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Looking to the
Future of PACS While you probably won’t end up with your head hardwired for DICOM, the next generation of PACS will be designed to share information across a broader network than most systems were originally designed to do. At nearly 30 years old, PACS can validly be considered “mature.” Its technology is well-understood, its clinical usefulness universally acknowledged, and ongoing research reveals new secondary benefits—from faster diagnosing and easier consultations to systemic cost savings. But in a computer-driven world, one of technology’s chief ironies is that you can usually measure a device’s value by how frequently it’s modified and how swiftly any particular “state of the art” is superseded. In PACS, a relatively thin but steady flow of enhancements through the early years swelled to a flood of significant innovations beginning in the late 1990s, as digital developments from the corporate and consumer arenas found their way into medical applications. A slew of advanced imaging, storage, and communication tools are finally bringing enterprise PACS within reach for many institutions. While that’s not an entirely new idea, today the final outcome is often envisioned more as a series of interlinked, collaborative departmental systems, with less emphasis on radiology as the hub controlling access to imaging files. Following the lead of cardiologists who want to take ownership of advanced modalities such as cardiac computed tomography angiography and real-time 4-D MRI, other specialties are slowly evolving their own requirements for PACS usage. The emergency department probably tops the list, but orthopedists, neurologists, oncologists, pathologists, and surgeons aren’t far behind. Using tailored workstations, multiple departments and specialty practices would be able to operate like a standalone, dedicated PACS, but, crucially, they would operate equally as members of the larger collective. The idea is to make sure that as new PACS come online, they don’t end up as radiology PACS all too often have in the past—an independent island, or silo, of vital but difficult-to-share information. To get some perspective on this envisioned wave of change, Radiology Today interviewed two experts in the field. Sharing Intelligence Says Bakalar, “In the last five years, with the development of department-centric PACS into enterprisewide PACS, we’ve seen that it’s not just the 10% of clinicians who are radiologists using the same stored images. It’s the entire community across the enterprise.” He characterizes today’s medical imaging user groups according to four categories: “The diagnosticians—the radiologists; referring specialists who have to access clinical and imaging information at a very high level and do the integration in their assessment and report; primary care physicians who generally focus on the reports and use reference quality images to interpret for and to educate patients; and the allied health professionals who typically used film in the past but have now become somewhat orphaned as film becomes more rare and difficult to access.” Integrating all these users into a cohesive network requires optimizing the total workflow and for that, he says, improving the ability to share long-term archives is critical. “We’ve learned that the extension of departmental PACS medical archives is not a direct, linear relationship,” says Bakalar. “Archives designed for enterprises, or even hospitals, are much different than departmental archives. One of the greatest challenges is the silos of information that have accumulated through the successful implementation of PACS, primarily in hospital imaging departments and now in enterprises.” Extending Imaging Services “In the more traditional approach, you have a system administrator at each location to coordinate resources,” Bakalar says. “The problem is that most other specialties outside radiology don’t have PACS administrators. They don’t have the technical resources to manage workflow and systems as radiology departments do. So what’s happened is that information technology officers try to manage PACS throughout the enterprise. And that’s put them in a position of managing not only the PACS applications [and] the workflow applications, but also the networks.” IBM’s solution for integrating the use of diverse data streams is the GMAS, which uses a service-oriented architecture that provides a universal access layer of software intelligence. This distributed intelligence enables supporting PACS applications wherever the appropriate hardware is interfaced. Bakalar says this solution, modeled from the IT world, offers medical imaging access to features that traditional PACS approaches can’t support, including the ability to use existing resources anywhere in the network; monitor network use and change network rules dynamically from a single portal; and provide hot copies of files, including DICOM files, as needed, even if some sites are inoperable. Because GMAS focuses on managing fixed content imaging data rather than the transactional data that typically comprises clinical records and information systems, the system supports multiple specialties equally. Imaging data from any source—spinning disk, tape, online, hard drive—is seen by the applications as one virtual hard drive, independent of local operating systems, and the innate network intelligence automatically performs storage management functions without disrupting applications. Shifting Emphasis “When we’re talking about taking electronic health record [EHR] information, PACS information, other registry information and integrating all of that vertically, on a service level as opposed to an application level, I think we’re going to see a lot of extended benefits related to workflow efficiencies and better decision making by both providers and patients,” says Bakalar. In particular, he says, everyone stands to reap major benefits from new capabilities for integrating healthcare information into “superwarehouses” or “data-marts” of clinical information: “The idea is not simply to replace paper with digital records but to establish a secure digital, interoperable environment. [That will enable us to] perform data mining and advanced analytics [by] accessing large volumes of clinical trial data as well as individual longitudinal clinical records.” Such complexities at present are only within the means of the largest marquee institutions, such as the Mayo Clinic. But, says Bakalar, “we can build the personal EHR incrementally. We can improve processes, optimize workflow distribution, maximize our ability to aggregate information, enhance data mining and analytics. All it requires is an IT infrastructure that’s already available in retail, in entertainment, in financial industries. Even though it hasn’t caught up in the healthcare space yet, it will be part of the future.” National Goals Hazari notes that Health and Human Services has delineated four main goals it believes must be reached sequentially: informing and interconnecting clinicians, personalizing care, and improving population health. “The changing economics of healthcare require optimizing efficiency as an ongoing means of controlling costs and reducing erosion in the standard of care,” he says. “In today’s current market, [new] technologies are often key enablers for enhancing efficiency.” And although they always want to protect their previous investments, facility administrators are more willing than ever to keep their options open for embracing inevitable enhancements. The solution for keeping the best from both worlds, according to Hazari, lies in deploying open, adaptable systems that will allow for accommodating legacy applications within the new, often rapidly changing workflow needs. The end result needs to appear seamless, even transparent, to the end user—wherever that user is within the enterprise. Collaborative Distribution Hazari notes, “The notion of a unifying NHIN presents more potential interactions and services and richness of capabilities than merely the flow of EHRs.” He poses the example of an independent, standalone imaging center in today’s volatile environment. “If and when a viable NHIN comes into effect, and the EHR is a routinely flowing envelope for quanta of health information, why would a ‘standalone’ facility not want the benefit of incorporating [each] patient’s EHR into the path of diagnosis, just as a larger hospital may do? [Doing so would both] improve the healthcare outcome and reduce the professional liabilities of the healthcare provider.” He continues, “In addition, imagine that [same situation] with the advent of an NHIN and with the establishment of EHR as an industry standard. For example, imagine being able to [coordinate] a hospital admission or an outpatient elective procedure from [the referring physician’s] office without any human in the path.” Expanding the Departmental Model Meta Fusion’s scalable PACS and information management systems act “like piping and wiring,” says Hazari, to provide a reliable infrastructure for just that kind of distributed collaboration. For example, being able to count on such connections allows the same basic solution to serve, “a single radiologist doing night reading for one or more hospitals or a single modality imaging clinic providing Web access for referrers and a single reading radiologist,” all the way up to integrated multiple care entities with multiple sites, such as a metropolitan healthcare system or a geographically scattered RHIO. And because “a mixed environment was contemplated as the norm from the outset of our design,” says Hazari, Meta Fusion RIS and practice management systems are multiplatform. They can run on a number of popular operating systems (including Windows, UNIX, Linux, and Solaris) and accommodate a wide range of DICOM workstations, viewers, and other end user tools. This ensures that clients aren’t locked into a single vendor or single system solution, a key to eventually supporting varied PACS usages throughout the larger network. Distributed intelligence helps system administrators deal with a number of critical issues that inevitably crop up as local and regional health information networks make their way to the NHIN. In Hazari’s words, “Business cannot stop and wait for prospective legally mandated reform” to resolve ongoing concerns about data security and access authorization; data location and storage; transport; mapping and delivery; and audit and authentication services, to name only a few obvious problems that come with extending the network. Meta Fusion’s intelligent infrastructure is also self-restoring across the network. “If communications or accessibility of information are temporarily impaired at one or more facilities, the systems gracefully self-adjust and provide continuity of operations for individual entities and clusters of entities … until the whole is restored,” says Hazari. Influences Outside Radiology The current interest in adding PACS coming from specialties such as cardiology, pathology, orthopedics, and emergency medicine is creating new opportunities for vendors and users alike to develop distinctive applications, says Hazari—often derived from or enhancing existing imaging programs yet retaining the original operating characteristics. He anticipates many advances springing from user-defined requirements and even user experiments to make existing PACS products do things they weren’t intended to do. And as the emphasis on vertical applications catering to specialties strengthens, it “creates the future possibility of uniformity of PACS management tools across vendors,” Hazari says—although that day may still be fairly far off. — J. K. Bucsko is a freelance healthcare and technology writer based in Westville, N.J., and frequent contributor to Radiology Today.
www.hhs.gov/healthit/goals.html www-03.ibm.com/industries/healthcare/doc/content/resource/insight/1684579105.html
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