The Guide to VNA (Part 2)
It’s Time to UnPAC Your Archives (Part 2)
Four Pillars of Enterprise Image Management: What You Need to Know About VNAs to UnPAC Your Archives and Control Your Imaging Data
Unlock. Unleash. UnPAC.
Next-generation enterprise imaging management solutions have given PACS owners a direct path to imaging management “freedom.” Gone are the days of proprietary storage architectures and “locked” patient data archives. Vendor neutral, architecture neutral solutions have arrived in healthcare and it’s time to unlock, unleash, and unPAC your archives.
The ability to finally “unPAC” imaging archives has ushered in the growth of the VNA market, projected to top $1 billion by 2018 and possibly eclipse PACS market share by 2020. Enterprise Image Management solutions are already unlocking disparate PACS archive silos, consolidating patient data, and simplifying sharing and access across the enterprise. Healthcare teams are building a comprehensive view of the patient electronic care record. They have “plug and play” access to best-of-breed specialty visualization solutions. They can resolve proprietary storage formats enabling standards-based storage and interoperability. And, all of these advances are making it possible to accelerate care delivery, centralize access, and lower IT costs across the enterprise.
These four pillars will help you identify an Enterprise Imaging Platform and solution that will help you unPAC your archives and finally take control of your enterprise imaging data.
Know a real VNA when you see one.
There are multiple definitions of a vendor neutral archive and lots of solutions that claim neutrality from the archive to the viewer. We’ll discuss what you should look for, and be aware of, as you begin to evaluate VNA solutions. The first place to start is with the archive. Let’s breakdown the VNA into its core components, so that you’ll know one when you see one.
Start with “A” – The Archive
What’s the simplest definition of an archive? An archive is a collection of documents or records providing information about a place, person, or group of people. Archives are added to, shared, maintained, and managed for the value of the target audience. As with any archive (medical or otherwise), the value of the archive itself is largely measured by the accuracy of the information contained within it and how easily that content can be accessed, updated, added to, and extracted from the archive.
A medical imaging archive is conceptually the same, representing a collection of patient study data that has both historical and current relevance. To achieve its maximum value, the archive must be kept up to date (maintained) and have a way to efficiently add, access, and share information in a medically meaningful way. A Vendor Neutral Archive (VNA) is a medical image management technology that is based solely on industry standards and contains at least the following key components:
- A storage sub-system,
- Interface(s) to applications that support the normalization, storage, retrieval, routing, sharing, and maintenance of images and associated documents in a “clinically useful, meaningful and secure” fashion1, and
- A database that manages and knows where, what, when, how, and who stored and accessed images and associated documents, regardless of file format.
The phrases “solely on industry standards” and “clinically useful, meaningful and secure” are key. These are the primary characteristics that make this set of components a vendor neutral medical image archive and distinguish it from archives of employee files, financial data, inventory data, etc.
Applications must be able to intelligently access, analyze, and share this data in clinically relevant ways, efficiently and effectively, often through specialty workflows and complex worklist protocols. This is what presents the greatest challenge to healthcare IT teams and clinicians when managing medical imaging data.
Archive vs. Storage vs. Database
These three words are similar but have distinctly different meanings when evaluating VNAs. An image archive is not simply “storage space” for images. An archive is a technology solution comprised of storage management software, physical storage, database content management, and communication technologies. These components are optimized to intelligently import (ingest), export (route), and manage the integrity of imaging media.
Archives without boundaries – scalability counts
Management of imaging data archives must be scalable to the full (and expanding) enterprise. Image consolidation at the enterprise level is a key consideration for VNAs. Images from all departments must be stored regardless of source (modality), file format, study size, or specialized viewer requirements. DICOM and non-DICOM files and media, patient histories, annotations, etc. for current and prior exams must be included in the archive.
A word on file formats and native format image file storage
Diagnostic image data is stored in one of two formats, DICOM or non-DICOM. DICOM, Digital Imaging and Communications in Medicine, is a standard for handling, storing, printing, and transmitting information in medical imaging.2 The majority of diagnostic medical imaging systems are based on the DICOM standard and produce images in DICOM-conformant formats (e.g., radiology and cardiology departments).
There are also a number of medical image data sources (modalities) that produce non-DICOM data objects. In some cases these objects are images (e.g., a photograph of a mole) and in some case these objects are clinical information associated with the images or studies (e.g., study annotations). Non-DICOM file types include AVI, PDF, JPEG, MPEG, TIFF, and WAV file formats. Non-DICOM image objects present a dilemma for first-generation PACS whose archives, viewers, and interfaces are based on the DICOM standard.
Native vs. non-native file formats
In the wake of the rise in VNA adoption, the discussion of how to store image files and whether to store them in their native format has drawn a lot of attention. Recalling one of the major limitations of PACS—their “lock” of images stored in their archive—that lock is largely the result of proprietary file compression algorithms and the use of non-standard presentation states including annotations. When the image file source (modality) sends the native (original) image to a PACS archive, images are often compressed and altered through proprietary algorithms. These proprietary algorithms create a non-native format that can only be fully restored using that specific vendor’s technology. They cannot be easily extracted, viewed or migrated to another archive “intact.” Borrowing a line from the song “Hotel California,” with a PACS archive, you can “check out anytime you want, but you can never leave.”3 As PACS administrators have learned, ownership of the data is an issue. PACS migrations (leaving the archive) are notoriously difficult, time-consuming, and expensive. In effect, once ingested, PACS data may never really be able to effectively “leave” the archive.
Healthcare organizations find themselves held hostage to their PACS vendors and formats. This data “locking” challenges the adoption of enhanced technology that improves patient care, challenges referring physician and patient access, and inhibits sharing across traditional enterprise boundaries.
Non-DICOM images present more issues for PACS users. To create a complete view of the patient, images from non-DICOM sources must be managed, accessed, and shared as part of a complete enterprise imaging management solution. VNAs have addressed the “non-DICOM dilemma” allowing both file formats to be managed within the same VNA. Most advanced VNA solutions allow non-DICOM media to be left in its native format. These files are natively optimized and do not require “rehydration” to be accessed and shared. Optionally, non-DICOM media can be “wrapped” in DICOM for easier integration with applications that may require files to contain DICOM header information for access and sharing. But let’s not repeat history and forget the challenges of non-native formats. It may be okay to wrap a PDF formatted EKG in DICOM to be viewed in a traditional cardiology PACS, but if it is a JPEG image from a dermatology modality, why change it? If endoscopy modalities require an AVI formatted movie file, an advanced VNA should be capable of supporting the storage, access, and sharing of this and many other native file formats.
Image consolidation and support of information exchanges – The “Napster™” or “iTunes™” approach
As enterprises grow, whether organically or through acquisition, access to complete, consolidated, and normalized patient data is paramount. Data acquisition and normalization is often a major challenge for IT teams. Make certain that your archive supports the ability to digest, or source images from third-party archives, CDs, DVDs, and mobile sources. Some hospital systems report that greater than 50% of the imaging files they manage come from sources outside of their network.
A consolidated VNA could contain the actual study stored “locally” (the iTunes™ model), or it could contain the study’s “address” (the Napster™ model) on a remote system. The most technologically advanced VNAs allow for both models and also allow non-resident studies to be imported from exchanges or networked locations should the clinical workflow require a secure transfer of the study to the local archive.
Image file compression algorithms – what to watch out for
Compression can be good. Managing data within what is known as a “lossless” state can be valid for use in diagnosis; storage consumption, network bandwidth requirements, power, and A/C may be reduced by up to 40%. A lossless state is a compression state that allows the original data to be perfectly reconstructed from the compressed data. This can reduce costs and improve overall system throughput and user satisfaction.
But be cautious. Traditional PACS solutions often require compressed files to be “rehydrated” before being accessed or shared. By storing files in their native file format (e.g., the image file “example.jpg” is natively optimized and stored as “example.jpg”), and using open, standards-based approaches to compression, rehydration may not be required.
Key Takeaway: Proprietary compression and “rehydration” algorithms used by PACS vendors can significantly limit file access and sharing and can corrupt image files by stripping away key study annotations and supporting information. Once ingested, images cannot be reconstituted to contain the same data they had when they entered the archive. Presentation state and annotations add value and context to imaging files and are a valuable source of patient data intelligence—but are lost in PACS archives.
Key Takeaway: The “A,” or Archive, of the VNA is a central component of the full VNA solution set. Don’t confuse proprietary, siloed PACS archives or standalone, unconsolidated systems common in first-generation imaging tools, with the power of a standards-based solution. A VNA is much more than a database or storage device; it is the underlying foundation of a robust technology solution.
It’s all about the “N”.
Neutrality – How to know for sure that you’re in the “Neutral Zone”
In the automotive industry “neutral” may mean standing still. But in the world of healthcare image management, neutral is exactly where you want your platform to be and you’ll have all the power needed to execute on your enterprise imaging strategy.
Most analysts now agree that the future of image storage will depend upon some type of neutrality. Vendors who offer first-generation PACS perhaps see the proverbial “writing on the wall” and have introduced the concept of “Enterprise PACS” options. Rather than a VNA architecture that seamlessly migrates and communicates data between PACS/visualization solutions, Enterprise PACS providers supply their own, often proprietary, archive option while maintaining their current PACS. This is also known as a “PACS-centric Archive” option. According to Paul Chang, MD, radiology professor and vice chair of radiology informatics at the University of Chicago, the PACS enterprise imaging strategy has emerged because PACS manufacturers want to retain their market share.4 Other vendors offer “VNAs” for every specialty department. These specialty-specific archives simply recreate siloed neutral archives in each department. Beware of siloed archives that claim neutrality but cannot be consolidated and normalized across the enterprise. A department-specific, standalone archive that is “neutral” is still a silo.
To achieve true neutrality, a VNA should allow interoperability between visualization solutions, including traditional PACS and universal enterprise viewers. From communicating with outside imaging sources to suffixing order numbers and translating patient medical record numbers, to removing proprietary and conflicting metadata attributes, to normalizing dictionary data for proper ingestion and function with PACS hanging protocols, VNA solutions should provide truly neutral communication. This neutral communication should allow enterprise users and specialists to select the visualization solution that best meets their specific requirements.
Green Takeaway: VNA solutions did not “evolve” from first-generation PACS solutions. This simple statement may help differentiate first-generation image archiving solutions from technologically advanced, next-generation VNA solutions. Neutrality of imaging archive solutions and the ability to consolidate image data into a common archive, regardless of the data’s originating department, modality, format, or physical location, is a unique and forward-thinking architecture specific to VNAs. Understand the difference between VNA and Enterprise PACS solutions and make certain that the solution you choose will scale with your growth plan and won’t take you down the proprietary “lock down” path of first-generation PACS.
The “C and W” in VNA.
Getting the right images to the right location at the right time is all about Communication & Workflow
Efficiently and accurately communicating the right data to the right location at the right time is critically important in any enterprise imaging solution. Early VNAs were born out of necessity, filling archival “gaps” created by the need for disaster recovery and silos of unconsolidated patient data archives.
In the early 2000s, radiologists partnered with IT visionaries to tackle the problem of first-generation archives (PACS) that could no longer address growing study sizes and complexities. These radiologists envisioned a “Super DICOM” archive that could store images enterprise-wide, regardless of the originating department’s modality. This Super Archive would be vendor agnostic allowing the technology to chart a course toward greater reliability and scalability. A standards-based image archive, when separated from the proprietary, and often constraint-driven wrapper of the vendor-specific workflow and viewing tools, delivered what had been lost.
Blue Takeaway: Clinical workflows enable users to store, route, and synchronize image and patient data across the enterprise. Healthcare organizations must manage patient information and images from remote locations, referring and networked hospitals, imaging centers, and non-local practice locations. These shared incoming and outgoing images must be uploaded (e.g. loaded from CDs and DVDs), routed, and synchronized with the correct patient records to create the complete care record required for real-time patient diagnosis and management. A VNA’s sophisticated image management and communication engine fetches patient data, expertly routes the data based on defined clinical workflows, verifies and manages patient identity tags, and consolidates the patient record allowing for rapid clinical diagnosis.
Blue Takeaway: Unleash the diagnostic intelligence locked in your proprietary PACS system with advanced clinical workflows. Advanced communication and workflows define the pathways through which patient data is collected, aggregated, synchronized, and displayed. These intricate and specialized “instructions” define, by specialty, the data set and flow of information that is most relevant for consultation, evaluation, and diagnosis. These workflows and pathways improve a clinician’s view of the data and help them derive intelligence from otherwise static datasets. This level of decision support drives actions that improve overall patient care.
The “V” in VNA is about more than the Vendor.
Make sure you have a great “View”er
Seeing is a lot more than believing in enterprise image archiving. Visualization and interpretation of images is the cornerstone of imaging. Data storage, access, sharing, and management are central components of an archiving system, but the entire solution has to deliver studies that can be successfully and accurately viewed. We are all here to improve patient care.
First-generation PACS have done a good job of advancing visualization tools, but at the expense and requirement of proprietary formats and image streaming algorithms. Because of this, PACS vendors created a complex and often cumbersome image viewing paradigm. In multi-PACS environments (remember, there is a PACS for every ‘ology’), physicians often don’t know which viewer to open to interpret their patients’ images. Think about imaging and health systems that read for and support multiple hospital systems with multiple PACS. These clinicians may need to learn dozens of user interfaces.
While VNAs are unlocking your images, they are also unlocking your image viewing. The “V” in VNA could also stand for Viewer Neutral Archive because VNAs allow total freedom to “plug and play” best-of-breed image viewers. Clinicians are free to step away from “swivel chair” scan reading and clear their desks of a myriad of PACS viewer systems that have clogged and clouded image interpretation. While a VNA “unPACS” your archive, it “unPlugs” a sea of disparate viewers and allows advanced visualization with the viewer of your choice.
What is a universal viewer?
A universal viewer (a.k.a., enterprise viewer, univiewer, archive-neutral viewer), is an optimal viewer that is fast and clinically adept, providing a single desktop for radiologists and referring physicians. It enables institutions to stop using dozens of disparate viewers and instead consolidates image interpretation and referring physician viewing with a single viewer for nearly all clinical needs.5
Just as a VNA allows for consolidation of disparate archives created by PACS, a VNA’s universal viewer allows for consolidation of disparate and siloed clinical viewers. Today’s advanced universal viewers are “zero-footprint” viewers which means there is no separate viewing workstation. These viewers are web-based and enable image viewing on your HIS, EMR, physician portal, patient portal, and mobile device. Advanced VNA viewers enable universal access and sharing of active and archived images over the web regardless of the media format (DICOM and non-DICOM). Integrate, train, and deploy a single viewing solution across a user community leveraging numerous platforms and devices.
Here are the key features to look for in a universal viewer:
- Zero Footprint – Requiring only a modern web browser, enable access to medical imaging data through zero client side installations (not even a Flash browser plug-in) and with zero clinical data downloaded to the client, protecting health information.
- Universal Access – Provide access to both DICOM and non-DICOM media through a single viewing interface that functions consistently across workstation, personal computer, and mobile device platforms. Simplify training and roll out. Simplify integration to EHRs. Build on a solution that enables universal access, protects health information, and lowers IT costs.
- Functionally Rich – Provide patients and physicians with a feature-rich interface designed to be simple. Remove complexities and challenges with user adoption while still providing the tools required for effective reviews and treatment planning.
- Simplified Integration – Integrate clinical viewing through standard web protocols.
- Secure Access – Securely view images through the latest encrypted web protocols and role-based directory authentication services.
Orange Takeaway: VNAs also offer viewer neutrality and finally allow unPACing of the archive and unPlugging of a desktop full of PACS viewers. In addition to archive consolidation, VNAs allow consolidation of your clinical viewers; reducing costs, increasing efficiency, and allowing interpreting physicians greater flexibility to choose the best viewer available for interpretation and referring physician access. Zero-footprint viewers also support mobile access to images.
Start unPACing – Now is the time
Smart healthcare leaders know they cannot afford to leave medical imaging management on the sidelines. Advances in image archiving architectures and best-of-breed solutions have freed users from “locked” first-generation PACS archives and have ushered in an imaging renaissance.
Advanced enterprise imaging management platforms offer the freedom to consolidate disparate, siloed databases, filled with imaging data, and unleash the intelligence that those archives can offer. By bringing together best-of-breed image management solutions and scaling those solutions across departments, the enterprise, and the region, healthcare organizations can finally get a clear and complete view of a patient’s electronic health record and be assured that patient information can be securely and compliantly shared where and when it is needed.
VNAs eliminate the need to maintain disparate, department-specific silos of patient information; reducing capital investment, IT resource requirements, and IT management time. More than two-thirds of healthcare enterprise IT budgets are solely devoted to maintaining existing infrastructure. Advanced VNAs support industry standards, including IHE (Integrating the Healthcare Enterprise) standards and XDS/XDS-I. This allows data sharing workflows across clinical data repositories and data types, such as DICOM and non-DICOM.
Finally, VNAs allow IT organizations to deliver operational improvement, scalability, reliability, and redundancy at lower costs while improving security and insuring compliance. Improved communication and workflows insure that imaging data is delivered in a fashion and timeframe that improves efficiency, provides analytics and decision support, and helps reading physicians deliver greater value.
From all corners of the industry the call for neutrality is loud and clear. It is time to break down the boundaries of first-generation PACS and redefine data archiving and communication with powerful imaging platforms that allow your patient data to flow effortlessly between clinicians, departments, and facilities. Unlock your archives and unleash the vast potential of your imaging data to improve patient care, revenues, compliance, and physician satisfaction across the enterprise.
- Music by The Eagles for album titled “Hotel California,” released by Asylum Records, 1977. Lyrics by Don Felder, Don Henley, and Glenn Frey.
- Brad Levin, AuntMinnie.com contributing writer; The time is now for deconstructed PACS, 03/31/14