Image-enabling the enterpriseFilling the gap for EMR systems and optimizing PACS performanceABSTRACTThe future of medical ...
Image-enabling the enterprise page 2Given that images are a critical part of thehealthcare process and the means to maketh...
Image-enabling the enterprise page 3Complicating matters for these legacy PACS istheir reliance on antiquated, dedicated n...
Image-enabling the enterprise page 4challenges, supporting the upgrade of PACSand RIS and the query of multiple informatio...
Image-enabling the enterprise page 5they provide secure access to images acrossand beyond the enterprise for physicians an...
Image-enabling the enterprise page 6Any exam captured anywhere in the enterprisecan be read by radiologists in any on-site...
Image-enabling the enterprise page 7business rather than keeping it by holdingpatient data hostage.As an integral part of ...
Image-enabling the enterprise page 8What’s next. Your specific needs, in the context of your financial and IT resources, s...
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Image-enabling the Enterprise: Filling the gap for EMR systems and optimizing PACS performance


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Carestream Vue's scalable enterprise workflow, vendor-neutral archiving and cloud-based services optimize medical imaging for clinical excellence and superior patient care.

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Image-enabling the Enterprise: Filling the gap for EMR systems and optimizing PACS performance

  1. 1. Image-enabling the enterpriseFilling the gap for EMR systems and optimizing PACS performanceABSTRACTThe future of medical imaging and the welfare ofpatients dictate that patient images areexchanged easily and rapidly across theenterprise. Ideally, patient images are part of theelectronic medical record, but certainly thisexchange must be effective within and amongPACS, as well as RIS, HIS and other informationsystems. Installed PACS, however, may not beup to this task. Yet replacing a PACS systemcan be very expensive and disruptive.Carestream Vue can serve as the one and onlyPACS for a facility. Or it can work with anexisting PACS, conserving resources at thefacility that uses a legacy system as an archivefor already stored studies.When images are stored on several PACS, andefficiency requires these systems to worktogether, an integrator can be installed to createa global imaging worklist. Carestream Vue forEnterprise Workflow, powered by SuperPACS™Architecture, can synchronize multiple worklistson disparate PACS into such a worklist,revealing information on installed PACS andapplying intelligent rules to balance workload atmultiple sites.The best solution to prevent incompatibility inthe future is for sites to begin installing neutralsolutions. Carestream Vue for Vendor NeutralArchiving provides this neutrality, lowering thetotal cost of ownership of healthcare informationsystems by replacing multiple outdated archivesand eliminating the future need to purchaseapplication-specific archives. Anotherexpression of neutrality is our Vue for Cloud-Based Services, a Software-as-a-Service(SaaS), which allows PACS and archiving to bepurchased on a predictable fee-per-use basis.Extending the EMR to include images can bedone with a zero-footprint viewer, so namedbecause it requires no software to bedownloaded. Carestream’s Vue Motion viewercan be embedded in EMR and HIS portals toaccess images contained in a PACS. The resultis an image-enabled enterprise and EMR withaccess to images through virtually any browser-enabled device, running on various operatingsystems on Macintosh or PC-based systems.WORDS WITHOUT PIXELSBillions of medical images are captured in theU.S. each year. According to the marketresearch firm IMV Medical Information Divisionin Des Plaines, IL, about 70 million CT and 30million MRI procedures are performed annually,each generating hundreds if not thousands ofindividual images. In a year, Americans undergo16 million nuclear medicine procedures, another1.5 million PET scans, 37 million mammogramsand 183 million X-rays. Countless more patientimages result annually from cardiac cath,angiography and ultrasound procedures.Yet, few electronic medical records includepatient images, despite their obvious importancein screening for disease, making diagnosis, anddetermining the effects of therapy. They may noteven be available within enterprises, particularlyones formed recently through the consolidationof multiple facilities using different PACS.Images provide the context for understandingradiological interpretations. They add visualdetail that makes written conclusions easier tounderstand and more complete. Consequently,their absence hobbles collaboration amongradiologists and specialists, as it impairscommunications among radiologists, referringphysicians and their patients. Images can helpreferring physicians home in on a patient’scondition, demonstrating subtle findings that arebest appreciated visually. These same imagescan serve as communications tools, helping thephysician convey information to patients abouttheir conditions.
  2. 2. Image-enabling the enterprise page 2Given that images are a critical part of thehealthcare process and the means to makethem widely available is at hand, it stands toreason that they should be easily accessiblethroughout the enterprise, as well as an integralpart of the electronic medical record.The problem with PACS. For the most part,images are sequestered in PACS, where theymay be accessed by collaborators or referringphysicians only through labor-intensive efforts,particularly when enterprises use more than onePACS.Even when enterprise-wide access is supported,all images may not be immediately available.The extraordinary volume of images generatedby today’s CT and MR systems can overwhelman outdated PACS, just as the rising demand forrapid access to images can drag down itsperformance and functionality. Underlying thisvulnerability is the dependence of legacy PACSon dedicated high-end networks, complexhardware configurations, and antiquatedarchiving technology. Downtimes get longer anddelays happen more frequently due to failinghardware. Such failures may necessitateexpensive upgrades or platform changes.Operations at facilities undergoing such changescan be seriously impaired, as this transition isaccomplished at the expense of efficiency.Facilities may even experience long-termproblems, if the data are not properly transferredto the enhanced or new PACS. For example, iflarge datasets remain outside the PACS, theymight be accessed only through inefficientinterfaces.Such inefficiencies may also occur when addinga standalone workstation or thin-client system inorder to perform advanced visualizationtechniques, such as 3D. Alternatively, they mayresult when healthcare facilities consolidate.Efforts aimed at reducing costs may actuallyincur new ones through inefficiencies createdwhen trying to link multiple disparate PACS.Similar problems may crop up when facilities linkthe many data islands created by “ologies”outside the mainstream of medical imaging.Physicians in these circumstances may dependon slow and costly methods to track down andobtain patient images, printing films or burningCDs and DVDs, wasting extraordinary amountsof time and money, ironically when thesebecome ever more precious. This inefficiencydrives up the cost of patient care. But thealternatives are worse.Not having patient images can lead toduplicative exams. This adds even more cost,and in the case of imaging exams such as CTs,radiography and nuclear medicine, additionalexams expose patients unnecessarily toadditional radiation. Not having critical images isworst of all, as it introduces the potential forerror, raising the specter of missed diagnoses,patient morbidity, and even avoidable death.An avalanche of data. Installing and usinghealthcare information systems that provideready access to patient data, including images,is the answer. This was, in fact, the reasonPACS and RIS were among the first informationsystems to be embraced by the medicalcommunity. Their early adoption, however, hasled in some instances to a medical Tower ofBabel. Enterprises with multiple disparate PACSmay not be able to share data efficiently, as theirinformation systems are not compatible, existingas islands of digital data.Complicating matters is the increasing demandfor timely patient data, particularly amongmultiple sites in expanding enterprises. This hasthe cumulative effect of degrading theperformance and functionality of informationsystems. This is happening just as the volume ofdata is growing at an unprecedented rate in thewake of modern developments in CT, MR anddigital radiography. Advanced visualization,including 3D reconstructions and the fusion ofdata sets from several modalities, have addedmore pressure, as well the pending use ofbreast tomosynthesis with its dozen or moreexposures per exam.The end result threatens to overwhelm the abilityof legacy PACS to process, distribute andarchive images and other patient data.
  3. 3. Image-enabling the enterprise page 3Complicating matters for these legacy PACS istheir reliance on antiquated, dedicated networksthat in recent years have been made obsoleteby wired, wireless and Wi-Fi networks.In an effort to link these systems with eachother, sites have constructed complex serverand client hardware configurations prone toinefficiencies and failure. In the meantime, thearchive technology underlying these systemshas been left in the dust by massive leaps inmemory.Underscoring the shortcomings of legacy PACSis their lack of post-processing capabilities,particularly advanced visualization techniques,which are becoming increasingly commonelements of modern PACS.But just as outdated PACS struggle to keep up,challenges in data migration, including theexpense in time and money to do so, aredelaying the transition of sites to more advancedPACS. Often the replacement process iscomplex and time consuming. Early PACSadopters are learning that DICOM compliancedoes not guarantee easy data migration fromone system to another.A big problem is that vendors typically have theirown ways of storing data. These may includeproprietary data management and compressionschemes. They may even involve multitierstorage technologies, including various digitalstorage arrays, jukeboxes, and different types ofmedia that use different types of retrievaltechnologies.Under these circumstances, changing from onePACS to another may not only be challengingbut highly disruptive to clinical operations,impeding the usual diagnostic process byslowing access to prior images during thetransition to the new system. This can reduceproductivity throughout the enterprise until themigration is done.Government Funding Accelerating ITadoption. Adding a sense of urgency to theupgrading of image-enabled IT systems is afederal mandate on the U.S. medical communityto convert from paper to electronic records. Thismandate, defined by the American Recoveryand Reinvestment Act of 2009, offers a near-term carrot in the form of added reimbursementfor the adoption of electronic medical recordsthrough 2015 and a long-term stick poised toexact penalties for noncompliance in the yearsafter.Where exactly radiology fits in is not certain.Radiology was not specifically included in thefirst of three stages of meaningful use criteriarequired to qualify for the earliest of the addedreimbursements. Those for stage 2, which mayyet have a role for radiology, are still indevelopment.Radiology may get some traction in meaningfuluse by utilizing RIS/PACS and enterprise imageaccess technologies. Through the modernintegration of RIS/PACS, radiologists couldpotentially meet several key criteria. Onerequires the implementation and tracking ofclinical decision support rules. Others call forproviding patients with electronic access tohealth information, possibly in the form ofradiology reports; patient-specific educationalresources; and a summary of care records. Aneasy-to-deploy image viewer, embedded in theEMR, may be interpreted as addressing theneed to test the exchange of key clinicalinformation, as in images that illustrate an illnessor other patient condition supporting a diagnosis.FILLING THE INFORMATION GAPRegardless of what happens with thegovernment stimulus plan and meaningful use,the future of medical imaging and the welfare ofpatients dictate that patient images beexchanged easily and rapidly across theenterprise. Ideally this exchange will be as partof the EMR but certainly within and amongPACS and health archive solutions, as well asRIS, HIS and other information systems thatshape these records. Patient images should alsobe available for viewing outside the enterprise.Solutions are already at hand to meet these
  4. 4. Image-enabling the enterprise page 4challenges, supporting the upgrade of PACSand RIS and the query of multiple informationsystems, just as standard Internet connectionssimplify their worldwide distribution.Upgrading the PACS. When a currentlyinstalled PACS is not up to current demands, adecision must be made whether to augment orreplace it. Often the choice is to install a newPACS integrated with RIS capability. The RISmay be tailored to support the EMR, as well asthe construction of reports containing images.An enterprise viewer might be installed toenhance this capability. Such a viewer might beoptimized to work specifically with the newPACS. Or, it may be compatible with a broadspectrum of technologies, thereby offeringaccess to images throughout and even outsidethe enterprise.But a new PACS is not always an easy choice.Replacing a legacy PACS can be very complex,expending money and time, while disruptingdaily routines. Data migration is often thebiggest challenge. Its problems can bemitigated, however, by installing a new-generation PACS that can leverageinfrastructure from the legacy system until thetransition is complete. For example, somevendors are offering metadata take-over toolsthat allow the legacy PACS to become anarchive, making the data available as an integralpart of the new PACS workflow.A single connector. Over the years myriadPACS may have been installed at facilities thatare now part of an enterprise. In order toimprove the quality of patient care, whilesimultaneously boosting productivity andresource utilization, radiology operations atthese multiple sites must be streamlined and thework coordinated. Replacing several PACS,however, may not be practical due to the cost intime and money to do so. A cost-effectivealternative is a variation on the theme of turningold PACS into archives. In this case, anintegrator is installed to synchronize individualworklists into a global imaging patient record fordiagnosis and review. This global imagingrecord allows users from multiple sites to accesspatient images easily and efficiently so as tocollaborate and balance workloads.Staying neutral. The best solution to preventincompatibility in the future is to install vendor-neutral solutions from this point onward. Onethat immediately fits the bill is the vendor-neutralarchive. Because of its neutrality, this archiveaccepts data from platforms developed bydifferent vendors. Serving as a centralizedstorehouse of radiological as well ascardiological images, for example, as well as labreports and video files, it reduces future costsbecause the enterprise need not buyapplication-specific archives. Similarly, it cutsoperating expense by reducing personnelmanagement tasks and equipmentmaintenance. It also boosts efficiency bycreating a common workflow across multiplelocations and establishing a single point ofaccess to patient information, allowing thisinformation to be shared easily amongauthorized users.A viewer with the light stuff. An image viewerthat does not require software download (zero-footprint) neatly fills the need to provide broadaccess to patient images, a tough but criticallyimportant consideration in any EMR. Zerofootprint offers many benefits. Like a webbrowser, it requires no software to bedownloaded. It boots up instantly, ready tosearch out and display images contained in theRIS report.It can be embedded inside an EMR system orany routinely used information system.Consequently, it allows the convenience ofsingle sign-in, eliminating the need for repeatedre-entry of passwords. Also, by embedding theviewer in a commonly used information system,users do not have to quit what they are doing inorder to see images.Especially attractive is that such Web-basedviewers are not confined to a single system orfacility. Because they have a zero footprint, theyare compatible with just about any platform fromWindows- and Macintosh-based devices. Thus,
  5. 5. Image-enabling the enterprise page 5they provide secure access to images acrossand beyond the enterprise for physicians andpatients alike.With the viewer’s reach to all clinicalcommunities, providing diverse exposure to ITwhile an intuitive design requires little or notraining for the end user, this technology canfree up implementation time and resources.Because a zero-footprint viewer may have towork in low-bandwidth environment, it does notnecessarily require the transfer of large volumesof data over the Web. Instead most solutionsdepend on the server to do the vast majority ofthe rendering, thereby significantly reducing thevolume of data to be transmitted. And, becausethe rendering is done on the server side, thereare no data storage requirements on the zero-footprint side.These viewers, therefore, can be easilydeployed, as the software upon which theydepend is loaded on the server. Consequently,they are a snap to upgrade, as softwareenhancements are done on the server. Onecaveat is that the server must be powerfulenough to handle the large number ofconcurrent users that may seek simultaneousaccess to patient images.SOLUTIONS BY CARESTREAMCarestream Vue is a comprehensive solutionthat covers every aspect of image augmentationin the electronic medical record and across thehealthcare enterprise from display to dataarchive, workflow to distribution. These can beachieved with or without data migration and thereplacement of legacy systems.To migrate or not to migrate. Carestream VuePACS can serve as the one enterprise PACS fora facility. Or it can work in tandem with anexisting PACS, conserving the facility’sresources to use this legacy system as anarchive for studies already stored on it.For those who want to replace their legacysystem, we employ data migration technologiesthat streamline the process and minimizeproblems. We begin by taking a snapshot of thelegacy PACS. This snapshot populates theregistry to allow access to priors during datamigration and while new studies are beingstored on the new database. As a result, datamigration can run in the background throughoutthe week, even during regular working hours.Alternatively, response time on the databasecan be maximized by migrating data only afterhours and on weekends.Facilities may avoid data migration altogether byusing their legacy PACS as archives for priorstudies. These PACS can then be queried bythe newly installed Vue PACS. In this, anexternal DICOM tier, called E-SIR, takes controlfrom the legacy PACS, turning it into an archiveand providing Vue PACS with access to thelegacy data.The process begins with Vue for EnterpriseWorkflow that works in concert with Vue PACS.Vue Connect can scout all the studies containedin the existing PACS, creating metadata in theVue PACS that describe each one. Thesemetadata serve as pointers to studies stored onthe legacy PACS, making all its studyinformation visible through the Vue PACSworklist. When queries about these prior studiesare made using the Vue PACS, the pointersguide the retrieval of their data. In this way wemake data migration optional.Boosting workflow throughout theenterprise. A similar process can be used toconserve the resources of an enterprise that hasseveral legacy PACS, a process that not onlyextends the value of these PACS but of theiraccompanying storage devices. For this, VueConnect, powered by our unique SuperPACS™Architecture, can synchronize multiple worklistson disparate PACS into a global worklist. Thisworklist reveals the information contained onthese legacy PACS and applies intelligent rulesto balance workload at multiple sites served bythese PACS, thereby boosting productivity.
  6. 6. Image-enabling the enterprise page 6Any exam captured anywhere in the enterprisecan be read by radiologists in any on-site or off-site location. The global worklist defines howthese studies are routed to specialists andsupports multiple patient identification numbersusing IHE profiles.Utilizing the unique SuperPACS™ Architecture,patient images and other information aresecurely shared among locations, whileradiologists at those locations have access topowerful diagnostic tools. Vue Connect alsoworks with vendor-neutral archives to managemultiple PACS at different facilities.Staying neutral. Because vendor-neutralarchives provide a single point of access topatient information, they facilitate data sharingamong multiple users in different locations. Theywork independently of the PACS, storing datafrom multiple systems in nonproprietary formats.And they provide context management to allowinformation to be transferred seamlessly amongdifferent information systems.Carestream Vue for Vendor Neutral Archiving isa complete solution with archive and viewer,lowering the total cost of ownership ofhealthcare information systems by replacingmultiple archives and eliminating the future needto purchase application-specific archives. It cancollect and store a variety of data, includingmedical images, lab and pathology data, videofiles and JPEGs to create a cohesive patientportfolio. Scalable across multiple installations,Vue Archive can be easily expanded. Thearchive nodes that allow this expansion can beconfigured to serve as backups for each other,providing redundancy and assurance againstcatastrophic failure. The Vue Archive alsoprotects against undue expense in the future,supporting the cost-free migration of data to anew PACS if, or when, required. This puts theburden on vendors to earn their customers’Site ASite BSite CSite DMetadataDataCenterVue Connect: Enterprise Workflow
  7. 7. Image-enabling the enterprise page 7business rather than keeping it by holdingpatient data hostage.As an integral part of our RIS/PACS/reportingofferings – Vue for Radiology and Vue forCardiology – Vue Archive acts as an IHE-XDS(Integrating the Healthcare Enterprise-CrossDocument Sharing) to access medical imagesthroughout the enterprise. Utilizing the XDSframework, our Vue Archive functions as aregistry, communicating with other systems suchas the RIS or HIS, which are enabled throughtheir support for DICOM, HL7, and other ITstandards. The result is a centralized repository,archiving data from multiple information systemsacross the enterprise.Additional features include a master patientindex and DICOM tag morphing, whichstandardizes data presentation throughout theenterprise. Vue Archive manages patient IDsfrom different sites and resolves metadatadiscrepancies. This user-friendly repositorystores diverse clinical data, thereby enhancingthe value of these data to the enterprise and,ultimately, to referring physicians and theirpatients. This value is further enhanced througha fully integrated viewer that can be easilydeployed to virtually any device running a webbrowser or embedded into the EMR.Enterprise access. Designed to distributeimages throughout and beyond the enterprise,Vue Motion viewer works with virtually anybrowser-enabled device to augment theelectronic medical record. This zero-footprintviewer requires a minimum bandwidth despitehigh performance and rapid access to images.As an independent viewer, Vue Motion is PACS-agnostic and can be integrated to other vendor’sPACS, as well as DICOM archives and XDSrepositories. Because this viewer can be easilyintegrated with diverse departmental systems,clinicians and referring physicians gain fast andeasy access to patient data and images.Particularly notable is its ability to be embeddedin EMR and HIS portals to access imagescontained in a PACS, thereby image-enablingthe enterprise and the EMR. The viewer can belaunched without calling up a separateapplication or logging into another systemintegrated directly into an IS. Alternatively, it canbe launched in a separate window withoutrequiring a separate log-in, using a URL fromwithin the system.Security and infinite scalability. As theultimate expression of neutrality, Vue for Cloud-Based Services is a Service as a Solution(SaaS), which allows PACS and archiving to bepurchased on a predictable fee-per-use basis.This lowers the cost of ownership by reducinginvestment in capital equipment and the need forstaff management personnel, as it eliminates therisk of equipment obsolescence.Our Vue for Cloud-Based Services approachlinks affiliated hospitals, imaging centers, clinicsand other facilities through a global patientworklist. This worklist enables providers tobalance their reading and reporting workloadamong available radiologists, boostingproductivity, accelerating the reporting process,and enhancing resource utilization.Advanced reporting tools allow current and priorexams to be automatically compared. Advancedpost-processing tools support analyses in suchstudies as cardiac and coronary CT, vesselsegmentation, and PET/CT.With deployment of ten data centers in fivecountries throughout Europe and North America,and with new centers planned for Japan andArgentina, more than a billion images arecurrently stored worldwide, representing morethan 500 terabytes of data securely managed byCarestream using technology and services thatcan be scaled to accommodate our customers’growing needs.
  8. 8. Image-enabling the enterprise page 8What’s next. Your specific needs, in the context of your financial and IT resources, should determinewhat you do and how you do it. You may need a new PACS, but you might want to operate your old andnew PACS together. You may want to link several PACS together or install a vendor-neutral archive as acentralized repository, an SaaS, or a zero-footprint viewer.MORE INFORMATIONContact your Carestream Health representative, or visit Health, Inc.150 Verona StreetRochester, NY 14608© Carestream Health, Inc., 2011. CARESTREAM is a trademark of Carestream Health.CAT 300 1002 2011-07-20Vue Cloud: New Collaborative Workflow