Poised to touch all things

A look into the future of PACS.

With RSNA 2010 — the 96th Scientific Assembly and Annual Meeting of the Radiological Society of North America — just around the corner (Nov. 28-Dec.3, McCormick Place, Chicago), we thought it would be a great time to ask industry leaders to comment on the evolution of PACS (picture archiving and communication system) and the challenges faced in adopting, implementing, running and growing a system.

“Diagnostic imaging and related content from PACS provide a critical component of the patient medical record,” says Paul Merrild, senior vice president, marketing and business development, Merge Healthcare. “Using information from imaging studies, physicians can detect the presence of disease, the progression of disease and the effectiveness of treatment. Making patient-care decisions without this information would be unthinkable, so images must become an integral part of any comprehensive electronic health record.”

But PACS is so much more than image storage and retrieval. Indeed, its processes and work flows, sometimes as a whole, sometimes in parts, are poised to touch all things related to electronic health records (EHRs) in the future.
“What's relevant here is not a focus on PACS vs. the EHR, but rather what is best from the perspective of the patient and the physician,” says Merrild. “For the most part, PACS is synonymous with diagnostic images and other 'big data' from multiple different specialties. So the question becomes: 'Are diagnostic images an important part of patient care?' The answer to that question is a resounding 'yes.'”

With so much at stake, we asked select RSNA exhibitors the following:

How do you see imaging informatics evolving as it pertains to the interoperability of disparate systems? What is the biggest roadblock to successful implementation?

Jay Backstrom, practice leader, EMC (healthcare consulting)

We are approaching a shift in the market that is driving the next evolution of PACS imaging. Initially, PACS systems were implemented to move to a filmless environment. Additionally, imaging standards were developed to get images into a PACS system. Now, with organizations implementing EMR/EHR for stimulus funding, healthcare organizations are trying to determine how to get images out of their proprietary imaging systems and integrate them with their electronic health records initiatives.
To accomplish this, clients will need to build a vendor-neutral imaging platform encompassing vendor-neutral distribution, archiving, work list, viewing and analytics that enable this information interchange. With that in mind, we find that the main road block our clients face is building a strategy that leverages their existing technology investments and prepares their technology environment for this transformation to a vendor-neutral platform. Our clients look for guidance on the best way to develop an actionable technology roadmap to move to the next evolution of PACS.

Jeffrey Kennelly, RT(R), CIIP, senior sales engineer, NovaRad

Currently, imaging informatics revolves heavily on the use of DICOM and HL7. Standards exist in both languages, but the implementation of these standards varies dramatically amongst all vendors and products. IHE (integrating the healthcare enterprise) standards have helped to start paving the way for obtainable cross-platform integration, but they still must be completely embraced by the developers of new generations of current products, as well as future offerings. HL7 requires interfacing between disparate systems, as it identifies no specifics for what fields must be used for what information in the transmission process. For true integration to ever exist regardless of system maker or use, standards must be agreed upon by the industry and adhered to precisely. Without intelligent design and standards across all imaging offerings, the dream of true, cross-platform/cross-information system integration will continue to be unrealized outside of single-vendor solutions.

Implementation roadblocks can be many in today's market. Roadblocks tend to be associated with hardware and infrastructure. Others revolve around training and acceptance by users. However, the majority of issues hindering successful implementation revolve around work flow. Identifying and agreeing upon work-flow processes by all parties involved is key to being ready for “go live” and being successful in the implementation of any system. Customers and vendors must involve users from every area that will use the system. Every process and procedure utilizing the new system has to be considered, and the translated steps to use it effectively and efficiently vs. the outgoing process or system have to be identified. No stone can be unturned in this process. If every step, no matter how insignificant or infrequent, is addressed, implementation success is almost certainly assured.

Finally, consolidating and integrating systems can mitigate another roadblock to a successful implementation. By selecting a system that can seamlessly connect with other systems, operational efficiencies can be significantly increased while, at the same time, reducing costs significantly. Selecting systems from vendors who provide standards-based systems can save hundreds of thousands of dollars in administrative costs alone. This is probably the most overlooked and under-planned budgetary consideration when selecting systems.

Betty Otter-Nickerson, president, Sage Healthcare Division

Interoperability has become one of the key drivers in health information technology. As such, it's such a critical factor of the decision-making process that it's also been written into the federal meaningful-use requirement. Needless to say, the evolution of imaging informatics will include interoperability, which, in turn, will continue to have a substantial impact on imaging informatics. The tie-in of imaging will be crucial to the overarching objectives as measured by meaningful use, as well as improving patient care and allowing improved communication between physicians and, ultimately, to patients.

Additionally, medical imaging has a substantial tie-in to quality outcomes, as it is already among the most common adjunct technologies used for assessing anatomy and pathology. To achieve the goals of the practitioners in the space and for continued evolution of improvement of care, quality outcomes will rely on clear and efficient communication between physicians — those that request medical imaging studies and those that provide reports on these investigations.

Bottom line when selecting, adopting and using health IT: Employ options that allow you to pull in imaging informatics that provide interoperability with other HIT solutions. It's not an end in itself, but it is certainly the future of healthcare.

One of the biggest roadblocks we're seeing with implementing a new solution is the change required. We often build into the implementation process the time to meet with practice leaders to discuss the changes and what they should expect prior to actual implementation. Once physicians and practice staff understand they will be doing things differently, we see success and satisfaction achieved more quickly than if we are unable to build this planning phase into implementation.
For the system implementation to be fully successful, change management can be pivotal and is fully worth the time and effort required. It's vitally important that practices dedicate sufficient time to ensure a successful implementation. The challenge of installing a new solution is daunting and necessary planning, coordination and execution is often overlooked.

Implementing software solutions isn't as simple as flipping a switch; rather it's an investment in education. We encourage practice leaders to develop a vision for success; we encourage the vision of success with peers in the practice; and we reinforce how this vision is necessary for realizing success.

David Smarro, president and CEO, INFINITT North American

With the emphasis on image and data sharing across multiple departments, multiple ologies and multiple facilities, PACS need to evolve more toward enterprise imaging (EI), supporting interoperability by implementing industry standards for easy integration with other vendors' products and with an EHR that hosts all images generated by the facility. Hospitals will have to maintain vendor-neutral archives that receive, store and distribute data in accordance with DICOM, HL7 and IHE standards, and allow images to be retrieved and viewed by any DICOM-conformant system.

In addition, EHR integration will require a fast and secure Web-based viewer that can be launched from the EHR for more advanced viewing tools. The biggest obstacle to this kind of interoperability is that hospitals still have many non-DICOM legacy devices. Although radiology and cardiology departments may be mostly DICOM, enterprise imaging has to encompass images that are not conformant with any of the latest standards. In ophthamology, for example, many devices can only output to a printer.

Hospitals are not going to go out and replace all non-standard devices overnight, so the PACS vendor has to be capable of converting that data into DICOM. We don't have a problem with that because we develop our own gateways and have the resources to develop a gateway for almost anything. We also have the ability to consolidate images from multiple PACS for reading on a single viewer.

Chris Hafey, chief architect, Vital Images

PACS is evolving and in the process of being deconstructed into three layers: archive, viewer and work flow. The archive layer is being established rapidly through the deployment of vendor-neutral archives (VNAs). The next evolution for VNAs will be to support the real-time demand of the viewers. Viewers will evolve to focus completely on the presentation and manipulation of specific types of data, procedures and modalities. The work-flow layer will weave together the viewers and archive with other healthcare informatics systems to ensure the right data is presented in the right way, to the right user, at the right time. To achieve this, an extendable model of the domain will be established with well-defined standard application programming interfaces (APIs) between each layer. Systems will have to adopt this domain model and integrate through standardized APIs to remain relevant.

The demand for this transition is increasing primarily due to the need to stabilize the increasingly complex enterprise imaging system. Once the system has stabilized, the data can be mined and used for analytical purposes to drive cost savings and improvements in patient outcomes. The biggest roadblocks to successfully integrating disparate systems include: the establishment of the domain model and APIs by the standards bodies, support for the domain model and APIs by vendors, and establishing imaging informatics as a strategic asset from both a resourcing and talent perspective.

Mitchell Goldburgh, senior vice president, marketing and business development, InSite One

Standardization for hospital information systems provided needed components to not only imaging informatics but other areas surrounding the work flow of patient care delivery. The combination of standards and an evolution of physicians' needs driving the quality of healthcare delivery led to the IHE. IHE defines actors and integration profiles for the exchange of information between disparate systems and entities.

The barriers to adoption in figuring out what to include or not include for data elements that were not mandatory resulted in widespread variations in how systemic models could be implemented. While IHE attempts to address this with their integration profiles, the historic implementations, there are an enormous number of older system software revisions in the field. This sets precedence for general financial barriers in upgrading these systems that will continue to provide barriers to imaging informatics.

A derived goal of imaging informatics is to bring value to the delivery of imaging services to users by integrating the process of diagnosis and the results delivery for patient care. These users who are external to imaging services bring new work flows, information systems and business issues to bear on the art of imaging informatics. As RSNA launches the RSNA clearinghouse at this year's RSNA 2010 conference, giving patients control of their imaging information and the market for “CD elimination” begins to take hold, bringing new focus on image sharing and creating new challenges to informatics. Now the information exchange challenge is no longer between technical systems but between solutions envisioned to simplify this information exchange.

Paul Merrild, senior vice president, marketing and business development, Merge Healthcare

Many believe that imaging has been at the forefront of interoperability. In using DICOM, HL7 and IHE, most would agree that imaging departments have a solid understanding of interoperability, and that many imaging systems have a solid base to “play” with other systems.

Despite this, confusion seems to exist around cross-entity and cross-vendor communications. Providers should not presume that it is overly complex or costly to link PACS systems from various vendors to one another, or to bridge PACS and EMR systems. Some vendors have made great strides in driving down costs and complexity.

Interoperability in imaging is going through a second phase of growth as providers consolidate. Legislation is encouraging more effective exchange of information. There is continued focus on reducing radiation exposure and avoiding unnecessary exams. A key challenge in this area is the cost associated with retrofitting legacy systems. Technology has advanced, however, to a point where organizations can justify the expense — either to retrofit existing systems or to start with an entirely new system.

Reaching beyond pure technical aspects of this question are continued concerns about the misalignment of economic and political incentives across providers, payers and even patients. This challenge may result in further delays in the move toward more effective interoperability of disparate imaging informatics systems.

Matt Long, vice president, healthcare informatics, Philips Healthcare

When radiology PACS systems were first developed, they were designed primarily for radiologists. What we, as an industry, learned over time was that for a PACS system to be truly successful the system needed to also meet the needs of referring physicians as well as IT. Over the past few years, as most vendors have been able to provide a solution that manages radiology images effectively, the focus for PACS has expanded from managing the movement of images to providing a platform for managing communications among users and to consolidate images from many different clinical specialties: radiology, cardiology, pathology, dermatology, etc.

As the role of PACS has evolved from a departmental imaging solution to an enterprise imaging solution and communication platform, the needs for integration have become more important. PACS systems regularly interface with RIS systems and more, and more often they interface with the EMR. Radiologists are frequently asking to have access to information traditionally stored within the EMR/HIS (biopsy results, pathology results, etc.) to facilitate the diagnostic reporting process. Ultimately, the bi-directional requirement with multiple information systems is the biggest challenge facing the industry as we
move forward.