Taking it to the Clouds

June 24, 2013
A health provider network in rural Montana has found that cloud technology brings interoperability and simplicity to the task of sharing radiology images, while saving considerable time and expense in the process.


Photos courtesy of eMix

A health provider network in rural Montana has found that cloud technology brings interoperability and simplicity to the task of sharing radiology images, while saving considerable time and expense in the process.

Gayle Knudson

When Great Falls Clinic radiology manager Gayle Knudson was asked at a leadership retreat in the fall of 2008 to come up with a Big Hairy Audacious Goal (the term coined by James Collins and Jerry Porras in their 1996 article entitled “Building Your Company's Vision” for the Harvard Business Review) for her organization, she came up with something much bigger. Her idea was for the hospitals and radiology facilities in Montana to have a completely interoperable system to share radiology images. The idea was the genesis of the Image Movement of Montana (IMOM), which has moved Montana clinicians forward in terms of health information exchange in a way that few other statewide collaboratives have done so far.

“What we were trying to do was resolve all of the interstate moving of images without [aggravating] the disparities from different PACS [picture archiving and communications system],” Knudson explains. “We wanted to be able to do it with very little cost, less than CDs, and make it seamless with no one facility having to take ownership, and keep politics out of it.”

William O'Leary

The model at the time for sharing radiology images at Great Falls Clinic, a 57-physician outpatient clinic in Great Falls, Mont., as well as much of the state, was when a patient's images were needed at another facility, the originating facility burned the images onto a CD and shipped them via FedEx for about $12. The images were then downloaded from the disc to the facility's PACS.


Following the retreat, in February 2009, Knudson and her colleague Bill O'Leary, regional outreach and PACS administrator at the 290-bed Kalispell Regional Medical Center, convened a statewide radiology manager/PACS administrator roundtable meeting to refine the plan of attack and develop the guiding principles for IMOM. To try to stay free of politics so the project could move forward more stealthily, Knudson and O'Leary took a backdoor approach and invited PACS administrators rather than CEOs and CFOs.


Eric Maki

According to Great Falls Clinic IT manager Eric Maki, who was brought into IMOM to offer IT guidance, early talks went in many directions that included building out an interoperable electronic medical record. “The technology is out there and won't be the issue,” Maki says. “The problem will be if you use too much technology and get too complex; you're going to kill the process.”

So with a lean goal in sight of solely exchanging images, and with their guiding principles in focus, the next issue facing the leaders of IMOM was funding. After realizing that applying for federal funding would involve much more money than they needed, the group decided to vet vendors by taking their show on the road to Missoula, Billings, Kalispell, and other Montana cities to talk to IMOM members to see what kind of PACS those facilities used. The trip yielded a pool of about eight vendors, which led to a request for proposal (RFP) process.

Meanwhile, eMix (a subsidiary of the San Diego-based DR Systems), an electronic information exchange company, was about to begin beta testing and needed testers. eMix uses cloud-based technology to house images after they are encrypted and pass through eight layers of security that include a physically secure data center and member and user authentication. The uploaded images are then accessible to the intended recipient through a simple download following an e-mail notification.

Beginning in November 2009, three Montana health providers-Great Falls Clinic, St. Luke Community Hospital in Ronan, and Kalispell Regional Medical Center in Kalispell, all with different PACS, started beta testing the eMix service. No significant problems were encountered, and three additional facilities-Benefis Health System in Great Falls, St. Vincent Healthcare in Billings, and Glendive Medical Center in Glendive, were added as beta sites. In March 2010 beta testing concluded and the facilities signed up with eMix to continue sharing images.


On average, users of the cloud save at least $8 per image or study they send, based on a $12 FedEx fee. Knudson adds that sending a CD from her organization can range from $20 to $25, including manpower and overnight shipping charges. She cites a recent savings of close to $20 when Great Falls Clinic sent a radiology image for about $4 via the cloud to a facility they had never been in contact with before.

Besides cost savings, cloud-based computing technology saves a lot of time. Because of the rural nature of Montana, some facilities may not receive a FedEx delivery every day; as a result, shipping an image could take up to three days. Maki recounts one Great Falls patient who made an appointment three hours away in Billings, but forgot to bring the images with him to the visit. Instead of having to cancel and make the six-hour roundtrip again, IMOM saved the day. “We found out 30 minutes before the appointment, grabbed the images and uploaded them to the cloud,” Maki says. “The other organization across town downloaded them and zipped it across their private network in the city and got it there with seven minutes to spare.”

With cloud technology, the facilities also don't have to worry about setting up virtual private network (VPN) connections with the other organizations and undergoing the tedious process of updating the VPNs after organizations upgrade their firewalls. O'Leary says that he plans to send images via the cloud every time a VPN connection to an organization becomes outdated to save time and manpower troubleshooting a new connection.

Cloud-based solutions have been becoming more popular in the healthcare industry lately. According to a report released earlier this year by consulting firm Accenture, 32 percent of healthcare respondents use cloud computing applications, while 73 percent plan to transfer some applications to a cloud-based model. Healthcare was on par with other industries as far as rate of adoption, but unsurprisingly lagged behind the technology and financial services industries.

As far as next steps for IMOM, Kalispell's Bill O'Leary doesn't see many. The lion's share of the work has been done already in figuring out a solution to Montana's imaging problem. The next hurdle will be to encourage adoption among smaller community radiology clinics and facilities. Currently, O'Leary still gets requests from facilities to send out images for them, but that will have to end soon. “I feel we are getting into some HIPAA regulations we probably want to avoid,” O'Leary says. “We don't have ownership of those images. But for continuum of patient care we do it.” Great Falls Clinic's Gayle Knudson plans to reach out to the IMOM community in September to assess where IMOM is and what should be done next. In Knudson's words her team did a “bang-up job” solving their interoperability issue with image transfer. “I honestly believe it was because we had the worker bees, the managers, and the PACS administrators in on it. No one had a personal agenda, and we were all there trying to make the right thing happen.”

Healthcare Informatics 2010 September;27(9):30-55

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