Wetering, R. van de, Batenburg, R., Lederman, R. Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning. International Journal of Computer Assisted Radiology and Surgery:
2010, 5(4), 401-409
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
Postprint Version 1.0
Journal website http://dx.doi.org/10.1007/s11548-010-0414-y
Pubmed link http://www.ncbi.nlm.nih.gov/pubmed/20379793
DOI 10.1007/s11548-010-0414-y
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Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning
ROGIER VAN DE WETERING* · RONALD BATENBURG** · REEVA LEDERMAN***
*Department of Information and Computing Sciences,
**NIVEL, Netherlands Institute for Health Services Research,
***Department of Information Systems, University of Melbourne,
ABSTRACT
Purpose: While many hospitals are re-evaluating their current Picture Archiving and
Communication System (PACS), few have a mature strategy for PACS deployment.
Furthermore, strategies for implementation, strategic and situational planning methods for the
evolution of PACS maturity are scarce in the scientific literature. Consequently, in this paper
we propose a strategic planning method for PACS deployment. This method builds upon a
PACS maturity model (PMM), based on the elaboration of the strategic alignment concept and
the maturity growth path concept previously developed in the PACS domain.
Methods: First, we review the literature on strategic planning for information systems and
information technology and PACS maturity. Secondly, the PMM is extended by applying four
different strategic perspectives of the Strategic Alignment Frameworkwhereupon two types of
growth paths (evolutionistic and revolutionary) are applied that focus on a roadmap for PMM.
This roadmap builds a path to get from one level of maturity and evolve to the next.
Results: An extended method for PACS strategic planning is developed. This method defines
eight distinctive strategies for PACS strategic situational planning that allow decision makers
in hospitals to decide which approach best suits their hospitals’ current situation and future
ambition and what in principle is needed to evolve through the different maturity levels.
Conclusions: The proposed method allows hospitals to strategically plan for PACS
maturation. It is situational in that the required investments and activities depend on the
alignment between the hospital strategy and the selected growth path. The inclusion of both
strategic alignment and maturity growth path concepts make the planning method rigorous, and
provide a framework for further empirical research and clinical practice.
I
NTRODUCTION
The first Picture Archiving and Communication System (PACS) was introduced more than two decades
ago to reduce reliance on film-based radiology departments [1]. PACS has since become an integrated
component of today’s healthcare delivery system [2]. The introduction of PACS within hospital practice
has significantly changed the working practices of radiologist and end-users of the system [3,4]. Achieving
this type of filmless environment with PACS is also a highcost venture, however [5]
. PACS is well matured
and offers customized archiving solutions and reading stations that fulfil the needs of most users [5–8].
More efficient, extensive, cost-effective, scalable and vendor independent infrastructure PACS solutions
Wetering, R. van de, Batenburg, R., Lederman, R. Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning. International Journal of Computer Assisted Radiology and Surgery:
2010, 5(4), 401-409
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
have been developed, to overcome the technical and practical limitations of current operational file systems
(e.g. Unix) and PACS database design [9,10]. However, the majority of commercial PACS vendors have
developed PACS specifically for radiology and need to change the structure of current systems to extend
PACS towards other specialties (e.g. cardiology, dermatology, ophthalmology, surgery, haematology,
pathology, neurophysiology, digestive, orthopaedics, obstetrics, gynaecology, allergology, urology and
pneumology) [6,10]
. Many hospitals attempting to extend PACS beyond radiology take this as an
opportunity to re-evaluate their current systems and are looking to replace their original imaging networks
with state-of-the-art equipment to improve overall system performance [11]. Moreover, many hospitals who
have 5–7 years of experience with PACS, are planning for major upgrades or have already migrated to a
new PACS vendor [12]. This upgrade development is driven by the current volume of imaging data
produced by modalities like CT’s and MR’s that have major impact on the common architecture
. The
selection of a (new) PACS vendor should go beyond purely financial considerations [13] and be based on a
deliberate consideration concerning project responsibility, compatibility, standardization, ease of upgrading
and updating, as well as service and maintenance [14]. However, in the vendor selection and purchasing
strategy process often important criteria such as detailed specification and descriptions of operational
functionality, project documentation and adequate specificity in the contract are forgotten [15]
. PACS
directly affects patient care, (clinical)workflowand clinical effectiveness [16]. As the importance of
imaging technology and the radiology practice grows and evolves, the importance of strategic direction and
preparation for the future are becoming more significant [17]
. In practice, we see that a strategic planning
approach towards PACS and PACS (re)deployment is lacking, both in hospital board rooms and in the
literature. There are case study examples about the implementation of PACS and the conversion to digital
imaging [18,19]. The Baltimore VA Medical Centre for instance, is such a well documented PACS
implementation case. It describes the implementation process over the years and the subsequent maturation
and evolvability of the PACS into a larger healthcare imaging system and ePR from the beginning
[7,20,21]. The strategic alignment between PACS and the hospital enterprise is not addressed, however, nor
is the strategy process behind the PACS deployment and its critical conditions.Most contributions in the
domain of strategic plans for PACS solely elaborate on the transition from a non-PACS environment
towards a fully digital radiology and diagnostic imaging environment [7,22,23]. While the parts concerning
the operational planning of a PACS are addressed, the strategic/situational investment and activity steps
required to evolve from the current system implementation (as-is) towards a higher level ofmaturity are not
.
Given the above, the main objective of this paper is to develop a method for hospitals that enables the
strategic planning of PACS deployment. The method put forward is based on the elaboration of the PACS
Maturity model (PMM) [24] through the strategic alignment concept and the maturity growth path concept.
By combining both concepts we propose a framework and method for the alignment of PACS development
and hospital strategy that is more likely to be achieved in practice. This framework can be used for both
further empirical research and practical application
.
T
HE PACS MATURITY MODEL
Several maturity models have been developed to measure, plan and monitor the evolution of Information
Technology or Information Systems (IS/IT) in organizations.Within this field Nolan and Gibson [25,26] are
considered the founders of the IS/IT stage-based maturity perspective that has been further extended by
others [27,28]. Examples of maturity models are theCapability Maturity Model for software development
[29], the Supply Chain Management Maturity Models [30], the Business Process Orientation Maturity
Model [31], the Maturity model for interoperability in digital government and so on. For PACS, Van de
Wetering and Batenburg developed the PMM [PMM; 24]. Based on a literature review of 34 scientific
papers on PACS development and a subsequent meta-analysis, they found three general streams in PACS
maturity and evolution: (1) radiological and hospital- wide process improvements, (2) integration
optimization and innovation and (3) Enterprise PACS and the electronic patient record. From this, they
defined five levels of PACS maturity that hospital enterprises can achieve:
• Level 1: PACS Infrastructure;
• Level 2: PACS process;
• Level 3: Clinical Process Capability;
Wetering, R. van de, Batenburg, R., Lederman, R. Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning. International Journal of Computer Assisted Radiology and Surgery:
2010, 5(4), 401-409
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
• Level 4: Integrated managed innovation;
• Level 5: Optimized Enterprise PACS Chain
.
These PACS maturity levels are defined by their increasing process focus. With the progression towards
maturity level 5, operational (workflow) efficiencies, IS/IT-integration and qualitative care using PACS
technology expand
. Additionally, the level of retrieving more timely and accurate information for
clinicians, physicians and hospital management increase as well. At the highest levels, processes are
effectively redesigned and underlying clinical processes and workflows are optimized, supported by the
integration of PACS within a larger hospital enterprise (strategy) and the Electronic Patient Record (ePR).
It is at the optimized enterprise PACS chain level where PACS is fully integrated into the ePR that PACS
can be maximized for efficiency purposes and clinical effectiveness
. The PMM is a descriptive, partly
normative model that is, as of now, not explicitly developed as a guideline for strategic planning, nor is it
made situational for different factors and conditions.Although themodel can be interpreted as a
straightforward (i.e. sequential) accumulation of PACS investments, it is not defined which steps need to be
taken to cross-maturity levels. Also, the development through the maturity model might differ in pace, and
in the ‘optimal’ cross-cutting route. Both shortcomings will be addressed in the next two sections
.
EXTENDING THE PMM: STRATEGIC ALIGNMENT
Strategic alignment is a central element of strategic planning, the process by which organizations develop
and deploy a competitive, long-term strategy in which internal resources are integrated into external
opportunities. The process for strategic IS/IT planning has been first addressed by King and Cleland [32].
They suggest that the highest level of ‘sophistication for strategic planning for information systems’ should
meet three criteria: (1) it should incorporate processes for relating IS strategy to the existing business
strategy of the enterprise, such that a significant change in business strategy would require a significant
change in IS strategy, (2) it should explicitly incorporate processes for assessing the existing and planned IS
resources of the organization with the objectives of identifying potentially useful changes in the business
strategy, tactics, or the processes that they may support, and (3) it should govern information and
information systems as a strategic resource or competitive weapon, and explicitly involves processes for the
identification of opportunities for the use of the information resource [33]
. As of now, the common term for
strategic alignment is business-IT alignment, a broad and widely used concept that aims to optimize the
organizational benefits from IS/IT at the strategic and operational level, as well as the mutual adaptation of
the business and IT domain [34]. Undoubtedly the most cited concept in the field is the Strategic Alignment
Model (SAM) by Henderson and Venkatraman [35], and extended by others [36]. The SAMwas driven by
the difficulty of many organization during the nineties to create value from investments in IT/IS because of
the lack of alignment between the business and IT strategy. The authors claim that a dynamic process is
needed to ensure continuous alignment between the business and IT/IS domains, to achieve ‘strategic fit’ as
well as ‘functional integration’. This is illustrated in Fig. 1, which shows the linkages between four
quadrants that emerge from combining the business and IT domain on the one hand, and the external (i.e.
strategic) and internal (i.e
. operational) domain on the other. The quadrants of the SAM can be connected in
several ways, illustrated by four different strategic perspectives or paths. Each path describes a perspective
that addresses the two linkages (strategic fit and functional integration) to realize business-IT alignment.
Plans and actions based on the four perspectives should envision strategic alignment by applying the ‘one
that fits best’ of the four perspectives, each with its own starting point (anchor), mean (pivot) and effect
domain (target) [37]. These perspectives differ by the path they define to ‘walk’ over the alignment model.
Henderson and Venkatraman [35] stress that neither of these perspectives is superior to one another: “If
they were, it would not be strategic because all firms would adopt it” (p. 482)
. The key in really creating a
competitive advantage therefore lies in choosing the right perspective for the right situation
. If we apply the
SAM and the four distinct perspectives by Henderson andVenkatraman to thePMMas described above, the
following can be derived:
1. The first perspective (path “1” in Fig. 1) is labelled by the authors as the Strategy Execution
perspective. Business strategy is the main driver for all organizational and IT infrastructural choices. This
perspective defines the role of top management (business) as the strategy formulator and IT management’s
role is that of strategy implementer
. The IT function is primarily seen as a cost/-service centre for the
Wetering, R. van de, Batenburg, R., Lederman, R. Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning. International Journal of Computer Assisted Radiology and Surgery:
2010, 5(4), 401-409
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
organizational processes and infrastructure. Applied to the PACS domain, this perspective implies that
investments and innovation are restricted by budgets that are defined by the hospital board. The hospital
board might develop strategic actions that touch the role of PACS within the organization, butmost likely
the maturation of PACS as such is not prioritized. In this perspective, PACS is a typical ‘supportive’ or
‘key operational application’ [34]
.
2. The second perspective (path “2” in Fig. 1), is the Technology Potential perspective. Here the business
strategy is explicitly aligned with the IT strategy in order to support the chosen business strategy with the
accompanying specification of the required IS infrastructure, systems configuration and processes for
system development and maintenance. An organization that follows this perspective seeks technology
leadership to differentiate from its competitors. IT is seen as imperative to support the business, but the
business is still leading on a strategic level
. In this perspective, PACS can become part of strategic
considerations if the hospital board aims to innovate and integrate the organization from a process
perspective taking into account the scope of PACS within the hospital enterprise and system competences
that better support existing business strategy
.
3. Competitive Potential is the third perspective (path “3” in Fig. 1). As in the previous approach, business
and IT strategy are aligned, but now the top management views IT as the primary catalyst (driver) for
changing the organization
. This approach allows IT to change the business based on new technologies and
opportunities, while the business still decides which technologies to implement
. PACS can be such an IT-
driver with ‘competitive potential’ (or: high potential) but this obviously requires top management support
and explicit investments within the hospital enterprise. PACS needs to be internally positioned in such a
way that it can actually drive chain optimization and thereby influencing the distinctive competences of the
business strategy
.
4. The fourth and last perspective (path “4” in Fig. 1) is the Service Level perspective. Here the aim is to
reach a world class IT service organization ensuring effective deployment and optimal use of IT resources
and be optimally responsive to the demands of end-users. The IT strategy leads the internal design of the IT
infrastructure and subsequently the organizational processes. In contrast with the other perspectives, the
role of business strategy drive is indirect. In this approach, thematuration and deployment of PACS can be
leading too. In contrast to the Competitive Potential perspective, alignment with the hospital strategy is less
important. This implies that PACS can be deployed as a direct driver for operational processes and/or
change
.
In overview, the four perspectives describe four types of alignment between the business and IT domain.
Two perspectives (Technology Potential and Competitive Potential) are based on a strategic fit between
business and IT, meaning that it will depend crucially on the strategic agenda and support of senior
management if PACS is to be matured to the highest levels. The other two perspectives (Strategy Execution
and Service Level) are based on functional integration, meaning that PACS can either be leading or
following within the hospital enterprise (i.e. high potential or bound to maturation)
.
[
FIGURE 1]
Extending the PMM: growth paths
In section “The PACS maturity model”, we referred to several stage-based maturity models, including the
PMM. After extending this model with four different perspectives on strategic alignment (that actually
condition the PMM), this section focuses on a roadmap for PMM, that is, how to get from one level
ofmaturity and evolve to the next [27]. While organizations tend to evolve from one stage to the next, some
organization take strategic leaps and evolve to higher levels of development [38]. Gluck et al. [39] indicate
that formal strategic planning does indeed evolve along similar lines and phases among different
organizations, with accompanying effectiveness of strategic decision making. This maturity process takes
place at varying rates of progress and is different for each organization operating in a different market, see
also [40]
. As was shows in section “The PACS maturity model”, the PMM assumes that levels have a
sequential, accumulated, relationship with each other. The next question is obviously how hospitals actually
realize this maturation and evolvability in terms of steps and accompanied actions, to reach a higher level of
maturity. This requires detailed investment planning focused on realizing transitions in practice
. Growth
paths can be considered as an extended method for the management of transitions that are needed to evolve
Wetering, R. van de, Batenburg, R., Lederman, R. Evolutionistic or revolutionary paths? A PACS maturity
model for strategic situational planning. International Journal of Computer Assisted Radiology and Surgery:
2010, 5(4), 401-409
This is a NIVEL certified Post Print, more info at http://www.nivel.eu
through the PACS maturity levels. As outlined by the previous section, growth and evolvability requires
strategic vision and planning. Synthesizing from literature on the underlying premises of PACS, case
studies and practical experiences of hospitals with PACS deployment, we believe that two main growth
paths can be gleaned:
A. Evolutionist growth paths: evolutionist growth paths (or: plateau planning) develop logically in stages.
These stages followone another based on predefined objectives and goals. Each of the PACS maturity
levels is a precursor for the next level, so that the structures on which the current PACS rest undergo little
change with movement to the next level. Thus, the evolutionist growth path is defined as going from PACS
Maturity level 1 to Level 2, from 2 to level 3 and so on (as indicated in Fig. 2 with small arrows). Such an
evolutionist growth path should not be interchanged with the evolutionary concept [41]. Evolutionary
concepts focus more on mechanisms and processes by which changes occur and new characteristics of
entities come into being, resulting in a new states of equilibrium [see also 42]. The evolutionist approach
follows the philosophy of total and continuous quality management in which incremental process
improvement is achieved [43,44]
.
B. Revolutionary growth paths: revolutionary growth paths take a more radical approach in that it takes
strategic ‘leaps’ in order to evolve to higher levels of PACSmaturity (see Fig. 2). Such a path introduces a
radical change and process focus for the hospital and does not follow the logic of monotonous sequential
development, i.e. that stages follow one another by definition. Rather revolutionary paths take leaps to
higher maturity levels skipping intermediary maturity levels [38]. It requires strategic deliberation to
implement such radical process changes. These paths follow the ideology of Business Process
Reengineering and Business Process Innovation that had high impacts in previous decades [44,45]
.
Revolutionary does not mean, however, that the intermediary levels (and their associated elements and
deployment activities) are not addressed in a strategic plan. For instance, the transition from maturity level
2 to level 5 is revolutionary in that it ‘leaps’ over the intermediary maturity levels, but still requires that all
the matured levels are addressed, either in aggregate or specifically
.
Since hospital strategic planning processes are formed on the basis of internal, external, market-driven and
non-marketdriven components [46], they are thus situational. Activities for each growth path to realize a
specified maturity transition are likewise conditional on given situations such as the given PACS’s state
ofmaturity and the specified strategic alignment direction. In other words, specified growth paths depend on
what is required to realize transition towards higher levels of PACS maturity. In our view, a desired
maturity level cannot be achieved without conscientiously governing and addressing all process focussed
elementswith inevitable investments and deployment activities at each of the intermediary maturity levels.
This does not favour either an evolutionistic or revolutionary growth path (or a combination), it does,
however, imply that careful consideration is required when choosing a strategic direction. Hence, growth
paths capture an important dimension of strategic planning for PACS
.
[
FIGURE 2]
Towards a situational and strategic planning method for PACS
Now that we have described the concepts of strategic alignment and roadmaps as extensions of the
PMM,the next step is to elucidate these into a strategic planning method for PACS
. We define eight
strategies that are based on the combination of the ‘four’ original perspectives that envision strategic
alignment (strategy execution, technology potential, competitive potential and service level) with two types
of growth paths (evolutionistic and revolutionary). These eight strategies build the decision space: an
extended method for PACS strategic planning
. The eight strategies are summarized in Table 1. The table
serves as a decision framework for decision-makers in order to choose a strategic direction and deploy
PACS towards a desired level of maturity
. The distinctive strategies defined by the framework incorporate
the triangle construct of the Strategic Alignment Model. It encompasses the three quadrants of the strategic
alignment model, and addresses the principles of strategic fit and functional integration simultaneously.
This first enables decision-makers to select a clear strategic direction, by taking the business or the IT
domain as the anchor point. Secondly, decision-makers are guided to decide how to travel in this direction
(the growth path), given the hospital resources and competencies. This decision is more internally and
operationally oriented
. In order to differentiate between the strategic perspectives and being able to select
![Fig. 1 The strategic alignment perspectives [35]](/figures/fig-1-the-strategic-alignment-perspectives-35-1ex6ptp8.webp)
![Fig. 2 Situational growth paths for PACS maturity, adopted from [24]](/figures/fig-2-situational-growth-paths-for-pacs-maturity-adopted-fczvb5na.webp)