Strategic Planning

Three-Step Strategic Plan for Achieving Meaningful Use of Medical Images

These are difficult times for Healthcare’s C-level administrators, as there are a number of major challenges looming on the horizon, appearing as dark clouds threatening to merge into a perfect storm. First and foremost I suppose would be figuring out how to support and encourage Meaningful Use according to the July 13 release of the final Stage 1 guidelines. Still no specific use of the word “images” in the text, but the same two objectives that reference the exchange of “key clinical information” are now codified in the 14 core objectives that hospitals are required to comply with at least six months before November 30, 2011 deadline. That’s the last day for eligible hospitals to register and attest to receive an incentive payment for FY 2011.

The incentives drop for every year of delay, so in this case, delay will be expensive, and effectively cost the organization precious development money.

While one may argue whether medical images should or could be included in the term “key clinical information”, there is no argument that exchanging images with outside organizations and providers based on data copied to CDs is problematic. It’s also expensive (labor and shipping costs). No wonder then that there are now twelve vendors offering either Electronic Image Share appliances or Cloud-based Image services. Should the C-level administrators look into solving this problem at the risk of taking their eyes off of the Meaningful Use issue? If the two issues are mutually exclusive, probably not.

Perhaps the darkest cloud on the horizon, because it is associated with hundreds of thousands of dollars in service fees, is the upcoming PACS data migrations. This cloud might appear to many as faint and unspecified, but make no mistake…it is there, it is coming, and it is going to be bad. Once again, should the C-level administrators spend time worrying about future data migrations, when there is only a year left to get the Electronic Health Record system up and running and meeting those Stage 1 objectives? If these two issues are mutually exclusive, probably not.

Here’s another important date bearing strong negative implications…2015; the year when Medicare payment adjustments begin for eligible professionals and eligible hospitals that are NOT meaningful users of Electronic Health Record (EHR) technology. “Adjustments” is political nice-nice for lowered reimbursements. Medical Images will most certainly be a stated inclusion in the Meaningful Use criteria by that time.

One way to look at the big picture is that there are a maximum of four years of financial incentives available for hospitals that can demonstrate support of Meaningful Use of key clinical information, for every year of eligibility. Deploying an IT and Visualization infrastructure over a five year period that will ultimately deliver all of a patient’s longitudinal medical record data to the physicians and caregivers is going to be expensive. It makes perfect sense to develop a Strategic Plan that goes after every bit of incentive funding available. That plan should and can weave all of the looming challenges into a single cohesive step plan. The aforementioned challenges are not mutually exclusive.

If one takes the position that electronic sharing of medical images outside of the organization is supportive of Stage 1 objectives, Step 1 of the Strategic Plan would be to deploy an electronic Image Share Solution. Whether that solution is an on-site, capitalized appliance or a Cloud-based service is another discussion, as the pros and cons are very organization-specific. Just make sure that the solution has upgrade potential, and is not a dead-end product.

By mid 2011 it’s time to start deploying Step 2 of the Strategic Plan…image-enabling the EHR. This might seem like an early jump on the image access issue, but we don’t know if specific mention of images will show up in the core objectives for Stage 2 or Stage 3, so why risk having to scramble to catch up? Perhaps the easiest way to image-enable the EHR would be to deploy a standalone universal viewer (display application). There are already a number of good universal viewers that require minimal server resources, feature server-side rendering, and require zero or near-zero client software. The IT department develops a simple URL interface between the EHR Portal and the universal viewer, and then individual interfaces between the universal viewer application and all of the image repositories in the enterprise (i.e. PACS). Ah but there’s the rub. All those PACS interfaces are going to be expensive to develop and maintain and replace with each new PACS, and there is no assurance that the universal viewer will be able to interpret all the variances in those disparate PACS headers.

Those of you that have been following my posts on this web site, see where this is going. The best solution, certainly the best long-term solution, is the deployment of a PACS-Neutral Archive and an associated Universal Viewer (aka UniViewer). The EHR is not designed to manage image data, relying instead on interfaces between its Physician Portal and the various established image data repositories in the enterprise. The PNA solves most of the organizations data management problems by consolidating all of the image data into a single “neutral” enterprise repository, which directly supports and encourages Meaningful Use of all the data objects that will constitute the patient’s longitudinal medical record. The problem is, most organizations will not be prepared to deploy a PACS Neutral Archive in 2011, so this would be a bit much to schedule for Step 2.

My Step 2 would be to expand the Image Share solution from Step 1 to include more storage…enough storage to accommodate the image data that the organization will start migrating from each of its department PACS. Of course this would mean making sure that the Image Share solution that is chosen in Step 1 was capable of becoming a PACS-Neutral Archive. At a minimum it would have to support bi-directional tag morphing. By the time the organization has completed the migration of the most recent 12 to 18 months of PACS image data, it will be possible to support Meaningful Use of the most relevant image data both inside and outside the organization. It is important to appreciate that the set of features/functions of a PACS-Neutral Archive required to meet the objectives of Step 2 (while the data is being migrated) is a fraction of the full set of PNA features/functions, so the cost of the software licenses required for Step 2 should be a fraction of the cost of the licenses for a complete PNA. Fortunately there are a few PNA vendors that appreciate this subtlety.

Step 3 could occur out there sometime beyond 2012, when the organization has sufficient funds approved to turn on all of the features and functions of a PNA, and purchase sufficient storage to accommodate all of the enterprise’s image data.

In this Strategic Plan, all of the major challenges looming over the horizon that have to do with images are addressed and solved in three creative yet logical Steps. Using the infrastructure to support and encourage Meaningful Use, in turn qualifies the organization for significant financial incentives that should go a long ways toward financing the Plan.

Hospitals required to demonstrate Electronic Image Sharing in 2011

Despite the key role that medical imaging plays in patient care, the inclusion of medical images in the Meaningful Use criteria for ARRA funding was supposedly all the way out in 2015.  One would think that that would give a healthcare organization plenty of time for planning, choosing a solution, budgeting and picking a vendor.

In theory, there are a number of ways to support Meaningful Use of images through the Physician Portal.  Whether you believe the best approach is [1] an Enterprise Archive with a UniViewer, [2] a multi-department PACS with its UniViewer, or [3] a continuation of individual department PACS, each with their own viewers; four-plus years would seem to be plenty of time to watch what the early adopters deploy and figure out your own strategy.

I think those four years just disappeared…in a puff.

In a recent article, Keith Dreyer, D.O., Ph.D., included a statement in his conclusion that came as something of a surprise to me.   That statement is worth repeating here in its entirety.  The underlines are mine.

“The Centers for Medicare and Medicaid Services proposed rulemaking of December 2009 suggests that providers will be required to demonstrate cross-provider patient medical data sharing by 2011. Furthermore, at least 80% of patient requests for electronic medical data must be able to be delivered within 48 hours. It is expected that medical imaging will be an important component of these requirements. As the federal government begins to require even more communication among all healthcare providers, the need for standards-based technology will undoubtedly become an integral part of the medical imaging IT infrastructure.”

“By taking a proactive approach and deploying technology such as image sharing applications, your department—and organization—will be better prepared for the impending future.”

Since this admittedly came as a surprise to me, I did a search and came up with an article in Healthcare IT News that listed the actual wording of the December rulemaking that Dr. Dreyer was interpreting.  Sure enough, in # 15 and #17 in the list of 23 Stage 1 Meaningful Use criteria, there appears a reference to “diagnostic test results”, and one can easily agree with Dr. Dreyer that that should be interpreted to include the actual images themselves.

What a timely discovery!

Medical Image (data) Sharing is already a hot subject.  By my count there are already 20 companies pitching some version of electronic Image Sharing…data transfer from site A to site B over a Virtual Private Network (VPN) or through an encryption application over the internet.  In most cases, these products are simply replacing the method of data transfer, replacing CDs with a network.  Most of these solutions fail to address a more subtle problem with data exchange between systems.  That problem is data compatibility.

All PACS systems are largely DICOM-conformant, but that conformance in and of itself does not guarantee data compatibility between different PACS.  Image data formatted by PACS A is not necessarily going to be fully compatible with PACS B just because the data is in the DICOM format.  I’ve already posted a piece on this subject on this web site. These new electronic image sharing products/services must be able to perform bi-directional dynamic tag morphing on the image data being transferred between systems in order to assure compatibility on the receiving end.

What makes Dr. Dreyer’s conclusions regarding electronic image sharing in 2011 so interesting is that they link Image Sharing with the larger subject of Meaningful Use by 2015.

I believe Meaningful Use in 2015 will depend on Ease of Use, and that strongly suggests a single consolidated image data repository and a single UniViewer, and the foundation of that concept is dynamic tag morphing…the ability to make image data from disparate PACS compatible with a single viewer.   So the PACS-Neutral Archive and the Image Sharing System have a very important key ingredient in common…Bi-directional Dynamic Tag Morphing.

There may be plenty of time to build the infrastructure necessary to achieve Meaningful Use of image data in 2015, but there’s no point in overlooking opportunities to build the stepping stones of that infrastructure this year.  An Image Sharing solution that includes the tag morphing application might easily be expanded, step-by-step, year-by-year to become the Neutral Archive an organization will need in 2015.

Picking the right Image Sharing solution, the one that grows into Neutral Archive, means having the bigger plan in place for the Neutral Archive.  Getting from 2011 to 2015 with the least number of dead-ends, restarts, forklifts, etc, means taking the time to build the big plan now.  Thank you, Dr. Dreyer, for providing a more immediate motivation.

What’s it going to take to achieve Meaningful Use of Images?

The other day a friend of mine forwarded to me a link to the Imaging Technology News eNews web site.  My friend encouraged me to look on the left bar of the web page and find the invitation to participate in their current survey.  The question was “Will PACS/RIS meet the meaningful use criteria to qualify for incentive dollars?”  If the survey is still running, you can check out the current results here.

Last time I checked, 33% thought that PACS/RIS would meet the criteria and another 30% thought that there’s a good chance it will.

I’d love to see the demographic of the survey participants, and I’d love to see a list of their assumptions.

I’m among the 30% that responded with a solid “no”, convinced that the PACS/RIS as we know it will not qualify for Meaningful Use, because it simply doesn’t have what it takes, and most likely never will.

If the survey participants gave serious thought to the question, they should have realized that the most critical component of what it takes to sustain Meaningful Use will be “ease of use”.  Most physicians are far too busy to learn and remember how to use more than one image viewer.  Most physicians are far too busy to switch back and forth between multiple viewers to assemble a montage of all the relevant clinical information in a single viewing window.  That’s exactly what will happen if we continue on the present path of developing individual URL links between the Physician Portal and the data elements being stored in each of the specialized departmental PACS, and using those department PACS viewers to view the data.  This approach shouldn’t make sense to IT, and it won’t make sense to the physician users.  So the participants must have been assuming that an all-encompassing Enterprise PACS will emerge, a single PACS that will embody all of the specialized department PACS requirements and thereby become the Uni-PACS.

In my opinion, it is highly unlikely that a current generation Radiology or Cardiology PACS or any other departmental PACS for that matter, will evolve in the next few years into an Enterprise Data Repository capable of managing the patient’s longitudinal record of all clinical information.  I seriously doubt that they will be able to manage all of the image information, much less all of the non-DICOM and non-image data objects.

Managing all of this clinical data is probably the easier part.  The harder part will be providing all of the expected display and processing applications that are specialized for each of the contributing imaging departments.  This is not to say that some of the larger vendors won’t try to become an all-encompassing enterprise PACS, or at least claim to be the Whopper of PACS, but I don’t see that happening.

In my opinion, the more likely scenario will be the Enterprise Neutral Archive fulfilling the role of the Enterprise Data Repository, and the (interfaced or embedded) UniViewer will provide the unified set of viewing tools that the physicians will use to access and view all of a patient’s clinical information, both the image and the non-image data being managed by that Neutral Archive.

Today, more and more Health Care organizations are “getting it”.  They see all of the advantages of separating the “archive” data management applications from the departmental PACS.  And it’s a natural to add a viewer to this new generation Archive.   Sooner or later, each of the PACS vendors will “get it”, and at that moment the push will be on in their R&D groups to further differentiate their department PACS products with the specialized applications unique to that department.  Their PACS will have to become an even better, specialized tool for each department, because the Neutral Archive will have already become the tool of choice for the Enterprise.  Meaningful Use will be much easier to achieve if the physicians know they only have to go to one repository and only have to use one viewing application to assemble all of the relevant clinical information in a single viewing session.  Get it?

Next Generation PACS will be Smaller

I read an article today in the Health Imaging & IT electronic publication.  In this article on the next generation PACS, the author states his belief  that the next generation system will have to become bigger, become all-encompassing, become a PACS for every department; or at least be able to interface with the other systems across the enterprise.  For good measure, the article mentions the need for a web product good enough to support meaningful use.

There’s nothing much new here, in fact the vision is distorted.

The major PACS vendors have been working on their Enterprise PACS for some time now, assuming that the “enterprise” consists of Radiology and Cardiology.  How’s that been working out?  How many vendors have achieved fully functional Radiology and Cardiology application packages that run on a single platform with a consolidated Directory database and can exchange image data with each other?  After all this time, there are perhaps two, depending on one’s interpretation of the adjectives I used in the definition.  History suggests that folding in Pathology, Ophthalmology, Dental, etc. is going to take some time.  I don’t think we can afford to wait.

As for interfacing with other systems across the enterprise…that certainly sounds easier for the major PACS vendors to achieve than trying to be pretty good at all those individual department PACS applications.  Unfortunately that’s not going to be easy either, because there are simply too many idiosyncrasies in the way the individual vendors have implemented DICOM.  Don’t misunderstand, the implementations are largely “conformant”, they’re simply not completely compatible.  You know that, right?

I offer as simple irrefutable evidence two well known issues:  [1] data exchange between PACS via CD is problematic, and [2] replacement of one generation PACS by another requires a costly and time-consuming data migration.

I’m making an issue of this issue again, because it is my opinion that the next generation PACS is not going to become the bigger Enterprise PACS, nor is it going to suddenly start playing nice with the other PACS.

In my opinion, the next generation PACS is going to get a lot smaller, focusing on and becoming very good at supporting a specific imaging department’s workflow and providing its diagnostic tools.  Some of this functionality will most likely migrate up-stream to the actual modalities and their associated workstations, making this generation PACS even smaller.  The next generation PACS will also lose a lot of weight.  There will be the appropriate but minimal working storage, but certainly nothing like the TeraBytes of girth in the current systems.  As for short-term and long-term archiving…nothing.  That’s not where to put archiving.

Basically the next generation of PACS will be individual department-specific applications sitting on their own dedicated servers, each embellished with the logo of that department’s favorite vendor, and interfaced to a PACS-Neutral Enterprise Archive.

The Neutral Archive will dynamically manage all those cross-vendor idiosyncrasies, which the PACS vendors should really  appreciate, because that means they can stop pretending that they are going to fix the problem they created in the first place.  The PACS vendors can go back to doing what they do well, building work flow and diagnostic tools.  The Neutral Archive vendors will take over the significant task of managing all of the data from across the enterprise, assuring full interoperability between the PACS, and providing the level of Information Lifecycle Management that is long overdue in this industry.

As for the holy grail…enterprise-wide access to all of the enterprise data through the EMR Portal using a single viewer…the PACS Vendors can give up trying to figure that one out as well.  Most of their “Web Viewer” solutions can barely lift a radiology image.  There are some truly good “UniViewers” as I call them on the market, and more in the works.  What’s more,  they’re simple, standalone applications that don’t have to be embedded into the bowels of the Archive.  They could be as easily changed as a tie, albeit more expensive than a tie, but you get my point.

My point is that rather than looking for PACS to become more than they already are, and rather than taking up pitch forks in the name of DICOM convergence, think small.  It’s time to think specialization.  Award true excellence that has been surgically applied to a specific task: a department-specific PACS, a Neutral Enterprise Archive, and a UniViewer for the Portal.  Think “meaningful use”.

RSNA 2009 Meeting signals beginning of a Paradigm Shift in Medical Image Data Management

Based on my conversations with both the vendors that really have  PACS-Neutral (Vendor-Neutral) Archive technology and those that do not, a significant number of attendees of this year’s RSNA meeting in Chicago (Nov 29 thru Dec 4), were seeking information on the subject.  Numerous motivations were sited for the surge in interest including: time and costs associated with data migrations, difficulty exchanging data between disparate PACS, and the requirement to image-enable an Electronic Medical Record system.  Having written extensively on the subject of  Neutral Archives, I find it encouraging that a growing number of Health Systems large and small are finally “getting it”.

My perception of the overall “buzz” on the subject at this year’s RSNA reminds me of 1992, as seventeen years ago the radiology PACS market had come of age and the degree of misinformation and deliberate obfuscation on that subject during that RSNA was shameful.   As Yogi Berra has said, “It’s deja  vu all over again”.  Numerous vendors that actually do not have Neutral Archive technology were actually claiming at this year’s RSNA that their Radiology PACS could effectively function as a neutral Archive.

Now that the vendors (both the haves and the have nots) are preparing their marketing strategies for Neutral Archive, the industry consultants are also coming out of the woodwork, preparing their statements of work.  It’s a good thing there are some good articles on the subject, so the consultants don’t have to learn the material the hard way.

So I guess if the vendors and the consultants are all over it, the age of the Neutral Archive has arrived.

Accurately defining what constitutes the Neutral Archive should be the next order of business for any Health System with serious interest, and especially for those organizations that have any of a number of problems whose solutions require this technology.  While there are at least ten key feature/functions included in that list, the one most important would be the ability to execute bidirectional dynamic tag morphing.

A good deal of information on this key feature/function has already been written and posted on this web site and on the new web site hosted by DeJarnette Research and I suspect a good deal more will be forthcoming in the next few months.  This time, if we are going to avoid a good number of the missteps and detours experienced in the early years of radiology PACS deployment, we need to make sure that detailed and accurate information on the subject is readily available to the decision makers.  My advice to the interested Health System is simply this, pay attention to the source of information on this important subject and always confirm the information with multiple trusted sources.

And now a word from our sponsor:  Gray Consulting has developed a simple but effective 3-Step Action Plan that will assist a Health System in understanding the subject of Neutral Archives, determine the compatibility of existing PACS with such an archive, and determine the costs of future data migrations that could be avoided.  Contact Gray Consulting for a description of the 3-Step Action Plan and a quote.

ARRA Incentive Funds Should Reward “Meaningful Use” of Image Data . . . Now Not Later

With all due respect to the learned leadership in the department of Health and Human Services and the Office of the National Coordinator for IT, it is my opinion that the early phases of the plan to award incentive payments to hospitals and physicians for  “meaningful use” of “certified” electronic health record systems is missing a key foundational component.  Without the appropriate technology foundation for clinical systems to capture, store and share image data objects across all ‘ologies, the EHR technology deployed by the providers will present a substantially incomplete view of the patient’s record.

According to a paper written and published by the  Markle Foundation Connecting for Health, 2009 titled “A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR – Achieving the Health IT Objectives of the American Recovery and Reinvestment Act”, there are seven Principles for Meaningful Use and Qualification for Certification of EHRs.  The first four of these seven principals are actually quite revealing.

  1. The overarching nationwide goals of health IT investments are to improve health care quality, reduce growth in costs, stimulate innovation, and protect privacy.
  2. These goals can be achieved only through the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth.
  3. Meaningful use should be demonstrable in the first years of implementation (2011-12) without creating undue burden on clinicians and practices.
  4. The definition of meaningful use should gradually expand to encompass more ambitious health improvement aims over time (i.e. image data).

The first three principals represent the kind of thinking that led to the decision to initially focus on what may seem to be the type of data objects that are relatively easy to access in electronic format.  At first glance it seemed to me that the early phase focus on Medication Management, Laboratory Results and Care Summaries, and the postponed inclusion of Medical Images, was a calculated attempt to capture, manage and distribute the kind of small data objects that are still being recorded on paper.  Score one for the Primary Care physician struggling to manage a barrage of paper-based information trapped in an inch thick manila folder.  I’m thinking “It’s a noble effort and besides, they’re little objects, so that should be easy!”

Then I began looking at this decision from another perspective.  Perhaps IHE and the Imaging Device manufacturers have been so successful convincing everyone that medical image data is so well organized under DICOM and therefore so easily distributed, that our thought leaders believe that there is no need to offer incentives to hospitals or physicians for meaningful use of image information.  Obviously Medical Image data is easily accessible within the hospital’s network and the internet or via those ubiquitous CDs.  With image data so clearly under control, the focus of those financial incentives should be placed instead on bringing the remaining paper-based sectors up to the same enviable status of Medical Imaging.

Forgive me, but I don’t see it that way.

From my perspective, working as a consultant to the Radiology PACS and Enterprise Archive market segments, DICOM is not so tight a standard that data exchange between disparate systems is assured.  In fact, the PACS vendors have deliberately created separate silos of medical images that (by their design) sequester their image content from universal access.  Once the images are delivered to another application, there is just enough proprietary information in a DICOM image header to assure that the best delivery and rendering of the image will be achieved by the vendor that created the image (Imaging Device) or by the vendor that modified and currently stores it (PACS).  The problems encountered during attempts to exchange image data between disparate systems using CDs are legend.  As for replacing the use of film by the referring physicians, most PACS have inadequately addressed the imaging needs of those physicians working in the hospital and especially those working in their offices and clinics off campus.  The consequences are complex, cumbersome and expensive. Can’t get the film anymore, but can’t get the electronic copy?  Not a problem, just redo the exam.

So the American Recovery and Reinvestment Act of 2009 (ARRA), the economic stimulus package enacted by Congress last February, is designed to reward hospitals and physicians with Medicare and Medicaid incentive payments for making “meaningful use” of “certified” electronic health records systems.  Back in May, Cheryl Proval in an article for Imaging Biz.com quoted Mr. Charles Christian, CIO and health systems manager of Good Samaritan Hospital, Vincennes, Indiana, and chair of the HIMSS board of directors. “The Medicare and Medicaid health IT incentives alone – which will be distributed through the states – could add up significantly for both hospitals and physicians. A 75-bed hospital, for 2011 through 2014, stands to reap $3.5 million: That’s probably twice what its annual bottom line is.  A 250-bed hospital has the potential to earn almost $6 million over four years, and a 750-bed hospital could qualify for nearly $12 million.”  The incentive bonanza estimated for the hospitals was used by PACS Consultant Michael Cannavo to launch a thread on Antminnie.com the very next month.  Vendors and Providers alike have been speculating ever since as to how to get their fair share of the funding.

Forgive me once again, but I think it’s going to be much more difficult than anticipated to collect on those incentives, if the focus of the first two years is on the accessing, sharing, and meaningful use of the electronic copy of Medication Management (recent medications), Laboratory Results, and Care Summaries.  While it’s a reasonable assumption that these data objects might be accessible and deliverable via HL-7, the last time I looked at the HL-7 “standard”, it was more open to interpretation than DICOM, and we know how well that’s working out as the type of standard that assures data exchange.

With the hope of finding significant movement towards interoperability between the type of systems that manage Medication, Lab Results, and Care Summaries, I recently visited the IHE website, specifically the Frameworks tab and discovered that there are no profiles as yet for Medication Management systems and that the Lab profiles were only recently tested in February at a European connectathon.  My hope is that Care Summaries would either be created in the electronic charting component of the EHR or could at least be managed as scanned documents.  My interpretation of the results of my research is just this: [1] Medication Management is not even on the radar and [2] the process of interconnecting Laboratory systems with external data repositories for the purpose of accessing and sharing lab results is just getting started, ergo [3] the sharing of Care Summaries through the EHR may be the only achievable objective of the first two years.

My conclusion is that the effort to access and distribute Medication and Laboratory data is many years behind the Radiology community’s efforts to standardize data format and communication protocol based on the DICOM standard.  If conformance to a single flavor of HL-7 is a requisite for accessing and sharing the kind of data that is the focus of the next few years, and the vendors proceed at the same pace as we have witnessed in the Radiology and now the Cardiology markets, it is going to take a tremendous volume of Care Summaries to justify the $Millions in incentive payments through 2011.

Here is my suggestion, and I make this in all seriousness to the hospitals and independent delivery networks out there.  Tuesday, August 25, 2009. in an article appearing on the HealthImaging.com website, the following was reported: “The Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) are asking for industry help through an official Request for Information (RFI) in determining the current status of the U.S. health IT infrastructure, and the steps needed to be taken to further develop that infrastructure.”

I suggest that we collectively lobby for the inclusion of Image Data along with Medications and Laboratory in the first phase.  Image data makes up approximately 85% of the patient’s medical record.  Repeating a lab test because we can’t find the result does cost time and money, but not of the magnitude of time and money that it takes to repeat a CT.  We are so close to being able to reliably and easily exchange Radiology and Cardiology study data and push it out to the most remote and clunky desktop (via a Server-side Rendering UniViewer).  All that is needed is a little funding for the PACS-neutral Archive movement, and we can set a fine example for Medication Management, Laboratory, and the more ambitious health improvement aims that would focus in the future on such data types as problem lists, allergies, vitals, findings, procedures, care plans, hospital discharge summaries, patient registration forms, etc.

Let’s argue that an incentive plan that focuses on the short term unattainable is no incentive plan, and that investing an appropriate expenditure in Neutral Enterprise Image Archiving is exactly what is needed right now to provide the required technological foundation to support “meaningful use” of images and then all of the other data objects to follow.

Federal Stimulus Funding for Health IT will drive adoption of PACS-Neutral Archives

A post on AuntMinnie’s PACS Forum on April 21 posed the question “Will EHR impact PACS?”.  A number of the regulars on this forum, including myself have posted their opinions.  I find it interesting to see a number of individuals suggesting that the Electronic Health Record (EHR) will morph into some kind of Super PACS supporting Radiology, Cardiology, etc. and featuring a universal viewer.

Last time I checked, the major PACS vendors were still having difficulty integrating their own Radiology and Cardiology PACS into the same platform, so I don’t hold out much hope for these PACS solutions suddenly becoming EHR systems, nor do I believe the EHR vendors are going to burden their development schedules with the effort it would take to add Radiology and Cardiology data management and display applications to their systems.

PACS will continue to focus on the individual imaging departments work flow and diagnostic applications, and EHR will continue to focus on aggregating all sorts of clinical information required to manage a patient’s course of treatment or general healthcare.  I realize that all this stimulus money targeted at EHR usage will “stimulate” the market, but I don’t think there is enough time for any of the vendors of any of these systems to reinvent their wheels.  The fastest route to market is to simply sell what already exists.

EHR systems have historically deferred to the PACS for the image management and the clinical review applications.  A relatively simple interface, currently based on a URL call, retrieves the image data referenced in the EHR listing and activates the corresponding PACS display application to display the images.  This model has been working just fine for some time now, with Radiology PACS being the principal data management system.

Unfortunately, as additional department PACS are deployed, each additional PACS would require its own URL interface to the EHR.  Multiple interfaces mean individual, separate viewing sessions based on individual separate display applications. The physicians would have to learn to use separate and different display applications. There would be no way to consolidate all of a patient’s images from separate departments into a single viewing session within a single viewing application.

My answer to the question posed by the AuntMinnie thread is that the stimulus package will most likely have an immediate impact on the PACS-Neutral Archive rather than the department PACS.

Assuming the EHR will continue to defer to another system for the image data management and display applications, it makes much more sense for that other system to be a consolidated PACS-Neutral Archive (PNA) than multiple department PACS.  The PNA is much further ahead of even the best departmental PACS in managing image data from disparate systems.  The PNA is much further ahead of the best departmental PACS in managing image data for the lifetime of the study.  The PNA is the better platform for managing non-DICOM image data and supporting a multi-modality universal viewing application.  Even before the promise of stimulus money, the PNA had a very positive ROI based on the cost of future data migrations avoided.

In conclusion, I don’t see PACS enveloping the EHR applications, and I don’t see the EHR enveloping the departmental PACS applications.  I see the EHR and the PACS remaining pretty much what they already are, separate entities.  Because of that focus, I do see them becoming more proficient at their respective tasks.  As a consequence, I see the PACS-Neutral Archive coming into its own as the central multi-modality image data repository and provider of the UniViewer display application.

PACS-Neutral Archive Action Plan

Interest in the concept of PACS-Neutral Archive is growing as evidenced by the number of new inquiries reported by several vendors responding to my informal poll.  However a significant number of those inquiries are for basic information: “What exactly is a PACS-Neutral Archive?”, and “Which PACS are compatible with a PACS-Neutral Archive?”. So my suggested Action Plan would start appropriately at the beginning with a foundation in the concept.

Obviously it would be useful to have a consolidated list of features and functions that comprise a PACS-Neutral Archive (PNA).   Not only would that list help explain the concept, it would help differentiate the various vendor solutions in the current market.  Unfortunately that list does not seem to exist.  Vendor-Neutral Archive, PACS-Neutral Archive, Enterprise Archive are just some of the terms being used to describe what is supposed to be the same concept.  Frankly I believe that all of these different names and the associated product descriptions are causing confusion.  It almost seems like the concept is being invented and reinvented as we speak.

Actually that’s not far from the truth.

The basic concept started with a few simple objectives like consolidation of separate PACS archives and replacement/upgrade of old storage solutions, and soon included normalization of all of the data to a standard data format, hence the “PACS-Neutral” moniker.  This last feature was tacked on as soon as it became obvious just how painful and expensive DICOM data migrations were going to be in future years.  In truth, the list of Features and Functions for the PNA has been evolving at a rapid pace, as each new problem surfaces and a matching solution is developed.  At this point in time no consolidated Feature/Function list exists, at least none that I am aware of.  And while the list would surely stretch to nearly 100  items, the following major features will easily separate the more promising solutions from the pretenders.

  • Open Storage Solution – supports multiple media vendors and multiple storage solutions
  • Dynamic DICOM Tag Morphing – on-the-fly conversion of data formats in support of data exchange between disparate PACS
  • Methodology for accepting and managing both DICOM and non-DICOM data objects
  • HL-7 interface support
  • Pre-fetching and Auto-routing support
  • Automated and Manual QA/QC support for interfaces with non-PACS data sources
  • Intelligent Information Lifecycle Management – data movements internal and external to the system based on meta data
  • Automated Data Purge with manual supervision
  • Set of integrated display applications, one for simple viewing, the other for advanced viewing of the image data through the EMR Portal
  • Pseudo Master Patient Indexing capabilities and optional full-featured MPI
  • Creation of XDS-I manifest and optional XDS-I Registry and Repository applications
  • Integrated remote system monitoring application capable of tracking hardware and software operations

Step two of my suggested Action Plan is to find out if a specific PACS is compatible with a PNA.  That’s not an easy question to answer as there are a lot of issues that affect “compatibility”.  Once again, there is no simple list to check. The best way to assess the degree of compatibility for a specific PACS is to simply submit basic vendor/model and software version information to a PNA vendor and request a formal PACS Compatibility Assessment.  If that vendor has experience with the specified PACS, they should be able to provide a reasonable assessment.

  • A  high degree of compatibility would support the recommendation to deploy a PNA, migrate the oldest data from the PACS first, and then set up the PACS to use its own archive for new data and access the PNA for the old data.
  • A low degree or no compatibility would support the recommendation to deploy a PNA based on a very basic but upgradeable hardware platform and simply begin migration of the PACS data to the PNA to reduce the future data migration costs.

Step three of my suggested Action Plan is to conduct a Migration Liability Assessment for your organization.  This is essentially a matter of running study volumes, study sizes, growth rates, retention policies and associated business objectives through a spreadsheet that calculates projected data volumes in future years and the cost of migrating that data from the current PACS to a new PACS.  The two most important pieces of information needed are: how much the migrations will cost and how long the migrations will take.  Given the complexity of data migrations from PACS-A to PACS-B, it is not unusual for the migration to span several years and cost hundreds of thousands of dollars.

If you have a clear understanding of the concept of the PACS-Neutral Archive, understand where your current PACS stands with respect to compatibility, and have solid numbers to support a sense of urgency, you have the three main tools you need to develop a working strategy to address this major data management problem.

If you need help performing the PACS Compatibility Assessment or the Migration Liability Assessment, Gray Consulting has considerable experience in these areas and would be happy to provide assistance.

Strategic Approach to PACS Storage Expansion

If your Radiology or Cardiology PACS is at least two years old, you’re probably running out of on-line storage capacity.  A more strategic approach to expanding the PACS on-line storage capacity is to deploy a completely separate storage solution, rather than simply adding more media to the storage solution that came with the PACS.  The right standalone Storage Subsystem could be the seed that grows into a PACS-Neutral Enterprise Archive.

In the two or more years since your existing PACS was installed, advances in CT and MR imaging have produced larger and larger data sets.  The addition of Full Field Digital Mammography has also added a large volume of digital image data to the PACS.  Echo and Cath Lab runs are also growing in data volume.  It is easy to understand how the amount of on-line storage  you originally projected for the PACS can no longer meet today’s actual storage requirements.

Up until a few years ago it was a common practice to configure a Radiology or Cardiology PACS with sufficient on-line storage media to manage the most recent 18 to 24 months of study data and install a Hierarchical Storage Management system to support near-line media in a jukebox, for example a digital tape library.  The near-line library has nearly unlimited expansion capabilities if it is linked to a shelf storage repository.  While this approach creates a sense of unlimited storage capacity, the practicality of the near-line library is limited by cartridge access rates and the manual loading and unloading of the tape cartridges.  All of this activity results in delays in image access.  After a few years of experience with the work flow associated with tape management, it is clear why the better solution is the expansion of the on-line storage solution.

Even if the Radiology PACS was configured with an all-spinning storage solution, the volume of storage required two or more years later has probably been underestimated. Whether the PACS is configured with a single or multiple tier storage solution, a storage upgrade is probably inevitable.  The question is, “What is the most strategic upgrade solution?”.

Adding additional media (drives), especially of the same type to the existing storage solution may not be the best solution.  In the last two or more years, the storage media technology has changed dramatically.  If the existing storage solution is approaching five years in age, it should probably be replaced, not expanded.   A completely new storage solution based on the latest technology would represent the best value, the most capacity per dollar invested.

Of course this type of upgrade, total replacement of the existing storage solution with a current generation storage solution with three to four times the capacity for the same dollars, will require a media to media data migration.   This type of data migration is not the onerous DICOM data migration that is required when one changes PACS, and that is the point!  A simple media to media migration moves all of the study data over to a new storage solution, preserving all of the ID errors, and retaining all of the DICOM idiosyncrasies of the existing PACS.  In my opinion, this could be viewed as a wasted opportunity.

The need for a storage expansion should be viewed as an opportunity to upgrade the storage technology AND normalize the image data format.

There are numerous arguments in favor of creating a PACS-Neutral Enterprise Archive: [1] Consolidation of multiple department PACS storage requirements into a single centrally administered storage solution, [2] Elimination of the cost of future DICOM data migrations, [3] Provision of data Acquisition and Management resources for imaging departments that have no PACS resources, and [4] Creation of a consolidated data repository for the Electronic Medical Record, accessible through the Physician Portal, viewable by a UniViewer display application.  The most significant problem limiting the deployment of this Enterprise Archive is the initial expense.

The same problem limited the early development of the Radiology PACS market.  Full-featured PACS was pretty expensive back in those days.  What finally got the PACS market going, what put the market on the upswing of the technology adoption curve was the invention of baby steps in the form of Teleradiology Systems and mini-PACS, individual systems that addressed individual needs that might be upgraded expanded or assimilated in to the larger more encompassing PACS that is commonplace today.

The emerging PACS-Neutral Enterprise Archive market needs a baby step, a “starter kit”, a “mini-PACS”.   I suggest that that starter kit could be a PACS-Neutral Storage Expansion subsystem for an existing PACS.  In  my next post, I’ll attempt to describe what I mean by a Neutral Storage Expansion subsystem, and why I believe that such a system is the right strategic move for any organization facing the need to expand their image storage.

The Problem with Proprietary Data/Object Formats – their Impact long after Data Migration

This is another take on a long-standing problem with most of today’s Radiology PACS: proprietary Data/Object Formats. It has been at least four years since Presentation States and Key Image Notes were included in the DICOM standard, yet the majority of PACS vendors continue to treat these key work products as proprietary objects. The most consistent excuse is “There are many more features on our engineering schedule considered to be more important to our users.”

I can almost believe that story, since I have found that most users are not aware of the implications of proprietary data objects. Since almost every PACS supports the creation and display of Presentation States and Key Image Notes, the fact that most PACS treat these as proprietary objects is lost on most buyers and eventual users. Provided that these objects are kept within a given PACS, there is no apparent negative to their being proprietary. The user may not experience a situation where the proprietary nature of these objects presents a problem.

The problem arises when the user of one of these proprietary PACS tries to forward study data to another Facility or Health System that is using a different PACS. Whether that other PACS is DICOM conformant or not, unless it is the same PACS, those presentation States and Key Image Notes cannot be transferred, accessed, or displayed. Physicians using the other PACS will not have the benefit of seeing exactly what the radiologist interpreting the study saw in the images or what he may have typed as a text message. The benefit of these “work products” is lost.

The problem also arises when a user of one of these proprietary PACS tries to copy study data to a CD/DVD. The proprietary work products either cannot be copied, or they cannot be accessed and displayed by another PACS. This is one of the reasons why there is so much consternation over the current CD/DVD copying solutions on the market. The vendors of these proprietary PACS typically have to place a copy of their own viewing software on these CD/DVDs, because their proprietary viewer is the only way to view their proprietary study data.

The real problem will manifest itself only after the user has decided to replace the proprietary PACS with the next PACS. Data migration services will typically migrate the study pixel data to the next PACS, but few of these services currently migrate any proprietary study-related data objects. To do so would require knowing where these objects were stored in the PACS, how to extract them and how to convert them to their DICOM counterparts. This extraction, conversion, migration is not being performed and as a result, those proprietary data objects are lost forever. The images are available for historical comparison in the next PACS, but none of the proprietary work products are available. Now imagine the implication of having to window and level all of these priors again, when they are recalled for viewing with the new images. Imagine not having the spine labels, and not having any other annotation or overlay graphics created when the prior was first interpreted. That’s working without benefit of prior information, or a possible expenditure of time redoing all that work.

A PACS should treat Presentation States, Key Image Notes, .wav files, Technologist Notes, Scanned Documents, even the Radiology Report as DICOM Objects, not only so they can be shared with other systems today, but also so they can easily be migrated and used in the next PACS. DICOM-conformance is always in the user’s best interest.

Now if a prospective buyer knew the negatives associated with proprietary data objects, would they choose a proprietary PACS anyway? Logic suggests that they should think twice. At the very least, if an organization goes ahead with the purchase of a PACS that still creates any proprietary data/object formats, that organization should negotiate a “no-cost” data migration clause in their contract that pins the cost of moving these proprietary objects to the next PACS on the vendor who has continued to choose NOT to conform to the standard.

Lack of DICOM conformance is a type of vendor lock. I believe that the PACS vendors still believe that anything that complicates moving to another vendor’s PACS may persuade the organization to stay with the incumbent. It’s time to make them pay for that strategy.