As recent reports and analyses have noted, the initial concept behind PACS (picture archiving and communications systems) was that of a departmental tool to store diagnostic images for the use of radiologists, and to replace film. Over time, PACS, along with its sister technology, RIS (radiology information systems), has evolved rapidly. And now, say industry experts, image management is becoming both cross-medical-specialty (encompassing many disciplines beyond radiology, including cardiology, orthopedics and surgery, emergency medicine, and so on), enterprise-wide, and even trans-enterprise.

Bill Moran

All this evolution implies a need for centralization. Indeed, leaders at hospitals and health systems that are implementing broader image management arrangements are confronting disparate silos of images as they seek to improve the workflow of physicians from all specialties, and control costs. All this is being attempted at a time when the ever-faster modality technologies are spewing out more and more images — including three- and four-dimensional ones — putting intense pressure on storage capabilities.

“CIOs are going to have to look at imaging across the enterprise,” says Lenny Reznik, director of enterprise imaging and information systems at the Greenville, S.C.-based Agfa Corporation. “And organizations are going to need a single foundation to make that happen. We believe that begins with a vendor-neutral enterprise archive.”

To get an idea of where the leading edge is, one might travel to southern Maine, where an affiliation of seven hospitals, serving a community of 50 radiologists and about 2,500 physicians, began building a regional imaging management system back in 2002. The main strategic goals of the affiliated hospitals were improving patient care, reducing overall diagnostic image acquisition, storage, and sharing costs, and helping the smaller rural hospitals participate in digital image management, says Bob Coleman, director of radiology informatics at the 600-bed Maine Medical Center in Portland, the original leader hospital in the group, and the largest facility in the region.

“We had a full vision for patient care, including clinical integration,” Coleman says. “Doctors see all images through one repository, and radiologists now always have prior studies for comparison online, automatically.” All images run through a unified RIS, as well. The cooperative is using solutions from Agfa.

Coleman says that in regions across the country like that of southern Maine, regionalization of image management, using a centralized-repository model, will become a necessity as consumers seek optimized care and providers look to manage costs and improve clinician workflow. In fact, he says, the concept of centralized archiving will become a necessity in itself, as providers learn to deal with increased patient mobility (as in the case of the many Maine “snowbirds” who summer in Maine but winter in Florida).

Next on the horizon? A potential statewide PACS repository for Maine.

Multi-hospital systems on the move

Certainly, leaders at large multi-hospital systems are grappling with such issues inside their organizations as well. That's definitely the case at the Kingsport, Tenn.-based 13-facility Wellmont Health System, says Bill Moran, vice president and CIO.

Roger Hertz

Using storage solutions from the Hopkinton, Mass.-based EMC Corporation, Moran and his colleagues have been working to knit together what had been a series of disparate clinical information systems (including separate RIS and PACS systems), following Wellmont's acquisition-fuelled growth. Following the waves of mergers and acquisitions, Moran says, “You find you have dispersed PACS solutions, and not all are on the same platform. As a result,” he says, “We've opted to take some of those dispersed systems — individual PACS at the different facilities — and to move towards a centralized system. We had to pull our facilities together to create a centralized system.”

In addition to using EMC as its storage provider, Wellmont is an Agfa customer for its PACS.

Mark Watts

Moran sees several key trends emerging in the next few years. In addition to image management centralization, they include intensified pressure on storage because of the growth in size and volume of diagnostic imaging studies, particularly as 3-D and 4-D studies become more common, and the need to tie together images and data from numerous medical specialties, and link everything to core EMR systems. No stranger to imaging-induced pressures, Wellmont's long-term archive storage for its PACS is already at 34.5 terabytes, and growing at the rate of one terabyte a month.

The growth of image and data volume is certainly on the mind of Roger Hertz these days. “I think we're really going to have to deal with the cost of storage,” says Hertz, vice president and CIO of the two-hospital Nebraska Methodist Health System, Omaha. “Storage is becoming less expensive, but we're growing our data,” he notes. “And as more and more organizations move towards paperlessness, you can't allow down-time.”

For Hertz at Nebraska Methodist, too, linking imaging management firmly to the core health system EMR will be critical. Nebraska Methodist is using solutions from Kansas City-based Cerner Corporation for its imaging needs.

Mark Watts, enterprise imaging manager at the six-hospital, 26-clinic Provena Health, a Catholic system based southwest of Chicago in Mokena, Ill., puts it this way: “Every CIO is interested in how they're going to image-enable their electronic medical record. They understand the significance of the image, and understand that they need to encompass images in order to achieve a robust EMR. So having an enterprise-wide storage solution is a huge advantage to the CIO.”

In addition, he says, developing storage-area networks will also be vital to success. Provena Health's strategy includes the use of image management tools from San Francisco-based McKesson Corporation.

Still, for all the talk of different technology solutions, ultimately, says Wellmont's Moran, it is the human issues that will pose the greatest challenges, and not the purely technological ones. Achieving consensus across more than a dozen Wellmont hospital facilities has been the biggest challenge to date, Moran says, and predicts that other IT and clinical leaders will undergo the same experience in the near future, as they push towards enterprise-wide (and even beyond), comprehensive, trans-medical-specialty image management.