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Interoperability headaches eased by VNAs?

By Jerry Zeidenberg

CHICAGO – Solutions for interoperability are hot commodities these days, and the market for Vendor Neutral Archives, which can house and interchange all manner of healthcare information, is growing by leaps and bounds. It’s estimated that sales of VNAs are growing by double digits each year, compared with single digit growth for traditional Picture Archiving and Communication Systems.

Hospitals and health regions have found their PACS often have a hard time exchanging images with systems provided by other vendors; moreover, most PACS do not easily accommodate data from electronic health record systems and other sources.

The latest Radiological Society of North America conference, held in Chicago last December, was a showcase for a variety of leading-edge VNAs. The booths of these vendors were buzzing with healthcare managers seeking solutions to their interoperability headaches.

Let’s face it, getting different databases and archives to easily communicate is no easy task – despite the pronouncements of vendors, who often assert that interoperability is a mere technical problem. Unfortunately, it’s a problem they either haven’t been able to solve or one they don’t want to.

The conundrum is so irritating that Quebec health minister Gaetan Barrette recently told the press that he’d like to rip out all of the electronic health records in the province and start over again. The only thing stopping him is that it would cost $1 billion or more, and the province doesn’t have the money.

Moreover, Alberta just struck up a task force to look at ways of getting the myriad of EMRs in the province to talk to each other. During recent discussions on the issue, Alberta College of Physicians and Surgeons registrar Dr. Trevor Theman called the current electronic system “a failure”.

Things aren’t all that bleak, however, and it appears that provinces, health regions and hospitals need not rip and replace their systems. New approaches to interoperability of computerized healthcare systems have appeared, using VNAs, and progress is being made.

Indeed, the whole state of Colorado and its 200 hospitals have produced a solution to share information. The system was created in conjunction with Perceptive Software, which has pioneered methods of consolidating incompatible data into a single archive, making it usable to all kinds of clinicians and administrators and their various computer systems.

“We’ve also got the whole country of Wales using the solution, and the Sussex region of the U.K. has started to roll it out,” commented Larry Sitka, principal solution architect at Perceptive Software, a company now owned by Lexmark.

Sitka, who was the founder of Acuo, an image management company that was acquired by Perceptive Software, explained the solution makes use of a ‘vendor neutral archive’, meaning it migrates all data from the various repositories used by clinicians and wraps it in codes, such as DICOM, that can be read and manipulated by viewers on any computer.

Vendor neutral archives originally referred to picture imaging archives, and emerged out of the radiology world – which produces massive stores of X-rays, CTs, MRIs, ultrasounds and other types of pictures. These diagnostic images resided in the original generation PACS, but too often, the images stored in the PACS of one vendor couldn’t be shared with the PACS of another vendor.

Add to that the challenge of accessing cardiology images from separate archives, along with non-DICOM images from endoscopy, pathology, dermatology, ophthalmology and numerous other disciplines, and the incompatibility problem is truly daunting.

To date, the strategy has been to build silos of separate images and data. However, that too is problematic.

“Maintaining these separate archives, which all do the same thing, is expensive,” commented Heidi Brown, an account executive with Perceptive Software Canada. Far better, and more cost-effective, she observed, is a strategy of keeping the images in a single archive.

VNA developers do this by migrating the images to a central archive. Before archiving, metadata is attached to each picture or ‘object’, so all of them can be indexed, searched and quickly retrieved.

For its part, Perceptive Software has added access to electronic health records to the mix, enabling clinicians to access various types of text and numerical data along with images. That means doctors and health professionals can access lab reports, medication histories, vital signs and other data, along with medical images.

“The electronic medical record, and radiology information systems (RIS), are now driving workflow,” said Sitka, noting that healthcare professionals want quick access to a wide variety of images and documents.

Demand for interoperability has spawned new and successful companies – Mach7, based in Burlington, Vermont, was launched in 2007 and now has over 45 customers using its VNA, including Massachusetts General Hospital, as well as hospitals in Saudi Arabia and other parts of the Middle East, Asia and Europe.

The company has succeeded, as it helps users standardize the components of archives – the images and data, worklists and viewers. “No custom coding is required, it’s all in the building blocks that we supply,” said Eric Rice, chief technology officer. “We neutralize everything.”

Theoretically, the traditional producers of PACS and EMRs should be able to easily interconnect their systems, as most have agreed to standard ways of exchanging data – such as HL7, XDS and the various IHE profiles.

In reality, there are many different ways of conforming to ‘standards’, and often enough, one vendor’s use of a standard doesn’t mesh with the way another vendor makes use of it.

“If everyone followed the standards [in the same way], no one would need VNAs,” commented Jim Prekop, president and CEO of Milwaukee-based TeraMedica, one of the largest and most successful providers of Vendor Neutral Archives.

Prekop mentioned that his company recently completed a project in the Australian state of New South Wales, in which the diagnostic images of 200 facilities were merged into a VNA. “Now each of them can access any study taken at any of the sites,” said Prekop. “And the studies all appear in the same format. If you call up a study from another hospital, it looks like it was taken at your own facility.”

For its part, TeraMedica emerged from the need at the Mayo Clinic, in Minnesota, to more readily access the medical images from different archives. TeraMedica was created to find a solution.

“At Mayo, we’re now managing 2 billion objects, from 15 to 20 clinical systems,” said Prekop. “And we’re contributing to better care.”

He noted the TeraMedica system serves a variety of users, including radiologists, cardiologists, surgeons and oncologists. All of them can obtain images generated by other departments, but they will appear in their viewer of choice, in the way they prefer. “If you are used to using a Terarecon viewer, your images will pop up in Terarecon. If you like using Vital Images or the GE viewer, the images will appear in Vital Images or GE,” said Prekop.

Prekop said TeraMedica’s technology is widely used in oncology around the world, and is currently deployed at the Princess Margaret Hospital, in Toronto, the largest cancer treatment centre in Canada. “They have a lot of outside data sets, from six or seven different systems, that need to be ingested,” he said.

TeraMedica is currently in talks to help integrate data at other imaging repositories across Canada, said Prekop.

At a press luncheon at the RSNA meeting, Agfa HealthCare highlighted the work it is doing with its own VNA solution at the Cleveland Clinic. Agfa announced that it has converged its successful Impax PACS with its enterprise information system, and is now offering only the one, enterprise solution. However, customers can acquire the components they need, as they need them.

Dr. Cheryl Petersilge, vice chair of regional radiology at the Cleveland Clinic, and medical director of the famous hospital’s integration project, described how “we’ve been driving toward a single archive for medical imaging.”

She added that the imaging archive is being integrated with the Epic hospital information system, so that “all information is accessible through the EMR.”

Cleveland Clinic has been adding images from various departments to the central archive, including radiology, surgery, ophthalmology and women’s health.

She noted there has also been an explosion in the use of jpg images, taken by doctors across the enterprise. In most hospitals, these photos are left unarchived, and can easily be lost.

“The iPhone is becoming a very important medical tool, whether we like it or not,” said Dr. Petersilge. “Doctors are taking and transferring a lot of pictures … we never guessed they produced so many.”

For example, in family practice and pediatrics, physicians are taking photos of rashes, to send to dermatologists. Surgeons are also taking jpgs to document various conditions in their patients, as are geriatricians and social workers.

To ensure these photos are captured and archived, so they can be viewed by other clinicians, Cleveland Clinic is about to start encoding them. “There’s great value in indexing photos,” said Dr. Petersilge, explaining that when they’re simply attached to a file in a department, they’re only of use to a few clinicians and can be very difficult to find when needed. On the other hand, when they’re archived, and associated with a patient, they can be easily accessed.

To start, the Cleveland Clinic will have a person in participating departments start indexing photos. “Photos will be DICOMized, and we’ll wrap every object in DICOM,” said Lou Lannum, director of enterprise imaging.

In time, said Dr. Petersilge, there will likely be a central indexing department. “Later, the process may even be automated,” she said.

(For its part, Perceptive Software just released an app that works on smartphones and automates the tagging of photos with the appropriate patient information. Devised by PACSgear, a company recently acquired by Perceptive, the solution was demonstrated at the Perceptive booth.)

Interestingly, Cleveland Clinic hasn’t yet added its renowned cardiology department to the central VNA. “They already have an established workflow, and their images aren’t lost,” said Dr. Petersilge. “There are many other departments that are generating images and losing them – they are our priority.”

She observed that in addition to jpg photos, there has also been a jump in the number of ultrasound images being generated. “Point-of-care ultrasound is everywhere now,” she said. “It has migrated from the radiology department to physician offices.” The Cleveland Clinic has a push on to ensure more of these images are captured and archived, too, so they can be easily found and shared.

For its part, McKesson has for a long time emphasized its strength as an enterprise-wide supplier, and it also produces a Vendor Neutral Archive. “We do PACS for the entire island of Ireland,” commented Bob Baumgartner, director of product marketing. He noted the company also produces workflow solutions, through its QICS engine, which is integrated with its enterprise system.

For example, the workflow engine can re-direct studies from an overloaded radiologist to others who are less burdened, to ensure that readings are done in a timely way. Peer review can also be integrated in the process.

Baumgartner noted that Island Health, in British Columbia, is rolling out the peer review component throughout the health authority.

While McKesson does have a central repository or VNA solution, Baumgartner observed that for many hospitals, it’s too expensive to immediately start migrating studies from a network of PACS. Using the McKesson solution, they can keep their various PACS and view studies, from different archives, through the McKesson viewer – as long as the PACS solutions are web enabled.

“This saves you from doing the migration until you’re ready,” said Baumgartner.

For its part, Chicago-based Merge Healthcare calls itself the top VNA vendor, in terms of revenues. It cites a recent IHS study which reported that Merge’s iConnect Enterprise Archive accounted for a 13 percent share of the market in 2013.

Merge is one of the granddaddys of the business, having acquired VNA technologies through its acquisition of Amicas, which itself had bought Emageon, a leader in enterprise imaging solutions.

“We have installs where there hasn’t been a second of downtime in eight years,” asserted Atul Agarwal, chief technology officer for Merge Technologies.

Agarwal, who is based in at Merge’s offices in Mississauga, Ont., observed that Merge VNA technology is used to consolidate some of the largest archives in the world, such as the Dignity Health system in the United States. “We’re used in archives with more than a billion objects,” said Agarwal. At the same time, the iConnect system is also used in relatively small, specialty clinics.

“It’s can be scaled down for use in single facility systems, such as orthopedic clinics,” said Agarwal. “These clinics are producing 50,000 studies a year, but they also want access to surgery plans and templates, which are often in the form of pdfs.” These and other documents are all housed in the central archive for quick access on the same workstations.

John Memarian, general manager of emerging markets at Merge HealthCare, noted the company in the last few years has launched a number of ‘do-it-yourself’ modules that give hospitals and regions more control over their own information. Once they’re trained by Merge, they can handle tasks such as migrations and setting policies and rules for workflow.

He said that in 2015, the company will be launching an awareness campaign in Canada for its VNA and other products, so that its brand is better known here. He pointed out that Merge technologies are used by many vendors in their own offerings, but Merge is now making a bigger push to become known as a brand name in its own right.

Like Merge, Carestream Health is one of the major global suppliers of Vendor Neutral Archives, and the company announced an innovation at the RSNA meeting in the form of a solution called the Clinical Collaboration Platform.

The system archives DICOM and non-DICOM images, offers a quick method of tagging non-DICOM images with metadata, and is said to offer a single view of patient information. It also serves as a telehealth platform, tying in remote specialists who can easily view a patient’s images and clinical information from afar.

Carestream is highlighting secure patient access to their own records, including images, something that’s a major issue in the United States, as patient satisfaction with care is being tied to funding and remuneration. In future, patient access to medical records may also become more important in Canada.

Interestingly, Vendor Neutral Archives aren’t only being used at the regional or provincial levels. Hospitals are the main customers, at the moment, as they’re having difficulties integrating images and data among their own departments.

“Seventy-five percent of our discussions about VNAs have been at the hospital level,” commented Lisa Shoniker, national sales director at Agfa HealthCare Canada.

Hospitals are also interested in the workflow improvements that can be gained through the use of enterprise-wide solutions. “You want systems that can give you more information,” said James Jay, global VP for imaging IT at Agfa HealthCare. “You want access to images from different departments, but you also want to see more information that’s associated with those images – like the diagnosis, the care plan and treatment, the whole clinical context.” It’s the more powerful VNAs that can deliver these capabilities as they’re solving integration problems, said Jay.

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