Image Management Across the 'ologies

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The unified desktop delivers across-the-board advantages

Siemens Healthcare’s syngo Imaging workstation is the basis of the goal to achieve a unified desktop or single digital patient jacket at Alamance Regional Medical Center in Burlington, N.C., enabling radiology as well as cardiology to access images via a web viewer.
For a number of leading-edge enterprises, image management across multiple ‘ologies is the logical next step in the ongoing image management process. Integrating image-intense ‘ologies such as cardiology, pathology and orthopedics into the radiology image management solution can deliver a number of advantages. Facilities and health systems working toward the vision of a unified platform anticipate benefits on all fronts: clinical, operational and economic.

On the clinical side, streamlined access to images across various specialties provides clinicians more complete data for decision-making, ultimately benefitting patient care. On the operational front, a multi-ology desktop improves clinician efficiency as the need to access discrete workstations or log into multiple systems is eliminated.

Consider for example a typical cardiac patient who has had chest x-ray, CT and echo studies. The physician might need to view the x-ray and CT images on the radiology system and then log into a separate CVIS workstation to view the echo studies, which can impede the diagnostic process. In fact, leading-edge enterprises like Scottsdale Healthcare in Arizona identify the need for cardiologists to access cardiac studies stored in the radiology PACS as a primary driver for a unified, multi-department desktop.

The unified desktop, or single digital patient jacket, also helps leverage IT resources by reducing the number of discrete systems requiring management. Finally, there’s a compelling economic rationale for image management across the ‘ologies. An integrated, multi-department image management system consolidates IT infrastructure and trims associated costs like storage. “Standardized image management infrastructure that supports the various ‘ologies is critical in large scale enterprises,” says Dennis Shelley, director of enterprise imaging at Sisters of Mercy Health System in St. Louis.

Cardiology connections

At many sites, cardiology precipitates the initial need to merge image access across multiple specialties. It’s a natural fit as cardiology is one of the heftiest consumers of imaging services, and many cardiology departments are invested in cardiac PACS or CVIS.

At Alamance Regional Medical Center in Burlington, N.C., “image management remains a work-in-progress,” says Director of Imaging Technology Chris DeAngelo. “Image management across the ‘ologies, or the unified desktop for viewing various image datasets, is a wonderful concept.” Currently, Alamance operates distinct radiology and cardiology PACS, but the lines are beginning to blur. That’s because the radiology solution—Siemens Healthcare syngo Imaging Suite—provides critical functionality not available on the CVIS. “The CVIS platform does not offer a good method for distributing images throughout the organization,” says DeAngelo. In contrast, syngo Imaging incorporates functionality that allows the center to deploy images via a web viewer throughout the organization.

When the center rolled out the web viewer and new features that allowed users to launch images from the EMR, clinicians started to access radiology images more consistently. But similar access was not available for cardiology images, except for cardiac nuclear medicine studies stored in syngo Imaging. Once physicians became accustomed to viewing radiology images online, the prospect of going to the cardiology department to view images on a CVIS workstation became more untenable. Consequently, Alamance Regional Medical Center decided to incorporate cardiac cath and echo studies in syngo Imaging.

The process, says DeAngelo, is fairly straightforward. syngo Imaging contains tools to handle cardiology images; the main tasks are configuring the imaging devices to send data to PACS and extending RIS functionality to other systems such as the CVIS. The IT department creates echo procedures in the RIS, so the images can be appropriately attached.

Less than two years into the project, Alamance is seeing its benefits. “We’re providing information to physicians ASAP and in one place,” shares DeAngelo. In addition to clinical efficiencies, the center has realized IT efficiencies because it no longer duplicates image storage in a second information system.

On the flip side, the storage advantage also carries a challenge. Specifically, the radiology department needs to plan its storage investments around cardiac cath and echo volume in addition to radiology volume. “The servers must be appropriately configured for the additional volume,” explains DeAngelo. 

The radiology-cardiology connection represents the tip of the multi-ology image management iceberg at Alamance Regional Medical Center. For example, one of the center’s OR suites contains a diagnostic x-ray system, and surgeons are beginning to request access to those images. “These aren’t radiology procedures. The typical RIS/PACS only handles radiology procedures, but clinicians want to view these extra-departmental images [on the PACS workstation],” explains DeAngelo. Although syngo Imaging includes tools to streamline storage and viewing of extra-departmental DICOM images, advanced applications require additional infrastructure.

The three-year vision at Alamance Regional Medical Center is based on a single application that not only provides access to all images, but also incorporates tools for post-processing and reporting. “We want to go beyond showing pictures and provide enterprise-wide interactability,” sums DeAngelo. The next step toward the goal is based on syngo Dynamics CVIS. The medical center plans to link the cardiology PACS to syngo Imaging, which will allow physicians to interact with cardiac datasets via the syngo Imaging workstation.

The latest fashion trend: Single patient jacket

Scottsdale Healthcare, a three-site healthcare system with 800 beds, started discussing a centralized enterprise PACS in 2004. At the time, very few enterprises had embraced the model. PACS Project Manager Victoria Myers and her colleagues realized the end goal—a single patient jacket—was a multi-year project that required a high degree of collaboration among clinical and IT departments and modality and information systems vendors. The healthcare system expected to realize a host of clinical, IT and economic benefits as it transitioned to a single patient jacket.

“The process starts with a long-term plan,” shares Myers. Imaging modalities and acquisition devices provide the foundation for the single patient jacket. “Acquisition devices need to be able to send digital data to PACS,” explains Myers. Consequently, as Scottsdale Healthcare upgraded its cath labs, it replaced legacy x-ray and hemodynamic monitoring equipment with DICOM compatible solutions. The healthcare system adhered to a similar selection process with echocardiography solutions. In some cases, setting an appropriate foundation requires departments to bypass certain investments. “If the goal is a totally unified PACS, the enterprise can not segregate departments. [It’s difficult to invest in] mini-PACS for one department and plan to integrate it into the enterprise PACS at a later date,” says Myers.

She recommends sites focus on the end goal and determine the essential building blocks that will move the enterprise toward its objective. It’s also important to communicate the ultimate goal to the vendor, so the enterprise purchases a system that performs to its specifications.

At Scottsdale Healthcare, the multi-department team set the single patient jacket with a central location for structured reporting as its goal. It invested in modality devices equipped to meet its goal and deployed various image management components to support the goal. The current configuration includes GE Healthcare Centricity Enterprise PACS, which holds radiology, nuclear medicine, cath lab and digital mammography studies. GE Healthcare DMS CVIS provides storage for cath lab and echocardiography images and hemodynamic data and will serve as the structured reporting solution for echo and cath lab studies by the end of 2009. Scottsdale Healthcare uses a dual-monitor setup for cardiologists; DMS provides case data and structured reporting tools on one side, and Centricity provides image access on the other. Finally, EMC Corporation’s Centera serves as the long-term virtual archive for radiology and cardiology datasets.

The healthcare system continues to grow its image management infrastructure. By the end of this summer, echo studies will be integrated into the enterprise PACS. GE Healthcare Image Vault, the current short-term echo archive, will be linked to Centricity PACS. Scottsdale Healthcare also relies on GE Centricity Web 3.0 for online viewing. Images are available across all sites and remotely and via McKesson Corporation Horizon Physician Portal.

“The single vendor approach offers multiple advantages,” says Myers. Integration among PACS, CVIS and the long-term archive is smoother. In addition, single-vendor shops tend to benefit from greater influence with the vendor. Finally, the approach eliminates the finger-pointing that hampers sites with multi-vendor image management systems.

The enterprise gains in other ways as well. “Many hospitals use separate radiology and cardiology systems, which require separate log-ins. With a central PACS, physicians don’t need to log into multiple systems to find images,” shares Myers. Workflow and clinical decision-making are improved with streamlined, efficient access to images. In addition, the IT department is not charged with maintenance and management of two disparate PACS. “An enterprise PACS impacts all aspects of PACS management: service agreements, the database environment, power use, space needs and training.” Every component is consolidated, which trims costs and simplifies management.

Like other multi-ology projects, Scottsdale Healthcare’s project is a work-in-progress with a robust, future-oriented platform. Although the enterprise has not yet integrated other specialties, the infrastructure to support other ’ologies is in place. For example, GE Centricity provides a foundation for storage of surgical video captures.

From a hybrid approach to a standard model

Sisters of Mercy Health System, a multi-state healthcare system with headquarters in St. Louis, Mo., epitomizes the hybrid approach to digital image management. When the enterprise first invested in PACS nearly 10 years ago, it focused on deployment. Consequently, its image management configuration is based on a series of fragmented systems. Emageon RadSuite (recently acquired by AMICAS) serves as the primary radiology solution. Cardiology image management is a works-in-progress, with five of the 18 hospitals using Emageon HeartSuite for cardiovascular image storage. The CVIS is not yet fully integrated; only two hospitals use it for reporting, and numerous specialty systems like Philips Healthcare (Witt Biomedical Corp.) hemodynamic monitoring systems are peppered throughout the enterprise. The configuration becomes more complex in other ‘ologies. Several of enterprise’s perinatal medicine departments use Siemens syngo Dynamics as a mini-PACS for storage and perinatal reporting system. Other departments including nuclear medicine, gastroenterology and mammography also operate mini-PACS.

“The arrangement isn’t ideal,” admits Director of Enterprise Imaging Dennis Shelley. “We’d prefer to have all images stored and read on Emageon.” Like other current-generation solutions, however, the radiology PACS is limited to storage of DICOM datasets; it doesn’t offer the viewing or reading tools for subspecialty images.

The health system is working toward an enterprise imaging management solution. “The vision,” explains Shelley, “is a global system for storage, movement and viewing of all visible light images. This flexible top-shelf solution will ‘anonymize’ all digital image datasets regardless of the native ’ology and allow us to leverage economies of scale in image management.” In other words, clinicians will be able to view and interact with images on a single PACS workstation regardless of the native acquisition device.

Sisters of Mercy has made progress by investing in the spinning disk archive, network and bandwidth to support its enterprise image management vision. The next step is a fully automated, integrated workstation that supports the viewing and reporting needs of the various end users. For example, when a radiologist opens a chest x-ray, the radiology reporting solution also will launch. The same process will be replicated across the departments with appropriate viewing and reporting tools. This standardized approach delivers clinical and IT efficiency, says Shelley. On the clinical side, a single workstation streamlines viewing and reporting. On the IT side, the current approach to image management is a conglomerate with different departments, clinical engineering teams and various vendors all responsible for support of visible light imaging. A standard approach helps the health system leverage IT resources and consolidate PACS support and administration.

Shelley acknowledges the challenges ahead. Mini-PACS workflows were not created with future technology in mind. They often use proprietary formats and overlook appropriate identifiers, which makes it difficult to maintain data integrity for migration. Currently, the health system dedicates significant IT resources to sustaining original mini-PACS as they become obsolete. The process often requires manual clean-ups and fairly unwieldy interfaces. The good news, says Shelly, is that larger PACS vendors are beginning to evaluate the ’ologies to determine if they can incorporate their images in their systems and develop a unified viewing solution.

The ultimate image management solution also incorporates other critical features. Tiered storage logic and policy-based deletion rules are essential. That is, the system employs smart, or hierarchical, storage; and it automates deletion. For example, the PACS would delete all chest x-rays for pediatric patients as they turn 18 if the x-ray is older than seven years. “These tools aren’t yet available in the detail needed to manage an enterprise archive,” notes Shelley. The writing seems to be on the wall, with vendors recognizing the need for and benefits of a robust enterprise, multi-ology platform.

Unified image management: Foundation & Vision

Image management across the ’ologies is a lengthy concept that begins with essential building blocks including a solid strategic plan, DICOM device infrastructure and IT investments. At the same time, stakeholders across all departments and various vendors should be engaged in the plan. For many sites, the initial foray into a multi-ology solution begins with cardiac studies. The benefits are clear and include better informed and streamlined clinical decision-making, consolidated IT management and reduced image management costs. It’s a win-win-win proposition.


Expert Advice
A handful of pioneers have been considering image management across the multiple departments for several years. Here, insiders share their insights.
  • “Take the time to understand, build and deploy a robust radiology RIS/PACS enterprise-wide before expanding out to other ‘ologies,” recommends Chris DeAngelo, director of imaging technology at Alamance Regional Medical Center in Burlington, N.C. After that’s accomplished, the radiology department will possess the know-how and toolsets to assist other ‘ologies.
  • “Obtain as much IHE [Integrating the Healthcare Enterprise] compliance on modality and image acquisition investments as possible,” recommends Victoria Myers, PACS Project Manager at Scottsdale Healthcare in Arizona. The rationale is simple; IHE-compliant systems are best-equipped for transfer to PACS.
  • Set and share realistic timelines. All stakeholders, including proposed vendors, clinical departments and IT staff, need to understand timelines. Remember that the project timeline impacts internal staff resources; simultaneous multi-department projects or upgrades may stretch IT resources too thin and compromise the ultimate success of the entire project. For example, integrating the cath lab and digital mammography into PACS in the same time span may be an unrealistic expectation.
  • Outline the desired workflow, project design and vision before the project is funded, says Myers. As enterprise stakeholders understand the desired workflow, they can communicate it to all proposed vendors. Vendors, in turn, can provide the enterprise with a more solid explanation of how their products will work with the  desired workflow plan model.