Picture archiving and communication systems (PACS) must be cost effective and productive to be successful. Referring physician and radiologist surveys, return on investment, and change in technical FTE productivity is evaluated. Referring physicians nearly unanimously prefer PACS over film, with productivity improvements claimed by 91%. Radiologists glean nearly 100% increased efficiency for computed tomography (CT), ultrasound, and Magnetic resonance imaging, and 50% for special procedures. Technologist productivity increased by 58% for MRI, 30% for CT, and 41% for ultrasound. Four-year experience with PACS reveals great success, with phase I return on investment after 3.5 years and more than $500,000 saved annually thereafter. There was instant conversion to 100% filmless interpretation and archive for all modalities on connection to PACS.