A Real-World Solution for Patient-Centric Workflow
White Paper | Vendor-Neutral ArchivesA Real-World Solution for Patient-Centric WorkflowWorkflow Evolution Driving New ArchivingSolutionsReducing healthcare costs, improving clinical quality andadopting a more patient-centric view are now universal goalsthat require ubiquitous access to clinical information. The needto integrate and consolidate information from disparate clinicalsystems is driving a shift towards enterprise IT solutions, suchas systems-neutral storage, enterprise workflow solutions anduniversal viewers. Healthcare system leaders know that clinicalinformation management and access are pervasive challenges,and that departmental systems are typically not designed toaddress complex workflow issues. Conversely, enterprisesystems often do not support the unique needs of every clinicaldepartment. Departmental and enterprise workflow needsmust be satisfied in an organized manner, to minimize ITcomplexity and cost. This requires IT and clinical departmentsto develop an enterprise imaging strategy that articulates theinstitution’s evolving clinical workflow needs.Much has been written about developments in enterprisestorage, workflow and display solutions, often creatingconfusion about capabilities and terminology. This documentattempts to provide clarity by emphasizing the operational andworkflow capabilities expected of a Vendor Neutral Archive(VNA). Examples from across the globe of institutionssuccessfully solving their critical workflow challenges will bepresented. This approach is intended to enhance readers’understanding of the challenges that may be encounteredwhen solving current enterprise workflow limitations andprovide insights that might smooth the process.Operational Capabilities Supporting WorkflowNeedsThe term Vendor Neutral Archive (VNA) commonly refers to anenterprise storage and workflow solution that embracesneutrality to resolve a range of enterprise workflow challenges.Understanding supported workflows and operationalcapabilities is critical as there is no lexicon of IT system terms.Only with this understanding can an institution determine howa specific solution will address their needs. Compounding thisis the reality that no single clinical IT solution will solve aworkflow problem on its own. Any VNA must work seamlesslywith an enterprise workflow engine, universal viewing systemand existing clinical systems.Enterprise storage solutions must integrate, and strictly adhereto, numerous open standards to enable complex information-sharing workflows and management of clinical information.Additionally, a VNA should uniquely support enterpriseinteroperability – so while consolidating data, it also supportsthe individual needs of departmental archiving and workflow.For example, departmental archives are often optimized forreading workflow performance by incorporating a customizedDICOM syntax that does not support the neutrality needed toresolve existing enterprise workflow limitations. This is theframework by which the following capabilities should beconsidered.The Concept of NeutralityNeutrality: The VNA must handle information in non-proprietary formats, regardless of the data sourceThe concept of neutrality is central to a VNA. These systemsmust comply with enterprise workflows standards by storinginformation in non-proprietary, interchange formats. This is theessence of “neutrality.” While seemingly elementary, thisconcept differentiates a VNA from the typical departmentalarchive running a DICOM implementation optimized by the
White Paper | Vendor-Neutral Archives2vendor to address departmental workflow – often to theextent that it is proprietary. The enterprise workflow challengeis to prioritize neutrality in favor of context and datamanagement, simplified migration and ready access todisparate patient information, regardless of source. Thisrequires storage and sharing of DICOM and non-DICOM data(as most clinical information is non-DICOM), text-basedinformation, scanned PDF documents and JPEG images.Support for the IHE standards XDS/XDS-I is also required toenable complex information-sharing workflow across datarepositories and data types (DICOM and non-DICOM). Even ifinitial plans call for DICOM-only storage, neutral systems mustbe in place to support XDS/XDS-I when the organization isready to execute the next phase of the plan.Data Consolidation and MigrationOrganizations must acknowledge that clinical informationconsolidation and migration can be an ongoing process, butone that benefits from software and hardware neutrality.Evolving business and vendor relationships, as well as newsystem implementations, may require data migrations acrossheterogeneous vendor systems. An enterprise-imagingstrategic plan should acknowledge this reality and balance the(sometimes conflicting) demands of clinical workflow and dataconsolidation. The ability to migrate the descriptive DICOMimage header information (metadata) independent fromDICOM image pixel data (actual image) should be sought. Thiscapability enables rapid data migration without clinicaldisruption, even when migrating large data volumes on low-bandwidth networks. This approach has the added benefit ofenabling a facility to maintain a legacy archive to managehistorical information until a new storage solution can beprocured.Data consolidation also requires mechanisms to ensure dataintegrity and synchronization – both necessary to supportdevelopment of global worklists. This is particularly importantas information often originates from multiple healthcarefacilities and clinical systems with non-uniform methods ofpatient identification and DICOM conformance. Synchronizingincoming (DICOM and non-DICOM) images, reports, faxes, labresults, notes, etc., from a given patient is critical to ensureclinicians obtain a unified view of the patient’s availableinformation. Powerful metadata manipulation techniques, suchas PIX, MPI and DICOM Tag Morphing, enable this capability,whether searching via Medical Record Number, AccessionNumber, Government ID or a patient demographic field (e.g.name, DOB, SSN).Data synchronization also enables a multi-VNA installation toprovide geographically dispersed disaster recovery and businesscontinuity. In large, geographically dispersed implementations,such as national or regional health systems, synchronizationensures caregivers can access important clinical information,even if one system is unavailable.Information Lifecycle ManagementWhen a unified view of clinical information is realized, andinformation is consolidated, sophisticated protected healthcareinformation (PHI) retention policies can be supported. A unifiedapproach to clinical information management enables aninstitution to balance escalating storage demands with clinicaland legal retention requirements. Information LifecycleManagement (ILM) of clinical data stored on a VNA is apowerful tool for managing PHI retention policies. Withinformation centralized, ILM rules can be applied moreuniformly and easily managed from a location. This can cutdata-management costs by reducing the FTE needed tomanage the large amounts of data and by leveraging theautomated rules common to ILM solutions.
White Paper | Vendor-Neutral Archives3IT Simplification and ConsolidationIT departments developing simplification and consolidationstrategies should consider how a VNA can reduce costs anddemands upon system administration while resolvingenterprise clinical workflow challenges. Consolidation ofexisting clinical storage systems through virtualization andelimination of multiple online/offline tiers should also bepossible. This simplifies future storage expansion and facilitatesdisaster recovery and business-continuity solutions. Systemconsolidation and simplification also create opportunities tomove infrastructure to the cloud, as many VNA providers offermanaged services that operationalize all aspects ofsystem-related expense. This can provide significant costsavings and management benefits, particularly when financial,site and IT support challenges might otherwise limit aninstitution’s ability to meet its goals.The productivity and clinical quality improvements enabled bystorage and workflow consolidation are enhanced when theyinclude clinical viewing consolidation. Implementing a zero-footprint universal viewer with expanded standards support,sophisticated workflow, display and security tools is animportant link to improving enterprise imaging workflow.Access to heterogeneous information via a unified globalworklist or image-enabled EMR/EHR requires sophisticated“neutral” viewing capability. In addition, the demands on IT tosupport hardware and software for a large clinical user basecan be significantly reduced by leveraging this new technology.Real-world Workflow ExamplesDeveloping an enterprise imaging strategic plan that clarifiesthe workflow challenges to be resolved should precede anyenterprise technology assessment. This is important because ofthe many constituents involved, range of technologiesimpacted and need to clearly articulate priorities. Approachinga VNA implementation incrementally can also increase thelikelihood for success by resolving workflow challenges in alogical and step-wise fashion. To this end, understandingothers’ experiences can help identify viable approaches anorganization may wish to follow. The following real-worldscenarios illustrate how a VNA, and a carefully consideredenterprise imaging plan, can simultaneously address these (andother) enterprise imaging challenges:• Unmanageable IT support costs because of the largenumber of disparate IT systems• Clinical users unable to get a unified view of patientclinical information across disparate systems• Poor system availability with inadequate businesscontinuity and disaster recovery• Slow data migration, often interrupting clinical serviceA Large Urban Integrated Health Network RealizesProductivity from a Unified WorklistWhen Rochester General Health System was planning updatesto their older multi-site, multi-archive distributed PACS, the ITdepartment recognized an opportunity to implement anenterprise architecture across their eight clinically integratedaffiliates. The IT department identified unnecessary redundancyacross multiple departmental archives, including networkdemands and additional maintenance and support costs.Current clinical workflow needs were being minimallyaddressed, but were not sufficient to support theorganization’s evolving needs and growing imaging volumes.The IT department implemented a best-of-breed solution byleveraging existing relationships with their IT hardware andvirtual machine (VM) vendor. A single, unified Rad/Card PACSwas implemented, with a virtualized Vendor Neutral Archiveproviding long-term online storage for 230,000 studiesannually, from two hospitals and four outpatient imagingfacilities. The VNA implementation accommodates future plansto store non-DICOM clinical information in addition to the
White Paper | Vendor-Neutral Archives4current DICOM image data. Operational and cost benefits forthe IT and support departments also enabled reallocation ofresources to other projects.Consolidation of the Rochester Health System infrastructureoccurred in conjunction with an assessment of enterpriseclinical viewing needs across the enterprise. Clinical viewingconsolidation was achieved using a zero-download viewer forenhanced access to the information stored on the VNA. Thisunified approach also leveraged other enterprise securitymeasures, such as LDAP, which were already in place. Clinicalinformation on the VNA is also available for viewing via thesystem-wide Electronic Medical Record (EMR), so clinicians’decision-making and productivity benefit from ready access torequired clinical-imaging information. Clinicians can also accesskey images, reports or the entire imaging study, from a single,familiar clinical viewer, enabling faster responses to clinicalneeds and greater focus on delivering high-quality care. ChuckO’Brien, RIS/PACS Administrator at Rochester General HealthSystems, reported, “Our unified approach to IT systemconsolidation and simplification enabled our radiologists tomore quickly access historical studies on PACS, as allinformation is now online. Radiologist productivity, decisionsupport and clinical learning have all benefited from easyaccess to historical information.”A Large, Urban, Integrated Health NetworkMaintains Critical Services During TransitionBecause of the complexity and range of capabilities inherent ina VNA, it is able to address numerous workflow scenarios andprovide many benefits. Data and hardware consolidation aremerely one example. The sophisticated image manipulationtools within a VNA should be able to speed the migrationprocess. For example, Saint John Health System, anine-hospital, integrated health system based in Tulsa,Oklahoma, was faced with a particularly challenging situation.They wanted to replace their legacy PACS and archive and alsoimplement an enterprise solution to consolidate informationfrom their many facilities. Rather than perform a costly andtime-consuming data migration of the existing PACS archive toa new platform, Saint John implemented a phased migrationapproach that leveraged the capabilities of the new platform:initially only the metadata was migrated from the legacy PACSarchive, leaving the image-pixel data on the legacy archive.Image-pixel data was then migrated on an as-needed basis,when priors were requested, or after hours when bandwidthwas optimal. This ensured historical information wasimmediately available to all users, as if it were stored on asingle platform. Establishing the enterprise repository in thismanner minimized the impact data migration would have hadon the day-to-day operations of the existing system andenabled the health system to go live faster with the new PACS.A Large Suburban Medical Center Seeks CostSavings from Simplified InfrastructureIt is important to ensure both clinical and IT departmentsbenefit from an overall shift towards an enterprise strategy.Winthrop-University Hospital in Mineola, New York, a600-bed, community-based teaching hospital and regionaltrauma center performing 200,000 annual exams, was carefulto ensure this was the case. When planning their PACSinfrastructure upgrade, Winthrop-University Hospitaldetermined it would be a good time to leverage the enhancedvendor neutrality (of a VNA). The goal was consolidation ofdata from multiple clinical departments and preparation forfuture hospital network expansion that would accomodateincreasing clinical data access demands. They implemented acloud-based VNA and migrated existing online and offlinediagnostic and interventional radiology, radiation oncology,vascular ultrasound and cardiac CTA studies. Cardiology andOrthopedic data are now being added and include DICOM andnon-DICOM studies and scanned JPEG files.The enterprise view adopted by Winthrop-University Hospitalextended to providing clinicians with “universal” workstationaccess. The goal was to leverage the “neutrality” of the VNAstorage infrastructure and single backend interface that wasno longer limited by multiple unconnected systems. Separatingclinical storage from clinical viewing is expected to simplifyfuture technology deployments by the hospital and increasethe technology options available for future consideration. TheIT department also rolled out new enterprise access policiesthat simplify deployment of new services to their large anddiverse clinical user base. Importing studies from apatient-supplied CD was also centralized, to ensure all studiesbecome a part of the permanent record managed by the VNA.This eliminated the need for radiologists to manage patient-supplied CDs and had a positive impact on radiologistproductivity.
White Paper | Vendor-Neutral Archives5“Consolidating pockets of disconnectedstorage helped the Winthrop-UniversityHospital balance institutional storageneeds, simplify creation andmanagement of a business continuitysolution, and better support facilitygrowth through redeployment of ITresources,” confirms Rick Perez,Administrative Director of Radiology atWinthrop-University Hospital.Their cloud-based approach now provides the hospital with aredundant offsite copy of all information stored in the VNA, inaddition to universal clinical access. IT has shifted focus tomanaging users instead of servers, improving clinicalinformation access and physician satisfaction. Hardwaredeployment no longer limits information access, as logincredentials and user class now define user capability andaccess. Winthrop-University Hospital leadership expects clinicalquality improvements to shorten length of stay and supportfuture Meaningful Use attestation. The strong relationshipbetween the IT and clinical departments will enable futuresuccess with these efforts and ensure that new technologiessupport improved clinical quality and customer service.Large Government Health Network EnablesEnterprise AccessThe geographic dispersion of national health networks favorscentralized systems with neutral-storage architectures. Patientsare often seen at different institutions, resulting in clinicalinformation and care teams being widely dispersed. In thesesituations, consolidating clinical information storage and accesscreates significant opportunities to improve clinician workflowand quality of care. This is the case with Assistance PubliqueHopitaux de Paris (AP-HP), a 47-hospital public health systemin Paris, France.AP-HP recently updated their 23 individual, multivendor PACSand consolidated storage of imaging studies into a unifiedsolution that uses global worklists to speed access. AP-HPimplemented a centralized, independent archive in theirprimary data center, storing 1.6M DICOM studies and reportsannually. This central database provides a registry for allradiology studies performed and enables subspecialty andcross-facility global worklist development, regardless of wherethe images originated. Imaging studies from all facilities areavailable to clinical users across the AP-HP system within10 seconds of being archived. Clinicians can view these imagesand reports via a zero-footprint viewer tied into the AP-HPcentral EMR.Dr. Daniel Reizine, AP-HP PACScoordinator and neuroradiologist atLariboisiere Hospital said, “By image-enabling our EMR access to clinicalinformation at the point of care,clinical decision making andphysician productivity have allbenefited. As more non-DICOM/non-image-based information is storedon the central archive, we believethese benefits will extend to otherclinical areas of the AP-HP system.”Large HMO Improves Patient Care ThroughConsolidated ArchitectureA patient-centric approach drove Clalit Heath Services in Israel,the world’s second largest Health Maintenance Organization,to implement a centralized storage architecture forstandardized enterprise-reading and clinical-viewing workflow.Eliminating repeat exams and enhanced productivity wereoriginal goals and have been achieved. Shared worklists and animage-enabled EMR provide 10,000 physicians, across 12hospitals and 40 imaging centers, access to 5M annualRadiology, Cardiology and Ophthalmology studies. Universalaccess to a complete patient record has also simplified theestablishment of clinical centers of excellence, providingoversight to Israel’s rural areas and speeding sequentialpathology follow-up of oncology patients. The Clalit centraldata center is also tied to a remote disaster recovery solution.Dr. Arnon Makori,Radiologist andDirector of ImagingInformatics at ClalitHealth Services, feels,“The only way toachieve increasedquality of care,centered on patientneeds, is to provideuniversal access toclinical informationand eliminate independent, site-specific workflows. If theworkflow is optimized, then everyone benefits: the patient,radiologist, specialty physicians and IT.”
White Paper | Vendor-Neutral Archives6Large Private Health Network Consolidates ClinicalViewing Across Disparate SystemsAs discussed earlier, IT storage consolidation and simplificationare enhanced when display resources are simultaneouslyoptimized. Spire Healthcare, a 37-hospital private healthcaresystem in the UK, has demonstrated that clinical viewingconsolidation can bring significant productivity and clinicalquality benefits – even if implemented prior to storageconsolidation. Spire Healthcare needed to enable theirclinicians to view patient images from any location, across amultivendor PACS environment, to satisfy physician andpatient needs. Spire implemented a zero-download clinicalviewer that leverages neutrality to enable viewing from mobileand stationary devices, across their multivendor PACSenvironment.Stephen Hayward, IT Directorat Spire Healthcare, points out,“We were aware of theimportance of unifying clinicalviewing to improve physicianproductivity and differentiateour services from those of ourcompetitors. We constantlylook at how we can usetechnology to provide a betterservice to both patients andphysicians.”The new unified clinical viewing approach enables radiologiststo discuss findings with offsite clinicians in real time, as bothparties can simultaneously view images. “Anywhere access”also enables radiologists to rapidly provide a preliminary reportfrom any location, providing clinicians a head start ontreatment options.As Andrew Milne, ImagingManager at SpireHartswood Hospital, pointsout, “The fact that thisworks across differentplatforms is a greatadvantage, as many of ourphysicians work at multiplesites. Our unified clinicalviewing solution enablesphysicians to accessneeded information fromany Spire hospital.”Strategic Planning Ensures SuccessIt is short-sighted to view a VNA purchase as merely anopportunity for IT hardware simplification or consolidation ofradiology images. This narrow view jeopardizes the enterpriseclinical workflow improvements that broadly benefit clinicalquality and physician productivity. As these examples haveillustrated, success is often driven by an enterprise imagingplan that reflects the organization’s overall needs – and notjust those of a single department. It is also reasonable toexpect that one or more of the following enterprise imagingchallenges can be addressed, even if primary drivers areimproved patient care, physician productivity and clinicalquality:• Unmanageable IT support costs because of the largenumber of disparate IT systems• Clinical users unable to get a unified view of patientclinical information across disparate systems• Poor system availability with inadequate businesscontinuity and disaster recovery• Slow data migration, often interrupting clinical serviceEnterprise imaging-technology assessment is clearly morecomplicated than assessment of departmental solutions. Duein part to a lack of common enterprise IT standards, butprimarily because of the integration of multiple systems, itremains critical to consider the entire spectrum of patient care.Understanding examples and speaking with those furtherdown the enterprise imaging path can identify needs andprovide guidance beyond the technical specifications of asingle component. This is particularly true because a VNAdecision impacts departmental PACS architectures andradiologist, clinical and IT staff workflow. For these reasons, itis also wise to plan implementation of these solutions inphases. With a plan in hand, plus clear goals and priorities,
White Paper | Vendor-Neutral Archiveswww.carestream.comCarestream Health, Inc., 2013. CARESTREAM is a trademark ofCarestream Health. CAT 300 1025 4/13a successful enterprise imaging-technology assessment canoccur. Because a VNA is only a single gear in an enterpriseworkflow machine, understanding the big picture is moreimportant than comparing the specifications of the overallsolution’s individual elements.Dictionary of Key TermsPIX – Patient Identifier Cross Referencing. An IHE standardmechanism for reconciling patient demographic informationacross disparate clinical systems.MPI – Master Patient Index. The ability to associate patientdata from different clinical systems that support differentpatient identification schemes.DICOM Tag Morphing – The ability to modify the DICOMheader (metadata) of an image to facilitate exchange across ITsystems with different DICOM conformance.XDS/XDS-I – Cross Enterprise Document Sharing for Imaging.An IHE standard profile that enables sharing of non-DICOM(i.e. JPEG images, scanned documents, text-based documents)information across disparate healthcare systems.Metadata – Refers to the DICOM header information thatdescribes the actual image (pixel) data (i.e. demographic data,study parameters).Pixeldata – Refers to the actual DICOM image pixel data thatconstitutes the medical image.