Image Management: The Online Option

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Online image management solutions offer a novel paradigm in the crowded PACS market. Under some online arrangements, the vendor assumes the bulk of the IT and storage burden, which can make for a smoother PACS implementation and upgrade process. The model works well in many types of settings including community hospitals and multi-site imaging enterprises. It can serve as a comprehensive or departmental solution depending on the needs of the site. In others, the online approach reduces the cost and burden of client server architecture to provide universal access to images across and beyond the enterprise. This month, Health Imaging & IT visits a few sites that have discovered the benefits of tapping into online image management.

Propelled out of the dark ages

“Yavapai Medical Center [in Prescott, Ariz.] resided in the dark ages at the turn of [the 21st] century,” admits RIS/PACS Administrator John Munday. Labor-intensive manual image management processes ruled at the small facility. Images were pushed to a teleradiology system, and radiologists dialed in to access images. A failure of the teleradiology system proved to be a blessing in disguise.

Radiology staff happened to meet InSite One Inc. at an Arizona Hospital Association meeting. The company shared its ASP model with Yavapai leadership. Essentially, InSite One proposed to store digital studies, convert analog images to a digital format and install black boxes to output digital studies on each older system that did not transmit digital data. The company also enabled radiology information system (RIS) functionality and worklist reading by storing all studies.

Yavapai Medical Center realized an immediate cost savings with the approach. “When we started storing digital images, the medical center did not have a place to store the data or a budget to purchase critical IT infrastructure,” says Munday. InSite One offered a budget-friendly option by providing the primary onsite archive and two redundant offsite archives in Connecticut and Phoenix. The dual redundant archives serve as the disaster recovery mechanism for the medical center.

The next big bang coincided with the PACS deployment in 2005. “Converting to PACS is usually a painful process with radiology working in two worlds during the transition: soft-copy current files and hard-copy historical images. Because we had more than two years of historical digital files, we were able to go filmless overnight,” says Munday.

The “install and forget” ASP model is a good fit for Yavapai Medical Center. Today, the center completes 112,000 imaging studies annually and stores radiology and cardiac catheterization lab datasets in the 6 terabyte (TB) archive. The IT oversight and management burden is comparably light; InSite One proactively monitors the medical center’s storage needs. When the archive approaches the high water mark, an InSite One representative simply phones Munday to make arrangements to increase storage, sparing the PACS administrator the burden of monitoring storage.

Tapping into the benefits of standardization

Universal Health Services, Inc. (UHS), a publicly owned hospital system headquartered in King of Prussia, Penn., aimed for standardization among its 23 geographically dispersed acute-care hospitals when it turned to online image management. The rationale was two-pronged, says Bruce Marcolongo, manager, information services. “[With a standard system], we could better drive PACS functionality with the vendor and also leverage our internal user group to develop imaging tips and address support issues.”

UHS selected GE Healthcare Centricity IW, and in the last two years, deployed the web-centric system in eight facilities. In addition to meeting its initial goals, UHS has realized additional benefits. “We’ve avoided the limitations of client-server based architecture and implemented a fully web-centric system to provide immediate access to images throughout and beyond our hospitals,” explains Marcolongo. Consequently, UHS hospitals running Centricity IW report improved turnaround time and lower costs. The cost savings are multi-faceted. Legacy client-server PACS carried licensing and upgrade costs as well as higher maintenance bills. Centricity IW, on the other hand, offers a volume-based model. If imaging volume remains flat at 100,000 studies annually at one site, PACS costs stay fixed. But if volume increases to 120,000 studies at another site, the hospital pays more and also profits more with the increased volume, says Marcolongo.

The IT structure meets UHS’ needs as well. For starters, Centricity IW incorporates SSL encryption to provide reliable security. And the system adapts to a server virtualization model used by one UHS site. Under this model, the hospital can reduce its physical server burden by using software to virtually imitate hardware and divide a single server into isolated environments. 

The single modality solution

Robert D. Russo and Associates Radiology in Norwalk, Conn., is an established radiology practice with eight offices in southern Connecticut. Four years ago, the practice began deploying digital mammography. At the time, the practice had not yet implemented PACS. In addition, the ability to integrate digital mammograms into the PACS environment was not available when the practice installed digital mammography, says Director of Information Systems David Grandchamp.

The practice decided to use InSite One for an offsite, online digital mammography archive. “The InSiteOne retrieval model differs from the conventional PACS model,” explains Grandchamp. “[Rapid] retrieval is always guaranteed.” Most PACS, on the other hand, guarantee retrieval for a few weeks to a few months, and then response time drops off. In addition, the conventional PACS model does not fit mammography as well as an online image management system. That’s because radiologists nearly always require prior digital mammograms, so efficient workflow hinges on rapid retrieval of archived images. What’s more, digital mammograms are hefty files that can consume an inordinate amount of space in a conventional PACS. A final advantage of the online approach, says Grandchamp, is that the archive remains an operating expense.

The InSite One archive has grown with the radiology practice. Initially, the practice installed three distinct databases at each office offering digital mammography. A T1 line linked the office. The model worked—except when a patient used a different office for the follow up study. In those cases, the digital practice generated films.

In 2006, Robert D. Russo and Associates invested in a network upgrade, installing a 1 gigabit fiber optic bandwidth line between its offices. Internally, the practice consolidated its databases into a large proxy server. Now radiologists can access mammograms regardless of the acquisition site. In addition, the practice uses DeJarnette Research Systems PACSware Intelligent Router for pre-fetching. The results are impressive. “Prior mammograms are available immediately, rather than a few minutes,” says Grandchamp. With razor-thin mammo margins, seconds saved represents financial returns. Grandchamp decided to remain with the successful online archive approach even after the practice deployed PACS. “Mammography is a different beast than other modalities.” The large files can take a disproportionate bite out of the storage budget, and the constant need to retrieve prior studies is unique. InSite One also maintains backup archives in Arizona and at its Wallingford, Conn., headquarters. 


Questions to Ask
As cash-strapped imaging facilities wrangle with the challenges of ever-increasing image volumes and fast access times, it’s wise to weight all options.
  • Analyze the facility’s situation, says John Munday, RIS/PACS Administrator at Yavapai Medical Center in Prescott, Ariz. Does it have the structure, infrastructure or support necessary to streamline image management and storage? “Sites should understand the total cost of ownership for any online image management solution,” adds David Grandchamp, director of information systems, at Robert D. Russo and Associates Radiology in Norwalk, Conn. Some solutions require a one-time storage/retrieval fee; others use a per-click charge each time a study is accessed.
  • Don’t overlook the obsolescence factor. On one hand, storage is getting cheaper, and most hospitals are equipped with IT staff and infrastructure; however, storage is growing obsolete at a maddening pace, translating into near-constant upgrades. An online provider can handle scalability and obsolescence by adding terabytes and upgrades as needed.
  • Know the practice’s volumes and bandwidth requirements. Find out if radiologists can wait a few minutes for retrieval or if they need it in seconds.
  • Consider an off-hours, pre-fetch system. It lowers the bandwidth requirements and may suffice for some practices, says Grandchamp.
  • Make sure the ASP provider markets a true DICOM archive and can connect to all PACS, says Munday.
  • Be sure to check into data migration processes and requirements of various systems under consideration.
  • Consider all users in the selection process. Radiologists may be the primary users, but solid, rapid image access for referring physicians can grow the business, says Bruce Marcolongo, manager, information services, at Universal Health Services, Inc., in King of Prussia, Pa. Make sure the image management model meets the needs of referring physicians.