Inside the Data Center
Image access and distribution can be particularly challenging for large, multi-site, multi-facility healthcare enterprises. Often, such sites must manage multiple, disparate PACS and other sources of imaging data. Consequently, image access for clinicians across the enterprise is less than streamlined. In addition, standard health IT challenges such as bandwidth limitations, myriad PC platforms, operating systems, version control and even locked down PCs exacerbate the situation. For many multi-site enterprises, the solution is clinical consolidation as well as integrated storage and management of clinical data from various departments and improved image access via an enterprise visualization strategy which can lead to better patient care.
In some ways, Ochsner Health System in New Orleans, La., represents the typical large enterprise. Ochsner Health System includes seven acute-care hospitals and 35 clinic sites. Its 650 physicians provide care for hundreds of thousands of patients annually. In addition, 2,000 community physicians share the hospital environment.
In other ways, the health system is unique. Repeatedly recognized as one of the most wired hospitals in the U.S., Ochsner Health System embraces an aggressive clinical consolidation and image and data management strategy. The goal, says Lynn Witherspoon, MD, system vice president and CIO, is to integrate all clinical and document images generated by enterprise imaging systems in the EMR for streamlined access. The ambitious plan includes images across the “ologies”—including DICOM and non-DICOM datasets generated in cardiology, dermatology, endoscopy, gastroenterology and pathology. It also includes EMR image sets such as imaged documents and digital photographs. In addition, Ochsner Health System’s vision includes a robust disaster recovery plan that provides near-immediate recovery of image data if the primary archive fails.
Early last year, Ochsner Health System deployed Agfa HealthCare’s IMPAX Data Center and IMPAX Mobility* as the cornerstone of their enterprise visualization strategy. This image and data management plan is integrated with EMC’s Information Infrastructure including EMC CLARiiON, Centera, and RecoverPoint for its virtualized environment. EMC RecoverPoint protects valuable data in heterogeneous VMware environments—with efficient and effective recovery to any point in time. The solution consolidates data from disparate multi-vendor PACS and a host of clinical imaging systems to provide a single point of access for radiologists, cardiologists, and of course, referring physicians. Early results are impressive with all clinical stakeholders gaining efficiencies and improving clinical decision-making because of more efficient access to multi-vendor, multi-department and multi-site images and reports.
As recently as last year, Ochsner Health System physicians worked in a fragmented environment with images and data housed in multiple disparate systems. The problem partially stems from rapid growth over the last few years.
In 2004, Ochsner Health System included a single hospital and clinic. All radiology images were stored in Agfa HealthCare IMPAX PACS, while the cardiology department used two separate cardiology image management systems from different vendors. The initial PACS deployments solved many first-generation digital image management challenges by providing radiologists and cardiologists with access to digital data.
More complex, second-generation challenges, however, arose when Ochsner Health System purchased three area hospitals in October 2006. The legacy 650-physician strong, closed staff Ochsner Clinic blossomed into a multi-hospital open staff system supporting 2,000 community physicians. Ochsner Health System scaled its core clinical IT systems—HIS, pharmacy, LIS, RIS and PACS—into the community hospitals. The enterprise also web-enabled the EMR and made all clinical information systems available to the new community physicians. None of the new hospitals had deployed PACS at the time of purchase, but each installed a separate digital image management system driven by its own RIS by 2007.
Despite the PACS deployments at the new sites, image management grew increasingly complex. In the new, larger enterprise, Ochsner Health System radiologists interpreted community hospital images, which required investing in community hospital PACS workstations in the main campus radiology department. Ochsner Health System had not installed an enterprise storage facility, so all images were stored locally and were not integrated across the enterprise. The result, says Witherspoon, was six separate islands of data. Access to digital images across the enterprise was fragmented and posed a hefty workflow burden on radiologists.
In practice, it meant a radiologist at the main campus location needed to log onto to a separate vendor workstation to access images acquired and stored at the one of the hospitals. “It was impossible for radiologists to obtain an aggregate view of the patient studies,” recalls Witherspoon. In addition, maintaining the separate silos placed a great demand on the system’s total IT resources.
Concurrently, the enterprise also realized that it faced increasingly complex “ology” image management issues. That is, various “ologies”—cardiology, ophthalmology and pathology—also generated images that were housed in their own systems. The fragmented approach seemed far from efficient or cost-effective.
Ochsner Health System decided to investigate the concept of enterprise visualization. The plan focused on uniting the health system’s multi-vendor image management architectures in a single solution with the EMR serving as the entry point for clinicians. Leaders at the health system realized the integrated system could address both challenges—fragmentation of radiology datasets and “ology” image storage and access issues.
The planning team approached Agfa HealthCare and decided to implement IMPAX Data Center and IMPAX Mobility to consolidate, integrate, and provide access for all diagnostic imaging across the enterprise.
Radiology and Enterprise workflow revisited
IMPAX Data Center improved workflow across the enterprise at Ochsner Health System. The solution provides radiologists access to all radiology images stored in Data Center from a central workstation. That is, if a patient presents with several sets of prior studies stored in PACS A and PACS B, but now transferred to IMPAX Data Center, a radiologist can view all of the imaging datasets from a single workstation. IMPAX Data Center eliminates the need to use a separate vendor-specific workstation to view images stored in the various site-based PACS. Radiologists no longer contend with multiple, workflow-busting log-ins to separate systems. Instead, a single log-in to IMPAX provides universal access to radiology datasets.
The system not only improves workflow among radiologists, but also helps Ochsner Health System better leverage its resources. Witherspoon explains, “With IMPAX Data Center, radiologists no longer have to be physically present at a site to read studies for that site. It allows the enterprise to better allocate radiology resources.” For example, a radiologist reading studies at the main campus can provide back-up for Kenner Hospital, one of the 2006 hospital acquisitions, located across town in New Orleans. The same principle applies to sub-specialist reads. A sub-specialist can interpret studies across the enterprise without traveling to each specific site. “Since deploying IMPAX Data Center, Ochsner Health System has better utilized existing radiologist resources and avoided hiring additional radiologists and sub-specialists,” sums Witherspoon.
Currently, the project integrates all radiology images including nuclear medicine studies. In addition, a different vendor cardiology PACS is integrated into IMPAX Data Center as are different vendors for ophthalmology and Ob-Gyn images. Because the archive manages images as well as non-imaging DICOM 3.0 data objects such as waveforms, structured reports and PDF-formatted documents, Ochsner Health System plans to incorporate other imaging datasets including gastroenterology, further cardiology, endocrinology, and the output from other departmental imaging systems into IMPAX Data Center in the future.
IMPAX Data Center also packs a powerful workflow boost for referring physicians, who will be able to access all images published to the system via Agfa’s IMPAX Mobility web viewer. The arrangement is simple. The Ochsner Health System EMR platform includes a URL that provides seamless access into the Data Center. “It eliminates the need for referring physicians to know which PACS holds each patient’s images,” explains Witherspoon. The system also consolidates and centralizes patients’ imaging records, so the physician need not log onto multiple disparate systems to view the patient’s imaging history. Instead, access in content from the EMR platform provides a complete longitudinal view of the patient imaging record.
IMPAX Mobility is an ultra-thin, web-deployable enterprise image viewer that extends the reach of IMPAX Data Center. It leverages its server-side rendering capabilities to securely deliver images and results as a standalone solution or as the image viewer for an electronic medical record (EMR) system. IMPAX Mobility is unbounded as it can deliver patient image data throughout the continuum of care to virtually any wired/wireless Windows-based PC, laptop, tablet, Ultra Mobile PC, or Smartphone devices. It features a micro-sized download and doesn’t use Active X, Java of a .Net framework. This innovative solution tackles some of the most daunting health IT challenges such as bandwidth limitations, myriad PC platforms, operating systems, version control and even locked down PCs.
The new approach also boosts patient care. Patient care improvements hinge in part on access to prior images, says Witherspoon, and IMPAX Data Center streamlines access to all prior studies. It does not limit the physician to the most current dataset. “This has a significant impact on clinical decision-making, especially for image-centric specialties like radiology, orthopedic surgery and neurosurgery,” Witherspoon says. For example, patients with lung nodules present on current chest x-rays benefit when older images are available for comparison. Similarly, the significance of breast abnormalities on current mammograms may be clear when earlier mammograms are available. In the past when these images were obtained at first one hospital, then another, the earlier images were either unavailable or difficult to obtain. The Data Center integration overcomes this problem as both hospitals publish to the same Data Center repository. The likelihood of orders for unnecessary—and unbillable-—repeat studies also is reduced.
IT infrastructure and disaster recovery
Increased dependence on digital data translates into reduced tolerance for disaster or downtime, which is a hefty challenge in the New Orleans area. “We’ve experienced many severe weather-related disasters in southeast Louisiana, and we understand how crucial it is to maintain access to patient images and information in the event of an emergency,” shares Witherspoon.
Ochsner Health System employed a comprehensive and robust redundancy and disaster recovery model as it deployed IMPAX Data Center. The system itself is delivered in a fault tolerant configuration that protects against a single point of system failure. It also features a high availability design, continuously monitoring itself for optimal system reliability and uptime.
Words of wisdom
Enterprise visualization is a process rather than a project. It is a complex undertaking that merits careful planning. As the engineer of Ochsner Health System’s deployment, Witherspoon recommends enterprises investigating an enterprise image management and distribution system visit one of the successful projects across the country to learn more about how they planned and tackled their deployment. “Ask smart, detailed, technical questions,” continues Witherspoon.
One complicating factor stems from vendor claims. That is, all vendors claim they can integrate across diverse PACS platforms; however, translating the promise into practice tends to be challenging. For example, private tag issues often arise. Images stored on one vendor’s workstation may not be fully retrieved on a second vendor’s workstation; some data elements may be lost or may not transfer. The enterprise needs to understand how each vendor interprets DICOM and work to maintain all data elements as images are shared across systems. Agfa understands these issues and is committed to a consultative, partnership approach to make the process successful where prior efforts with other vendors may have failed.
The enterprise visualization advantage
Enterprise image management infrastructure carries critical benefits, providing care-givers streamlined access to essential imaging datasets for improved clinical decision-making. “By providing access to the most current data from across the entire Ochsner system, IMPAX Data Center gives our clinicians a complete longitudinal view of the patient imaging record. IMPAX Data Center makes imaging information available to physicians using a single query, while allowing hospitals and clinics to keep their existing PACS and imaging solutions in place,” sums Witherspoon.
|When It's Time to Re-evaluate Data Storage|
When Ochsner Health System in New Orleans, La., deployed Agfa HealthCare IMPAX Data Center as its enterprise image management solution, it re-evaluated its storage architecture. Several issues factored into the decision-making process including archive management, upfront and long-term storage, disaster recovery and data integrity. After surveying the storage marketplace, Ochsner Health System decided to deploy a pair of EMC Centera active archiving platforms as its long-term archive and disaster recovery solution. The EMC Solution is jointly engineered, certified, and pre-integrated with Agfa HealthCare IMPAX.
EMC Centera delivers several advantages over other options, says Director of Network Services Kurt Induni. For starters, EMC Centera is an online solution, which eliminates the challenges of long-term tape management to gain instant access to patient images. "We believe the tape era is coming to a close. Managing a tape library requires more resources than spinning disk," explains Induni. Hierarchical storage systems that include tape rely on regular uploads to the tape library, which demands precious IT resources.
EMC Centera provides a second advantage, too. "Unlike an unmanaged SAN [storage area network], EMC Centera automatically manages and protects data," Induni says. EMC Centera makes each file an object and stores each object with a number, title and associated policies that archive, delete or protect it to meet regulatory requirements for Protected Health Information (PHI). Smart archiving policies facilitate management of DICOM datasets, which must be retained for seven or 21 years, depending on the patient image. Based on our individual clinical protocols, EMC Centera simply applies the rules to the appropriate file and manages it according to the rules. "The policies are built into the system," explains Induni, "there's no tampering or human error."
The other plus of EMC Centera comes on the cost side. At first glance, tape may seem more economical than disk. When Ochsner Health System factored in the original storage acquisition costs and the long-term management needs of tape and disk archives, it realized that the EMC Centera active archive represented a more cost-effective solution.
A final critical factor in the weather-intense locale of New Orleans is disaster recovery. EMC Centera delivers streamlined disaster recovery. Ochsner Health System installed a second EMC Centera archive at an offsite location with data replicated in real-time. "In the unlikely event of a failure, disaster recovery is assured," sums Induni.
A future-oriented solution
As an extensible object repository, EMC Centera fits well within the larger data management vision at Ochsner Heath System. As a component of the IMPAX Data Center solution, it supports both the ability to scale to handle the ever-increasing volume of data from radiology, cardiology, ophthalmology and all the other imaging "ologies," and to replicate itself to a secondary data center as part of Ochsner's Disaster Recovery strategy. That means, as Ochsner Health System scales IMPAX Data Center to include the "ologies," its archive is ready to meet the growing requirements.
The long-term archive is a central component of the enterprise image management and visualization solution. It's critical to select a future-oriented archive like EMC Centera that accommodates the initial plan with minimal impact on IT staff. It's equally essential to consider the future direction of the project as the archive and image management system need to grow and scale together. Thus, the archive should be equipped to handle future data elements such as non-DICOM datasets if they are to be incorporated in the data center. Sites integrating a long-term archive with a data center need to focus on the big picture—storage management, data needs, IT efficiencies, and cost. At Ochsner Health System, EMC Centera fit all parameters.