Sunday, May 1, 2011

Tips from a Road Warrior (11): Have a Backup for your Back-up Plan

The recent actions in Pakistan brought back memories of the 9/11 events when I was literally a mile away from the Pentagon. I was on the 11th floor at a DICOM working group meeting with a clear view of most of the city and could clearly see what was going on. I saw first hand the confusion, smoke, and semi-panic in Washington DC on that early morning. The first reaction of course was to call home, as I knew they would be trying to find out if I was safe. Of course, cell phones did not work as the circuits were over-loaded. It took me about an hour to realize that the landline might work so I went back to my hotel and made my calls to my family from there. 

The second challenge was to get back to Dallas from DC before the weekend. I thought, no problem, we also have trains don't we? I could not get through to Amtrak and decided to walk to the main station. Well, I found out that there were trains, if I was willing to be on the stand-by list for up to three weeks from that date. That left me with no other option than to rent a car. There were plenty available, although I had to negotiate a one-way rental penalty of $1,000 or so when I turned in the car in Dallas. Lessons learned: have a back-up for your back-up, in my case, renting a car for the train back-up. That is why I have a back-up of my laptop computer and also keep a copy off-site somewhere in a cloud just in case. 

Many institutions keep multiple copies of their images available for the first days to weeks at a modality. Some PACS architectures have gateways that store images for a certain period of time. Many also archive a copy off-site at a Vendor Neutral Archive, and then also have a tape-back-up that they put into a vault off-site. Determining what to duplicate where, when, and for how long should be based on a risk analysis. This analysis should include the unimaginable. 

This is especially important for those components that directly impact critical care such as the ER. Most ER’s by now have multiple CR systems, and if the volume does not justify large units, a single plate reader should be sufficient as a back-up. You might even keep a laser printer, and make sure there is sufficient film to go with it. If the printer is connected to a network, keep a direct patch cable around that allows the CR to connect directly to the printer in case there is a major network failure. Another solution is to have a CD burner in the ER that allows images to be stored on exchange media that can be transmitted over the "sneakernet" to the radiologist who can review them temporarily on his or her workstation. 

One should use common sense, however, and do not go overboard, which is where the risk analysis comes in. I have seen institutions where the images are still archived on removable disks on the CT or MRI, just because it makes the technologists “feel safe” or just because it “has always been done that way.” If over a period of, let’s say one year, no one ever asked for these to be retrieved, one might rethink this and possibly eliminate it from the workflow. I also have seen an institution where there were five copies available: one copy at a gateway, one at a local server, one at the archive, one at the web server and one at an electronic medical record server, which was functioning as a Vendor Neutral Archive provider. This also could use some analysis. 

In conclusion, make sure you have a back-up and redundancy so you are never “stuck,” and also make sure that there is a back-up for your back-up in case the first back-up fails as well, however, don’t go over board. This is what I learned when traveling, and this is what you should consider when doing a risk analysis so you won’t be caught scrambling for a solution. 

Enterprise Information Management and Archiving Hot Topics

During the recent vDHIMS ePosium on the subject of the evolving digital healthcare enterprise, attendees had an opportunity to interact with the distinguished faculty to ask their questions in a Q and A session. Here are some of the notable Questions that were asked ant the respective responses: 

Data migration is still a major issue and Steve Horii from the Hospital of the University of Pennsylvania (HUP) is able to attest to that, going through this experience several times. One of the issues he noted was the potential loss of annotations when migrating the data. These annotations are also referred to as overlays in the DICOM standard. To store this information there are several options. The first option is to "burn-in" the data, which actually means that the pixels are replaced. This is seen a lot with Ultrasound and creates a lot of potential issues in case the information happens to be incorrect and needs to be modified. Some users put “XXX-es” over the text; however, if this annotation not preserved during the migration, there could be a major issue. Another option is to save this information in a database record in a proprietary method, which is what Steve had to deal with in his migration. The proper way of storing overlays is by creating a DICOM standard object, the so-called “Presentation State”, however, this requires the migration software to be able to interpret the database of the PACS system which is used as input to allow for the conversion to the presentation states. 

There are other reasons for being able to interpret the proprietary component of the input data to be migrated, for example, if the archived images were stored on non-rewritable media such as an optical disk, the changes to the patient demographics or the deletion of certain images or even complete studies after the fact, are not reflected in the image archive but only in the database. This is another proof that data migration does not include only the transfer of the images but also requires a lot of knowledge about the input and output database structure. 

Another question that was asked at the ePosium by the audience is what to do with any of the modality disks, as many CT, MR and even some Ultrasound units might have archived their images on optical disks (MOD) long before PASC was installed. These studies might occasionally need to be retrieved. The HUP solution for that was to have the vendor create a special data input station with a single disk reader. Remember, that the CT or MRI might have long be retired and replaced with a newer modality which meant that the “old” MOD or DVD readers could have been retired with the old units and therefore the capability to read this media has disappeared. 

Another insightful series of presentations was from Kevin McEnery about the EHR and their in-house developed viewer which were built using Service Oriented Architecture (SOA) principles at MD Anderson cancer center in Houston. One of the participants asked about the staff at this institution and it was an impressive 200 people strong. Major reasons for this institution to develop their in-house viewer and infrastructure are the very different workflow for radiation therapy, the need for clinical trial support and the submission requirements of treatment data to regulatory agencies. Even for “typical” institutions” there are already significant differences in workflow, making it hard to match the EHR systems, let alone if you take into account the difference between very specialized institutions such as a cancer center. 

One of the issues noted was also the requirement to have a certified EHR to meet the new Meaningful use requirements so that the institution can apply for incentives as part of the Hitech section of the ARRA. As Dr. McEnery noted, it is possible to apply for a “modular” certification, and re- use the certification of a “core” functionality and only certify the additional modules, which will be a big help for many institutions as they are customizing their EHR and MPR implementations. 

If you are interested in the complete text of the presentations of Dr. Horii and McEnery, you can find these archived as part of the symposium, in addition to the other presentations and copy of the hand-outs from this three day event. It is even possible to gain continuing education credits by taking a simple quiz after the presentation so you can keep up with your certification requirements, see for more details.