|Typical light traffic at the exhibition floor|
The May 28 -30 meeting of the Society for Imaging Informatics in Medicine (SIIM) held at NationalHarbor in Baltimore (just south of DC), was well attended. It seems the decline in attendance has stabilized and there were, what I estimated to be, between 500 and 700 attendees. This is the only PACS meeting in the US and it is a good opportunity to network and find out what is new. I attended all three days, however, I had a difficult time finding any new developments, technologies and/or products. Much of what was talked about was either said or published before. Anyway, here are some of the questions that came up during the meeting:
1. Is PACS dead? The opening session by Donald Dennison, one of the SIIM directors, was a rehash of his article in the SIIM publication Journal of Digital Imaging called “PACS 2018, an autopsy.” It was actually the journal’s most down-loaded article last year, which might be more due to the controversial title aimed at scaring PACS professionals, than any new information it shed on the future of PACS. Yes there will be VNA’s that provide access to physicians and yes there will be image enabled EMR’s, but these are just replacing the clumsy non-patient centric physician viewing capabilities that have been part of PACS for many years. It does not mean that the advent of the VNA’s and EMR’s that we are ready to perform an autopsy on a dead PACS. I also thought it interesting that the keynote speech of a PACS conference talks about the “death of PACS,” I surely hope that is not the case.
2. When are people going to understand what a VNA is all about? VNA’s are still touted as the next greatest thing, especially by vendors. What is missing is an honest discussion about the issues with early implementations and experiences. One of the major issues with using a VNA is that if you have to maintain yet another place where images are being managed and archived, you better make sure that the information is synchronized. For example, if you delete an image at the PACS, it should be automatically deleted at the VNA without manual intervention. There is a standard for that defined as an IHE profile, called IOCM (Imaging Object Change Management), which has not been widely implemented (yet). Second, it has become clear that DICOM metadata is not sufficient to manage the images at an enterprise level, additional information is needed as defined by the XDS profile, but storing that information in the VNA image database defeats the purpose of having a VNA to start with as it is again yet another proprietary database implementation that requires knowledge of the database tables to get that information out. Lastly, there is a lot of talk about VNA access by viewers using open standards, but I have found only one US institution so far that really implements XDS-I image access to do this. So, it appears that even though VNAs are sold as the greatest thing since sliced bread, there are still many issues to solve.
3. What is a MERR? I heard a new term, called the Multimedia Enhanced Radiology Report or MERR. What I understood is that it is basically a report with pictures and graphs. I could not really figure out what the novelty is, as mammography reporting has done this for many years and measurements such as from ultrasound are already captured through DICOM Structured Reports and represented accordingly. Sounds like a marketing ploy to me.
4. What about non-DICOM data? The fact that most VNA’s are advertising that they can manage non-DICOM objects seems to make for a free-for-all for storage of all types of objects, especially from the non-radiology specialties, which was referred to as the “LTFFT” or “Left To Fend For Themselves” objects. Yes, these objects are in many cases “orphans,” as they are often stored and managed locally. And there are many of these still to be discovered image sources ranging from medical photos, to pathology, to video’s that are taken to monitor gait for orthopedic patients and many more. However, I have yet to find an object and/or encoding that cannot be encapsulated into a DICOM format, including MPEG video’s, PDF documents, and even waveforms. Therefore, as suggested several times, to store these objects using new formats such as MPEG7, which is yet another encapsulation of a MPEG4 file, should be strongly discouraged.
5. What about non-radiology imaging that is DICOM? There is a wide proliferation of POC (point of care) devices that create images. At Duke medical center, a survey showed that only 19% of all ultrasound exams are performed in radiology, meaning 81% are created elsewhere ranging from OB/GYN’ office, to the OR, the ER, labor and delivery, and specialty clinics, etc. The challenge is, how to capture all these images in a useful way in the electronic health record so they can be available to practitioners outside these departments. It appeared that only 45% of these ultrasound devices support DICOM and therefore have a way to export the data in a standard manner, of which only 75% have DICOM worklist capability to allow for patient demographic and order capture at the device. This is going to be a challenge, requiring device upgrades and user education to make sure the information is captured.
6. How do we implement mobile technologies? The installed base of healthcare information and imaging devices use predominantly DICOM and HL7 for their communication between the different devices. Neither one of these standards lend themselves well to access over the web such as used by mobile devices, therefore we need the new “web-services” version for both standards. These are called DICOMweb and HL7 FHIR. The good news is that these web services are relatively easy to implement – there was actually a hackathon as part of the conference for the true geeks to show how easy an application can be developed using these tools. The SIIM presentation about these new services is exactly the type of information that PACS professionals want to learn about. Too bad that there were so few of these and that the next level of integration using these services, i.e. by using the appropriate IHE profiles, was not discussed at all.
7. What is XDS anyway? XDS is yet another buzz-word, meaning the IHE profile to provide Cross Enterprise Document Sharing, which was used in the context of VNA and PACS as well as EMR integration, however, I am convinced that very few actually understand the details of this and that stating “XDS support” is as useless as stating that a system supports “DICOM” or “HL7.” One needs to be very specific about which actor one supports, i.e. does a device create documents or images (acts as a “source”), is it a repository, registry, or consumer and what about the patient identity feeds, where are they generated? To understand the workflow and identify any gaps or overlap, it is strongly recommended that you create a diagram with all of the IHE actors in your system. This might be a good exercise for next SIIM meeting, which was dearly lacking content on IHE anyway.
8. When will DICOM finally become plug-and play? After all these years (DICOM was introduced in 1993), it amazes me that there are still Issues with DICOM connectivity. One speaker said that his institution cannot pull back images from a PACS at the ultrasound for contrast processing. The solution is a simple matter of configuring the devices to do a query from the PACS and the PACS initiating an association back to the modality to store the images. Sounds simple, and it is, however, apparently it is not, I expect due to a lack of training and understanding resulting in finger pointing between the vendors. Amazing but true.
9. Is it show time for mammography tomosynthesis yet? This new modality which produces a set of 20-30 image slices of the breast instead of, or in addition to, the traditional 2-view image is poised to be introduced in many facilities because of marketing pressure caused by supposedly better outcomes when using this for routine breast screening. Based on comments from the audience during the special session about this topic, it was clear that there are still growing pains. One attendee reported that the reading takes 20 times (!) longer than when using conventional mammography screening, another attendee had major problems with the hanging protocols, obviously unaware of the IHE profile that explicitly addresses these issues. Somewhat scary based on the number of attendees that were planning to install this modality in the upcoming year that there are still many technical issues to be resolved, including required bandwidth and storage capacity.
10. What to do if the PACS is down? Many institutions are relying on cloud solutions for a backup. The increasing use of DICOMWeb making images available on mobile devices in an easy manner from the cloud now provides a backup solution because practitioners can access images from their PCs, and increasingly their tablets. Mobile access is evolving as another good solution complementing a redundancy and backup strategy.
So, yet another PACS meeting, with, as I mentioned, not much new; in my opinion it was light on technical content, but not poorly attended so I guess it has its niche audience. The location (National Harbor) was kind of a bummer, so close to Washington DC and yet too far to easily get to the city unless you want to take a taxi. Next year is going to be in Portland, OR, kind of far out in the northwest corner of the US. I’ll probably attend, hopefully there will be more to learn by that time.