the issue of who should have responsibility for pacs has been around for many years . in the early days of pacs in the 1990s , there were valid reasons supporting pacs management by the radiology department . in those days , pacs usually ran as standalone systems and were not widely used outside of the radiology department . today , more compelling reasons support the treatment of pacs as a component of an enterprise strategy that appropriately falls under the chief information officer ( cio ) and the it organization . the cio is the executive who has responsibility for integrating information technology into the health care workplace . over the past few years , the cio s role has become more complex as public policy has encouraged the adoption of the electronic medical record ( emr ) . the total emr , including computerized provider order entry ( cpoe ) and clinical documentation , is the strategic goals for most health care cios in the usa . achieving this goal pacs is only one of the pieces that must be considered in the context of how it fits into and contributes to the emr . because it is the cio s responsibility to deliver the emr , it is appropriate that the selection , implementation , and operation of the system be under his or her authority . a second compelling reason is that pacs is no longer a radiology - only asset . diagnostic images are part of clinical information that clinicians outside of radiology expect to have readily available when viewing the emr . moreover , pacs technology is regularly used by many other areas , such as cardiology , anatomical pathology , ophthalmology , gastroenterology , and document image management . many of the large emr vendors have taken pacs architecture and expanded it to incorporate the potential for any nontextual clinical information . as pacs technology becomes more pervasive in the organization , it must be centrally managed to avoid duplication of costs and maintain consistency of service . another reason that pacs should be managed by the cio is the technical complexity of today s it environment . health care organizations are moving away from an application - centric approach to an enterprise - wide approach in managing systems . this migration has been triggered by regulatory and economic requirements . under the health insurance portability and accountability act ( hipaa ) security rule,1 health care organizations have a fiduciary responsibility to safeguard protected health information . hipaa requirements are mirrored in the joint commission on accreditation of health care organizations information management standards , which are being updated for 2009.2 approaching these requirements on an application - by - application basis is too costly and too complex to ensure compliance . when any information system is managed outside of the it organization , it becomes difficult to ensure compliance , and the entire organization is at risk . pacs requires more storage capacity than any other single application.3 pacs storage requirements will also increase more rapidly than other applications as more types of images are captured and stored . despite the fact that data storage costs have been decreasing rapidly , storage is a significant cost element that requires careful management . many organizations have begun to plan their storage requirements on an enterprise - wide basis rather than on an application - by - application basis . organizations derive significant benefits by planning and managing data storage on an enterprise - wide basis , particularly in meeting system availability and data redundancy requirements . the final reason why pacs should be managed by the cio has to do with its importance to the emr . pacs is a strategic component of the emr and must be sold to the organization in that way . the cio is more likely to get capital support for pacs than if the organization sees pacs as a departmental system . the cio and the it organization are structured to be service providers to the rest of the organization . they are more likely to have the resources necessary to support pacs and are better positioned to secure future funding . the issue of who should have responsibility for pacs has been around for many years . in the early days of pacs in the 1990s , there were valid reasons supporting pacs management by the radiology department . in those days , pacs usually ran as standalone systems and were not widely used outside of the radiology department . today , more compelling reasons support the treatment of pacs as a component of an enterprise strategy that appropriately falls under the chief information officer ( cio ) and the it organization . the cio is the executive who has responsibility for integrating information technology into the health care workplace . over the past few years , the cio s role has become more complex as public policy has encouraged the adoption of the electronic medical record ( emr ) . the total emr , including computerized provider order entry ( cpoe ) and clinical documentation , is the strategic goals for most health care cios in the usa . achieving this goal pacs is only one of the pieces that must be considered in the context of how it fits into and contributes to the emr . because it is the cio s responsibility to deliver the emr , it is appropriate that the selection , implementation , and operation of the system be under his or her authority . a second compelling reason is that pacs is no longer a radiology - only asset . diagnostic images are part of clinical information that clinicians outside of radiology expect to have readily available when viewing the emr . moreover , pacs technology is regularly used by many other areas , such as cardiology , anatomical pathology , ophthalmology , gastroenterology , and document image management . many of the large emr vendors have taken pacs architecture and expanded it to incorporate the potential for any nontextual clinical information . as pacs technology becomes more pervasive in the organization , it must be centrally managed to avoid duplication of costs and maintain consistency of service . another reason that pacs should be managed by the cio is the technical complexity of today s it environment . health care organizations are moving away from an application - centric approach to an enterprise - wide approach in managing systems . this migration has been triggered by regulatory and economic requirements . under the health insurance portability and accountability act ( hipaa ) security rule,1 health care organizations have a fiduciary responsibility to safeguard protected health information . hipaa requirements are mirrored in the joint commission on accreditation of health care organizations information management standards , which are being updated for 2009.2 approaching these requirements on an application - by - application basis is too costly and too complex to ensure compliance . when any information system is managed outside of the it organization , it becomes difficult to ensure compliance , and the entire organization is at risk . pacs requires more storage capacity than any other single application.3 pacs storage requirements will also increase more rapidly than other applications as more types of images are captured and stored . despite the fact that data storage costs have been decreasing rapidly , storage is a significant cost element that requires careful management . many organizations have begun to plan their storage requirements on an enterprise - wide basis rather than on an application - by - application basis . organizations derive significant benefits by planning and managing data storage on an enterprise - wide basis , particularly in meeting system availability and data redundancy requirements . the final reason why pacs should be managed by the cio has to do with its importance to the emr . pacs is a strategic component of the emr and must be sold to the organization in that way . the cio is more likely to get capital support for pacs than if the organization sees pacs as a departmental system . the cio and the it organization are structured to be service providers to the rest of the organization . they are more likely to have the resources necessary to support pacs and are better positioned to secure future funding . radiology is too large , too complex , too valuable , and too dependant on it to be treated as an ordinary it customer . radiologists and technical staff are advanced users of complex information systems . the hospital it organization originated as billing systems under the control of the chief financial officer . while it has grown up , the organizational culture is still predominantly corporate lacking clinical expertise . without domain expertise and local accountability to radiology system requirements frequently lack exception reporting in workflow or adequate support response times to ensure the clinical mission . an it organization without any accountability to radiology has a very hard time doing the necessary tailoring of technology to make it successful . the information systems in imaging are not generic systems ; they require specialty knowledge and maintenance skills . it is a fulltime job that does not end when the  go - live  date passes . radiology is crucial to the financial well being of a medical center . at a large academic medical center , such as northwestern memorial hospital , more than 20% of patients revenue from the technical component of imaging procedures can approach 2025% of net patient revenues of the institution . revenue in excess of expenses subsidizes many other areas of the institution and provides for a state - of - the - art imaging environment . maintaining these revenue streams in the face of decreasing reimbursement and sigma4 parlance , this means defining , measuring , analyzing , improving , and controlling the improvement of every process in the department . it needs to go beyond simple support but be an active participant in process redesign . another challenge to an independent it organization structure is the allure of using a single vendor over best of breed solutions . no single system from a single vendor can provide all of the it functionality necessary for an imaging department of any significant size . yet , central it can not resist the appearing simplicity of synergies and lower costs from a single vendor at the expense of end user functionality and satisfaction . if a group is not cognizant of their users needs and how things really work in practice , it is difficult to differentiate vendors on factors other than cost . although some of the processes found in medical imaging are common business activities , such as human resource and supply chain management , other processes , such as the integrating the health care enterprise ( ihe ) radiology integration profiles5 are unique and complex . mastering the analysis of these processes requires in - depth knowledge of the imaging environment . it staff must be embedded in departmental operations , often arising from the rank - in - file . it is somewhat surprising that many enterprise it organizations do not use industry best practices in business continuity and fault tolerance . this can be understood in part because the vast majority of enterprise it systems are not defined as mission critical . what is the response time to a pacs failure in the operating room ? detailed fallback and what - if plans must be in place throughout the department . executing these plans in a specific situation requires dedicated it resources with detailed knowledge of the environment and personnel . understanding the appropriate response model is hard to appreciate for a corporate it group which is frequently based outside of the hospital . the only standard they are experienced with is the hl7 version 3 messaging interface standard . there is little knowledge of the digital imaging and communications in medicine ( dicom ) standard , the predominant standard in radiology . lastly , radiology as a specialty has been a rapid adopter of disruptive technology such as multidetector computed tomography scanners . it takes a more diligent awareness of new technology and its impact upon architecture than traditional areas in the health care enterprise . radiology is too large , too complex , too valuable , and too dependant on it to be treated as an ordinary it customer . radiologists and technical staff are advanced users of complex information systems . the hospital it organization originated as billing systems under the control of the chief financial officer . while it has grown up , the organizational culture is still predominantly corporate lacking clinical expertise . without domain expertise and local accountability to radiology system requirements frequently lack exception reporting in workflow or adequate support response times to ensure the clinical mission . an it organization without any accountability to radiology has a very hard time doing the necessary tailoring of technology to make it successful . the information systems in imaging are not generic systems ; they require specialty knowledge and maintenance skills . it is a fulltime job that does not end when the  go - live  date passes . radiology is crucial to the financial well being of a medical center . at a large academic medical center , such as northwestern memorial hospital , more than 20% of patients revenue from the technical component of imaging procedures can approach 2025% of net patient revenues of the institution . revenue in excess of expenses subsidizes many other areas of the institution and provides for a state - of - the - art imaging environment . maintaining these revenue streams in the face of decreasing reimbursement and sigma4 parlance , this means defining , measuring , analyzing , improving , and controlling the improvement of every process in the department . it needs to go beyond simple support but be an active participant in process redesign . another challenge to an independent it organization structure is the allure of using a single vendor over best of breed solutions . no single system from a single vendor can provide all of the it functionality necessary for an imaging department of any significant size . yet , central it can not resist the appearing simplicity of synergies and lower costs from a single vendor at the expense of end user functionality and satisfaction . if a group is not cognizant of their users needs and how things really work in practice , it is difficult to differentiate vendors on factors other than cost . although some of the processes found in medical imaging are common business activities , such as human resource and supply chain management , other processes , such as the integrating the health care enterprise ( ihe ) radiology integration profiles5 are unique and complex . mastering the analysis of these processes requires in - depth knowledge of the imaging environment . it staff must be embedded in departmental operations , often arising from the rank - in - file . it is somewhat surprising that many enterprise it organizations do not use industry best practices in business continuity and fault tolerance . this can be understood in part because the vast majority of enterprise it systems are not defined as mission critical . what is the response time to a pacs failure in the operating room ? detailed fallback and what - if plans must be in place throughout the department . executing these plans in a specific situation requires dedicated it resources with detailed knowledge of the environment and personnel . understanding the appropriate response model is hard to appreciate for a corporate it group which is frequently based outside of the hospital . the only standard they are experienced with is the hl7 version 3 messaging interface standard . there is little knowledge of the digital imaging and communications in medicine ( dicom ) standard , the predominant standard in radiology . lastly , radiology as a specialty has been a rapid adopter of disruptive technology such as multidetector computed tomography scanners . it takes a more diligent awareness of new technology and its impact upon architecture than traditional areas in the health care enterprise . channin illustrate the traditional perspective of silos of care . from the perspective of the radiology department , he is absolutely right that the priorities of the radiology department , and it will probably never be the same . coordinating the care of a patient among all of the diagnostic and treatment options in the most efficient and cost - effective manner must be the priority of our health care delivery system . it has been charged with delivering the emr , which focuses on the patient  not the hospital department . the patient must be the priority , even if this means compromises elsewhere in the delivery system . what is best for the patient may not necessarily be the best or most efficient for individual departments . an it organization that is truly responsive to the needs of the organization will be embedded within each department and will have domain expertise . an enlightened cio is not threatened by it innovation within departments but will try to find ways to work with departments to develop solutions . in the end , however , everything must go back to the number one priority : the patient . although it may be true that the cio has ultimate responsibility for any it activity within the institution , the role of the cio is clearly strategic not tactical . glaser and williams wrote ,  the cio is a critical contributor to the development of the organization s strategy ; a valued member of the  c suite ; a leader of and manager of a high - performance it staff ; able to lead and support major change in organizational processes ; an astute judge of the potential of new technologies ; effective in managing the organization s it suppliers .... .6 no leader operating at that level , regardless of technical expertise and background , can hope to understand the detailed requirements and technology of the myriad clinical and support entities . the cio must lead in the support of standards , interoperability , compliance with policies , procedures , and regulations . he or she should supply intellectual and financial nourishment to let a garden of innovation grow . i contend that radiology understands the requirements and needs better than a centralized it organization . health care providers need to view and manipulate images as well as be assisted by the work product of the radiologists . the radiology community has developed a number of technical frameworks that serve as an example of how clinically centric it can be developed and managed locally . radiology can and does also serve as a technology exemplar for the other -ologies . nowhere is this more evident than in the evolution of ihe . similarly , within an institution , we can share our best practices and our infrastructure with our colleagues . if it makes sense for pathology images to be in pacs , great ; if it makes sense for them to be in pathology , all the better . standards and interoperability will push them where they need to be , just in time , for clinical decision support . central it has no role in managing a department s evolution , and certainly making them evolve in lockstep would be disruptive . my argument that the technical complexity of radiology mandates local it ownership stands . that regulatory complexity is increasing is a fact of life with which every organizational unit must contend . the role of the cio is , again , to provide leadership and guidance and to monitor compliance . the vice president of safety and facilities does not come to our department to lecture on the chicago fire code . all staff shall be versed in fire response procedures  ( a joint commission requirement ) ; we make it so . senior management , including the cio , need to make prioritization decisions that leverage its resources wisely . once those decisions on resources are made , however , only the department has the knowledge to make contracting decisions and plan , deploy , and manage the technology required to meet those metrics . we do not plumb our own water lines , generate our own electricity , or smith our locks . specific detailed operations and complex devices , however , are not commodities and can not be treated as such .
considerable debate within the medical community has focused on the optimal location of information technology ( it ) support groups on the organizational chart . 
 the challenge has been to marry local accountability and physician acceptance of it with the benefits gained by the economies of scale achieved by centralized knowledge and system best practices . in the picture archiving and communication systems ( pacs ) industry , a slight shift has recently occurred toward centralized control . 
 radiology departments , however , have begun to realize that no physicians in any other discipline are as dependent on it as radiologists are on their pacs . the potential strengths and weaknesses of centralized control of 
 the pacs is the topic of discussion for this month s point / counterpoint .