Since October, 1988, a picture archiving and communications system has been our primary means of managing ultrasound images. The ultrasound area was selected because of satisfactory image resolution with PACS, relatively low volume (18-20 cases per day), and minimal clinician request for the images. We have performed over 6,000 examinations, comprising over 50,000 images during this time period. The images and examination reports, stored on optical disks, are available on line for one week before removal to shelf archiving. When shelf archived studies have required de-archiving, most have been retrieved within five minutes. Rapid, reliable image acquisition allowed for decrease in the study performance time. Display monitor illuminance stability eliminates density variation associated with improper exposure of films. Immediate availability of images makes possible on-line monitoring of technologist performed cases. No images have been lost. Technical problems have included image degradation because of pixel shift artifact, hardware and software failure, and duplicate entry of patient demographic data. Despite rapid initial display and review, subsequent image review is 6-10 times slower than with film based studies. If PACS are to succeed, automatic archiving and de-archiving, improved system reliability, and improved speed of display must be developed.