A focus on improving patient care and decreasing healthcare costs has created a need to centralize image and data access, enabling highly mobile caregivers to make decisions nearly anywhere. Data access must be instant, while safe and secure. Web- or cloud-based technologies, equipped with open DICOM standards, are presenting unique adoption avenues for innovative healthcare providers to begin the process toward true interoperability.
Breaking down access barriers
Through the HITECH Act, the U.S. federal government is providing financial incentives for healthcare organizations to adopt EMRs and electronic order entry systems, mandating the proliferation of electronic information exchange and patient communication. Additionally, some meaningful use criteria are built around quality measures that require enhanced sharing of information and images, as well as the consolidation of those data.
“Meaningful use criteria present requirements for data to be accessible across multiple settings. It’s a driving need for providers to access data across multiple areas within a hospital network and share information with other providers,” explains Judy Hanover, research director at IDC Health Insights.
Simultaneously, clinicians need to be able to use the EMR for clinical documentation and to view other relevant information about patients, from both the ambulatory and inpatient setting. “There is a need to make all data accessible in the EMR, which may include the need to access images,” Hanover says.
Traditionally, images have been siloed in radiology and cardiology departments, where they were created and stored in separate PACS. Recently, there has been a call to integrate and centralize image and medical record storage, according to Hanover, and web-hosted or cloud-based technologies are presenting new options to provide services beyond simple storage.
To achieve interoperability, providers are beginning to adopt middleware technologies such as web services and service-oriented architectures (SOA) that are DICOM aware, allowing disparate PACS, for example, to communicate through open standards. This allows providers to lower costs while achieving greater efficiency. On the near horizon are services that will unlock proprietary vendor formats, opening up data access, allowing better patient care and reducing the cost of business because legacy systems will speak freely with one another.
Getting interoperable from the inside out
“Due to the high costs associated with utilizing a traditional PACS-based, client-server environment, web-based solutions present an inexpensive means of dispersing images and reports throughout the hospital network, even outside the firewall,” explains David S. Mendelson, MD, chief of clinical informatics at Mount Sinai Medical Center in New York City. “They typically employ a local VPN service, which the institutions use to connect their staff to a variety of data and images, from outside of the enterprise.”
First, healthcare facilities must ensure their disparate technologies can communicate through enterprise-wide standards. “Having a DICOM umbrella across a network allows varied PACS and storage technologies to speak the same language,” says Philip Politowicz, PhD, associate director of information systems at University of Wisconsin (UW) in Madison.
Through an internet browser or VPN, healthcare professionals can access EMRs, as well as clinical data and images, allowing secure, authenticated access from outside the hospital setting.
“The trend is moving to web-based technology for image and information exchange,” says Tom Coppa, infrastructure architect at Iowa Health System (IHS), based in Des Moines. “In choosing a new platform, we sought to make access easy through the web, especially for referring physicians and appropriate caregivers.” Earlier this year, IHS, which incorporates 13 hospitals and 30-plus additional outreach facilities, went live with a McKesson platform in a four-month period, embracing 3.5 million studies of nearly 200 million images and 60 terabytes of data.
Iowa Health System physicians now can access PACS images via a context sensitive or context aware link in the EMR, from which they are brought into the PACS viewer.
Because they adhere to DICOM standards, images can be accessed throughout the network. For transferring additional data, the health system is seeking to use HL7 and other standard protocols, as well as to employ non-proprietary database systems, such as Oracle.
Increased access often increases concerns about privacy and security; however, the added layer of web-based services also adds a layer of security. “Our entire enterprise is firewalled from the general environment, which extends to data that are accessed remotely” says Coppa.
To assist with the increasing need to provide telehealth services, various technologies have been adopted across the U.S. and Europe. One Portuguese provider of tele-diagnostic and reporting services of radiology medical urgencies assists hospital services via a PACS platform based on Oracle Linux and Oracle Database 11g DICOM, says Aristides Meneses, chief marketing officer at Tecbra Telehealth Solutions. “Offsite radiologists receive the medical images with an alert and are able to diagnose and report on urgent situations,” he says.
Various centralized image repositories have sprung up to facilitate image and data exchange, and to create a standards-based image exchange framework beyond the provider’s setting—to the patient or industry partners. The trend is reinforced by meaningful use, which calls for healthcare organizations “to provide patients with an electronic copy of their health information,” including test results, discharge summary and procedures.
For example, the RSNA Image Sharing Project, sponsored by the National Institute of Biomedical Imaging and Bioengineering, seeks to empower the patient. Mendelson and colleagues are using the IHE XDS-I.b (Integrating the Healthcare Enterprise cross-document enterprise sharing-images) profile to service consumers. The project allows the transfer of patient images outside of the facility where they were initially imaged. The patient is the conduit to allow transfer of images from provider to provider via a personal health record (PHR).
“We are driving a standards-based solution that anybody can replicate,” Mendelson says. “We wish to extend the model so that images obtained in any facility can be easily viewed at another with the proper security model.”
Also, providers who manage clinical trial images, such as UW, need to share images securely from multiple sources across multiple organizations. UW’s DICOM project, which utilizes an Oracle-based architecture on a storage area network, has allowed the provider to extract images from a central database for various industry partners that are seeking FDA approval for new drug applications. UW also exports data results stored in the database to the pharmaceutical companies.
Leaning toward the cloud
Virtualized servers and storage allow for the abstraction of the physical layer with the actual end-user layer, which will allow providers to easily transition to cloud-based technologies. At Iowa Health System, “virtualization has allowed resources to have a similar look and feel across the network,” Coppa says.
The shift is not just in the U.S. “The trend toward interoperability in Europe is due to a greater use of the internet and their inherent lower costs, says Meneses.
“This is becoming a popular trend for storage and servers with client applications because it allows the hospital’s data center to consolidate its physical resources while providing high-level performance and availability to end users,” says Hanover. “In addition to accessing additional processing power or storage, virtualized systems save money by optimizing computing resources, space and energy consumption.”
According to Mendelson, healthcare is transitioning to network and internet solutions, which are in a state of “evolution,” and make security and confidentiality “more challenging.” He concludes that technologies based on open standards will provide the patient with greater flexibility; and for providers, interoperability will result in better quality of care, operating efficiencies, a reduction in costs and improved, quality-related outcomes.