essential, For the most part, using a “PC without a hard drive” provides no economic
benefit, and eliminates the possibility of working off-line or using the local hard drive
for alternative workflow purposes, including back-up and emergencies.
Thin Client - Software Definition
Regarding the software definition, a thin client can be defined as a form of client/server
architecture in which no data is stored and relatively little processing occurs on the
client machine.
An alternative definition is a simple client program which relies on most of the
functionality of the system being located on a connected server.
Further complicating matters, thin client software may run on thick client hardware (a
PC).
In this discussion – thin client refers to software
To keep things as simple as possible, for the remainder of this article, let’s assume that
the PC and its derivatives (PDA’s, Tablet computers) are here to stay, so that
henceforth the discussion and debate regarding “thin client” refers to software.
Smart Client
The term “smart client” was coined to highlight the differences between yesteryear’s
rich, fat clients, and the next generation of more easily deployable, yet feature rich
applications. Older applications were standalone, operating without regard to the
other applications and to the network environment.
RIS/PACS Thin Client vs. Smart Client facts and fads: 7
Understanding RIS/PACS Past, Current, and Future Trends
As a result, deployment was difficult and applications often interfered with each other
(“DLL Hell”). Smart clients emerged in the attempt to gain the best of both worlds:
ƒ
The easy deployment of thin clients
AND
ƒ
the rich user experience of thicker clients.
Smart clients have the intelligence to manage data and connectivity to produce a rich
user experience, while offering the benefit of off-line use.
Smart clients can run on many types of computing devices such as a PDA,
Smartphone, Tablet PC, retail terminal and more. Because smart clients are network
aware, upgrades are easily deployed. For these reasons, DR Systems has embraced
smart client solutions for some applications, while offering thin client applications
where appropriate.
The Latest False Trend
In the past few years, ”thin client” or “web-based” have become catch words in the
world of RIS/PACS and healthcare information technology. They have been falsely
used to mean “modern technology”.
ƒ
While it seems indisputable that thin client solutions are here to stay and will play
a role in all information technology, is it really advisable at this time for all
components of a RIS/PACS to be web-based?
ƒ
What is the definition of a thin client and what are the strengths and limitations of
this approach?
ƒ
Is the best design “all thin client” or a mixture of thin and “smart clients”,
depending on the individual user’s needs? When one scratches beneath the surface,
are there really any products that are true thin clients anyway?
As noted previously, the theoretical advantages of thin client architecture are leaner
hardware and easier deployment. For the hospital/imaging center manager, owner,
employee, or physician, the ultimate litmus test for any technology is whether it
provides true savings and operational superiority.
In other words, beauty is defined not by thinness but by growing
profits and clinical improvements. RIS/PACS saves money
primarily by saving human resources, so any technology that slows
down throughput or communication breaks the basic logic of a
RIS/PACS implementation.
While thin clients are generally adequate for relatively simple tasks, with more
complex tasks, smart clients provide faster performance and a richer user experience.
Try searching Google for “thin client vs. smart client” and you will find unlimited
articles and blogs supporting this contention. Each of our own real-world experiences
with the most popular software applications reinforces the conclusion that resident
applications continue to play an essential role.
For example, you may find using a thin client e-mail system acceptable for creating
quick messages, but when creating a complex document, you use Microsoft Word®. A
thin client may be great for simple math, but when creating a spreadsheet, you still
require a full-featured application such as Microsoft Excel®.
RIS/PACS Thin Client vs. Smart Client facts and fads: 8
Understanding RIS/PACS Past, Current, and Future Trends
Misrepresenting “Thin” vs. DR Systems’ True Thin and Smart
Solutions
Perhaps the most remarkable aspect of the latest surge in the marketing of RIS/PACS
thin clients is the false representation that any one product is really thin. We recently
evaluated the referring physician software of a competing vendor whose marketing
claim to fame is “thin-client, web-based” architecture. We found that it was indeed
browser-based in that it ran inside a launched Internet Explorer® window. However,
it was anything but thin. Its “plug-in” install was ~18 MB worth of C/C++ OCX and
DLLs.
The menus and dialog boxes in the user interface were standard Windows components
(presumably being displayed by the installed C/C++ OCX) – it was not using an
HTML-based UI for the viewer module. The OCX and DLL’s appeared to rely on
Microsoft C++ MFC/ATL.
So, our competitor provides a “thin client” about the same size as the DR Systems’
Web Ambassador, our referring physician smart client. The thin client competitor’s
system is no faster or easier to deploy compared to DR Systems’ solution, and offers
less functionality.
For example, the system lacks DR Systems’ patent-pending system for automatic
download of referred exams, lacks several important software tools, and provided no
ability to display scanned documents. Furthermore, in real-world environments, this
competing systems is often deployed in conjunction with a VPN, an additional timeconsuming step.
In contrast, for referring doctors who want to use unmodified Internet Explorer®
without downloading any software, DR Systems offers a pure thin client solution that
requires no plug-ins or downloads. For schedulers who are working at home, or for
referring physicians using our web-based programs for exam scheduling, the DR
Systems solution is also pure thin client—no plug-ins or downloads—accessible via any
device that can run Internet Explorer, such as a PDA.
Other competitors’ so-called thin client solutions for radiologists, transcriptionists, and
administrators require local loading of Microsoft® Word®, Microsoft® Excel®, Dragon
NaturallySpeaking® or advanced image processing programs to provide essential
functionality.
Is a thin client that requires loading of a thick client - really a thin
client?
How about price?
Does thin client really mean lower price to the customer? Not necessarily. Just as
with ASP-model RIS/PACS, architecture does not define price. The vendor and the
marketplace define price.
The best way to predict RIS/PACS pricing is to carefully examine the long-term cost of
ownership of previous customers.
RIS/PACS Thin Client vs. Smart Client facts and fads: 9
Understanding RIS/PACS Past, Current, and Future Trends
The RPEI – RIS/PACS Exam Index
For this reason, DR Systems developed a very useful metric called the RPEI
(RIS/PACS Exam Index), a measure of total costs including purchase, tax, upgrades,
expansions, and support over time minus current depreciated value, divided by the
number of performed exams.
Depending on exam mix, our customers have experienced a RPEI of $1.50 to $5.00 per
exam, compared to the $4-8 per exam often charged for just archive alone by our thinclient competitors.
A thin or thick client, multi-vendor approach to RIS/PACS can often result in longterm costs of $20-30 per exam, in contrast to DR Systems proven RPEI of $1.50 to
$5.00 for a complete RIS/PACS solution.
Safety Considerations
The FDA classifies PACS as a Class II medical device. All PACS manufacturers must
achieve pre-market clearance by the FDA and must maintain records of their quality
programs.
Part of this process requires validation testing of PACS software on the hardware that
is employed during use, and maintaining appropriate records.
While there is no doubt that customers must be positioned to provide there own
hardware, there are safety considerations that some vendors and customers may
overlook or fail to define. For example, with regard to customer-supplied hardware,
procedures must be adopted to maintain hardware records and ongoing quality
assurance, especially assessment of display monitors.
How does your vendor handle customer alerts or recalls when one
customer reports an imaging artifact or other safety hazard that
only appears on certain hardware?
Whose job is it to determine if the problem is software or hardware
when your PACS vendor doesn’t even know what hardware your I.T.
department has in use?
The Next Lasting Trend—Unified Systems
So now that you are an expert on the history of false trends in RIS/PACS, are you
wondering about upcoming trends?
At DR Systems, we believe that RIS and PACS will shortly disappear as separate
entities. Customers are simply too busy and under too much economic pressure to
maintain a separate RIS and PACS, let alone separate systems for reporting,
transcription, voice recognition, mammography, mammography tracking, document
imaging, management reporting, film tracking, patient location tracking, marketing,
and scheduling.
That’s why we offer one Unity Platform™ that does it all. This provides the most
simple, easily deployable, and supportable solution in the field of medical imaging
information technology.
RIS/PACS Thin Client vs. Smart Client facts and fads: 10
Understanding RIS/PACS Past, Current, and Future Trends
Conclusion
DR Systems believes that ”thin client” and “web-based” have become catch phrases
designed to create an impression of “modern technology”. In fact, the so-called thin
client competitor systems we’ve examined - are not thin at all.
More importantly, the true success of our customers is measured by
their economic and clinical performance, which today requires a
mixture of smart client and true thin client architecture, as well as
the unified family of RIS/PACS solutions we provide.
About the Author and Company
About Murray A. Reicher, M.D.
Dr. Reicher is a Board certified diagnostic radiologist with subspecialty CAQ in
Neuroradiology. Dr. Reicher joined Radiology Medical Group in 1986 and continues to
make numerous significant contributions of teaching, scientific publications, and
research in the area of neuroradiology, musculoskeletal MRI, and related MRI
technologies. In 1992, he founded one of the world’s most successful PACS companies,
DR Systems, Inc. He is the past President of Radiology Medical Group, Inc. and
currently serves as Co-Chairman of Imaging Healthcare Specialists, LLC.
About DR Systems, Inc.
DR Systems, Inc. is a leading provider of film-free medical image and paperless
information systems with integrated RIS/PACS that includes dictation, reporting and
Internet-based distribution solutions for hospitals and medical imaging centers.
DR Systems’ DICOM-compliant system includes the Dominator Diagnostic Reading
Station with Instant Reporter option (automated voice recognition, dictation, and
report distribution), the Catapult Technologist QC Workstation, the RIS Admin
Station, the DR Central Server and Communicator Web Server, the Ambassador
Clinical Review Station, the Messenger Diagnostic Portal, and the Guardian Archive
System. DR Systems’ ease of implementation and user training allows customers to
rapidly achieve financial and clinical success. With a modular design scalable for
growth, DR Systems RIS/PACS can handle current and future medical image and
information management needs.
RIS/PACS Thin Client vs. Smart Client facts and fads: 11
Understanding RIS/PACS Past, Current, and Future Trends
DR Systems, Inc.
10140 Mesa Rim Road • San Diego, CA 92121
Toll Free: (800) 794-5955 • Tel: (858) 625-3344 • Fax: (858) 625-3334
www.dominator.com • Email: [email protected]
Copyright © 1997-2006 DR Systems, Inc. All rights reserved.
Specifications are subject to change without notice. Ambassador, Catapult, CD Ambassador, Communicator, Dominator,
DR Scheduler, DR Systems, Guardian, Instant Reporter, Messenger, Report Manager, Universal Manager, Web Ambassador, and
Web Dominator are trademarks of DR Systems, Inc., San Diego, CA. Other trademarks used herein are the property of their
respective owners. Products and equipment by DR Systems described herein are manufactured under one or more patents,
including U.S. Patent #5,452,416.
MKT-000056-A