Part 6 – The economics and the politics

Previous blog posts of this series:

• Part 1 discussed the use case of PACS migration
• Part 2 proposed a DICOM Media Exchange interface between the PACS and the archive data
• Part 3 showed how an Enhanced DICOMDIR facilitates exchanging the archive database
• Part 4 addresses standardizing journaled updates for performance optimization
• Part 5 described some additional advantages of the proposed architecture

Let’s be frank – who wins, and who loses?

Standardization is about economics – optimizing the economic efficiency across a market so as to lower the total overall cost. In such an optimization, there are some stakeholders who benefit more, and some who come out on the short end.

With standardization of the archive to support migration, the big winners are the user organizations. The key metric in this proposal is a lower cost for long-term management for the archive data set, especially at the inevitable point when it must be transitioned to a different front end (PACS/VNA) application.

So, if the users win with lower cost, one might think that saved money comes from the pockets of the PACS/VNA vendors, but that is not the case. Yes, there are some short-term costs for the vendors in redesigning and testing their apps for the new architecture, but actually most PACS/VNAs already store their data in some variant of DICOM Part 10 format files; their major technical challenge will be in creating and managing the Enhanced DICOMDIR, which should not be a problem. There is, in fact, an economic win for PACS/VNA vendors. The archive storage is actually a lower profit margin component of PACS/VNAs, and is often a pain in the neck for evaluating and managing the constant evolution of storage hardware. By separating the archive data set and its storage from the application, and turning it over to a separate product group, or to the end user organization, the vendors get to focus their attention and resources on the higher margin aspects of PACS/VNAs.

The big savings for users actually will come from the lower cost of the migration services, but the service vendors win, too! The lowest margin aspect of migration, with the least added value for the customer, is watching a petabyte of data move across a wire; i.e., simply having a person to be responsible during the long transfer process. Again, standardizing an interoperable archive data set removes the need for this low value data movement, so migration service providers get to focus on high value services.

Standardization opens markets, and a standardized archive interface opens the market for players in each area – enterprise scale storage vendors, PACS/VNA vendors, and migration service providers. With additional competition, the prices should come down somewhat – a clear benefit for the users, but a potential challenge for the vendors. However, the complementary aspect of lower prices is that the overall market becomes larger – more user organization will be able to afford upgrading their infrastructure, more PACS/VNAs will be sold, and more migrations will occur. Without a standardized archive interface, the increasing cost of migration may freeze the market, such that there is no business for anybody.

Now to the politics. The DICOM Standards Committee needs to approve a work item to develop this proposal into an actual standard. Some members of the Committee are understandably wary of diving into a new area for the DICOM Standard, and others may be concerned with certain technical aspects of the proposal. I think it is fair to say that few have considered the larger economic/strategic challenges and opportunities that are present.

Laitek has been sponsoring a DICOM New Work Item Proposal (NWIP) for the migration use case since early in 2019. Approval has stalled due to the reluctance of the vendor members of DICOM to commit to the technical approach as laid out in this blog series. It now appears that DICOM will instead set up a new Work Group to address data archiving and management use cases, specifically including migration. The members representing the user community, as they are the ones with the greatest need and the greatest potential benefit, have to actively engage with the DICOM Standards Committee and this Work Group to ensure the use case is adequately addressed. All members of SIIM, RSNA, ACR, ESR, or any of the other professional society members of DICOM, are welcome to participate. Write to me hsolomon@laitek.com.

Harry Solomon is an interoperability consultant for Laitek, Inc., and past Co-Chair of the DICOM Standards Committee. He has been involved in the development of DICOM since 1993, and has taught graduate courses in healthcare interoperability and standards at Northwestern University and at Oregon Health & Science University.