Cloud Computing: The Forecast for Image Management
Cloud computing technology—a market that Merrill Lynch values at $95 billion over the next five years—has recently begun to move  into healthcare. However, questions remain about how facilities and departments, including radiology, will fully take advantage of these zero footprint solutions.

Cloudy today

In provider settings, cloud computing is currently being utilized to allow practices to flex their resources to the height of their capabilities, according to John Moore, managing partner at Chilmark Research, a healthcare technology industry analyst firm.

“Smaller practices and health information exchanges are often using applications that are based in a cloud computing model, or software-as-a-service [SaaS] model,” says Moore. “Large hospitals and IDNs are increasingly looking to provide a repository for the massive amounts of data that they need to store and access, on an as-needed basis—more of a utility service.”

Moore believes that hospitals will initially adopt cloud computing for data storage and archiving purposes, transferring the costs and maintenance of in-house hardware, such as PACS, to a cloud service. “Therefore, the provider can still access the records or images, but they won’t have to store them on their servers,” he says. “Particularly in the imaging space, there are enormous amounts of data that are produced with the newer scanners. The question will be where to put them as the vat continues to grow.”

In addition to data archiving, cloud computing in its current form involves image sharing between institutions, according to Garry Choy, from the department of cardiothoracic imaging and informatics at Massachusetts General Hospital in Boston. “Numerous vendors are releasing cloud-based solutions to enable on-demand access of imaging data from anywhere, such as teleradiology setups and mobile applications for smartphone access,” he says.

“At Mass General, we are exploring better ways to use cloud-based technologies for image sharing and elimination of hardcopy CD-ROM-based image sharing between institutions,” Choy says.

Moore adds that cloud computing technologies will benefit from the influx of funding from the HITECH Act, because the American Recovery and Reinvestment Act does not specify the required technologies, except that EHR systems need to meet the meaningful use definitions.

“The ambulatory market, which happens in physician offices of five or fewer physicians, will be very challenged to adopt and install an EHR/EMR system, as well as manage the upgrades. They will, as a result, turn to a SaaS model for a given application,” Moore explains. “Just about all the vendors now offer a SaaS solution, and if they don’t today, they will in the near future.”

Health information exchanges (HIEs) are mostly cloud-based technologies, and “there’s a lot of money—about $500 million—to be distributed from the Office of the National Coordinator for Health IT [designated from ARRA] going into the HIE market,” Moore notes. “These funds will assist with applications that will be in the cloud and particularly help HIEs with care coordination, as defined by meaningful use in the HITECH Act.”

“Some emerging applications that would make a big clinical impact definitely include using cloud computing to eliminate the need to transfer images between hospitals via CD-ROM,” Choy says. “Cloud-based image access of a patient’s entire medical imaging record would eliminate the need for repeated unnecessary exams, lower radiation exposure, decrease healthcare costs and simply provide better quality healthcare.” 

To date, there are few current models of how cloud technologies allow for the sharing of images, beyond current DICOM standards and HIPAA compliancy.

Clouds on the move

Radiology departments in Montana have already discovered a way to put cloud computing to use—and eliminate the transfer of data in hard copy form. The three facilities—Great Falls Clinic in Great Falls, Kalispell Regional Medical Center in Kalispell and St. Luke Community Healthcare in Ronan—are currently sharing live patient data via eMix (DR Systems), as part of the Image Movement of Montana (IMOM), a grassroots organization comprising 30 Montana healthcare facilities.

In early 2009, the idea was born during a discussion about the difficulty of sharing images among providers at a statewide radiology managers’ seminar. “We were lamenting the limited nature of our technology,” explains Bill O’Leary, PACS administrator at Kalispell Regional. “For instance, every vendor has DICOM, but DICOM tags don’t always match when a CD is burned and sent out to a facility—some PACS can read it, some can’t. We decided some kind of unified, vendor-neutral statewide network to transfer data was needed.”

Over the next few months, the representatives from across the state decided the cost of a single server and router was too high to maintain. Also, there were questions about security and HIPAA compliancy with this method.

By October 2009, IMOM had chosen a cloud-based solution because it required no upfront expense, and only necessitates e-mail technology to send and receive images, radiology reports and electronic records to other facilities. “Anything you print, you can send to the cloud to be transferred,” O’Leary says. “The next step could involve our health record vendors, so now EHRs and personal health records also can be sent to other healthcare facilities, regional health information organizations or a physician practice.”

The beta-testing period was scheduled to last from November 2009 until the first quarter of 2010, but three original hospitals—which have three disparate PACS and serve varied purposes and patient populations—decided to go live “with full-resolution images almost immediately with no complications,” O’Leary says.

Currently, IMOM is sending images and radiology reports from the PACS to the server in the cloud. The receiving site receives an e-mail indicating they should access images in the cloud. The person receiving the images opens the email, can view the images in a patient portal viewer, burn a CD or export the image set to their PACS. “This way, anyone can view the images—a patient, physician’s office without PACS or a radiologist with PACS looking for diagnostic-quality images,” O’Leary says.

The system has allowed Kalispell Regional, which is located in a resort community, to all but eliminate the cost of burning and shipping of CDs and DVDs. “Now, within 10 minutes, a hospital receiving a transferred trauma patient from our facility can download the images,” O’Leary notes.

“The only time size [of the study] could become relevant is if the person or facility receiving the images doesn’t have quick enough internet [connection]—which could cause a slow download,” he adds.

Interestingly, IMOM chose not to create an archive within eMix; thus the images live in the cloud for a month before disappearing. O’Leary says that he’d prefer images to live in the cloud for only a week, due to security concerns. “Not that security issues abound with the technology, but if the provider doesn’t need the data, why leave them out there? If they want them later, we can resend,” he says.

The economics of IMOM are handled like this. The facilities partaking in IMOM are billed for each transfer, based on how many megabits are used in the transfer. Also, the providers are presented with a HIPAA-compliant audit trail, indicating how many exams are sent, how many are received and user authentication.

O’Leary also contends that cloud computing will meet the new privacy and security requirements in the HITECH Act.

A cloud’s potential

On a more widespread scale, it remains unclear how cloud technologies will truly be integrated into the healthcare setting beyond the current DICOM standards and HIPAA compliancy.

There is no one set model that providers are adopting; it is dependant on what services are required from the cloud service provider, according to Moore. “But, it is important to distinguish between a base-utility model versus a SaaS model versus platform model versus a web services model,” he says. “The base-utility model is often based on how much data are stored and how frequently that data are accessed. In the platform model, applications get layered in, as well as functionality, to allow access for affiliated or referring physicians. The models go up in complexity.”

To overcome interoperability concerns, practices may employ web-based or service-oriented architecture “wrappers,” to have the hospital systems, such as EHRs and PACS, communicate with each other and become more user-friendly. This approach was recently adopted by Kaiser, according to Moore, who says in the future the provider could potentially store or archive those data offsite, adopting a complete web services model. “In this model, the physician can call up an image when in a given record. It will look like a seamless process to the user,” Moore says.

“More often than not, there are interoperability issues, but these aspects of cloud-based computing are easily solved by using standards-based methods,” Choy says. “For example, data stored in the cloud should minimize proprietary wrappers and employ as often as possible universally accepted standards. PACS and EHR vendors must begin to collaborate and work together more than ever for healthcare cloud solutions to succeed.”

The security caveat

Privacy and security remain on the forefront as these technologies gain acceptance. “Cloud services will have to remain cognizant of these concerns, as well as their users,” Moore says. “The providers will have to understand what they are using in order to ensure they are properly encrypted on the servers of the cloud provider.”

When employing cloud computing, security and integrity of your data becomes a critical issue as you are placing your mission-critical data under the management of a third-party, according to Choy. “When selecting a cloud-based solution, one must ensure that data back-up is robust and that there are contingency plans for disaster recovery. Also, a prerequisite for employing clouds for healthcare use dictates that all patient data must be secure and compliant with HIPAA and HITECH Act stipulations,” he adds.

“Clouds in healthcare are not the same as sharing vacation photos on social networks such as Facebook or flickr,” Choy says.

Future forecast

Cloud-based computing technologies hold true potential for a patient to be able to access and virtually carry his or her entire record, including images.

“It will be interesting to see what happens with the personal health records, especially with Microsoft’s HealthVault and Google Health,” O’Leary says. “Currently, there isn’t a lot of work being done to incorporate images into PHRs, and cloud-based technologies may present an opportunity for the future. Now, patients are more involved with their health trek. This is where the cloud technology will become important.”

In addition to the process of EMRs being streamlined and shared between hospitals with the use of clouds, Choy says the technology will allow “healthcare data to follow the patient—how it should be.” 

“There may be a number of models adopted,” says Moore, “but the future of clouds holds a lot of potential due to the nature of the technology.”