Monday, June 18, 2012

What’s In and What’s Out: Top 10 PACS Trends

Listening to the latest innovations
at the 2012 SIIM conference
Listening to the speakers at the recent SIIM 2012 PACS conference in Orlando, Florida, one could distinguish several new trends and technologies, some of them being clearly disruptive, some of them are merely an evolutionary development and some are just repackaged with a sexy buzz word (aka marketing hype) for a technology that already existed for many years. Especially with the latter, it sometimes takes a little bit of questioning and investigation to find out what the big deal is, which is kind of unfortunate, as it makes it seem as though it has been done to purposely confuse potential customers. In any case, here’s what I found:
1.       In with iPad, Out with the Workstation. This is a clear example of a disruptive technology as it is clearly overtaking an existing technology and reaching new markets and applications. Physicians can use the iPad not only to access images in conjunction with the EMR to review a case, but also utilize these for patient education and to discuss images at the bedside and by sharing with patients and families. Almost 50 percent of all physicians already use tablets and the use for nurse practitioners, physician assistants and other healthcare practitioners is expected to follow. A Johns Hopkins group reported that the security of these devices was far superior to any regular laptop because of the ability to remote wipe a lost device, access code expirations, auto-lock and several other security features. They also noted that the viewing capability was indeed the “killer app.”
2.       In with AVN, Out with VNA. The Archive Vendor Neutral solution (VNA) vs the Neutral Vendor Archive (NVA) seems to be a typical example of another word for the same solution. There is still confusion about what a “real VNA” means (see also the white paper). But the good news is that VNA solutions seem to have matured however, it has become obvious that several PACS vendors have problems with disconnecting their archive and image manger/database. Almost all PACS vendors have now renamed their own enterprise archive into a VNA, which seems to defeat the purpose. It still takes quite an effort to “connect” an existing archive with a VNA as reported by the Mayo clinic, which has done 13 migrations to date and is in the process of doing three right now. They reported that it can still take from a few weeks up to two years for “discovery” of the images of a PACS to the VNA image manager.
3.       In with Zero Footprint, Out with Thin Client. The zero footprint is a logical evolution from the thick client to thin client workstations, emphasizing the fact that there is no trace left at a device as soon as the software application has exited. That means that all information from a cache is flushed, making it a perfect solution to address patient privacy and security concerns. The protocol most often mentioned for viewers and other applications is the HTML5 protocol. While not quite considered mature, it seems to be emerging as the implementation of choice. This solution also seems to be favored over any other protocol solutions such as WADO (Web Access to DICOM Objects), which has some limitations such as not being able to exchange (yet) images in a single transaction or to bundle them in a series by study, or by the physician, or viewer solutions connecting to an enterprise archive or VNA.
4.       In with MINT, out with DICOM. The DICOM native protocol is not quite suitable for web access, especially as used by zero-footprint viewing applications. Issues that arise are because the DICOM protocol was defined in an era of fixed IP addresses, hierarchical queries, and the need for application level addressing (AE-Titles), instead of URLs.
The web version of DICOM, called WADO, has its limitations as mentioned above, and therefore a new protocol was developed called MINT, which claims to provide a significant (although maybe overrated) performance improvement for retrieval. It is especially effective if the data is preprocessed in the MINT format. There are vendors who have implemented a MINT interface and even use it natively as a data storage format to optimize access to large multi-frame datasets. Whether this will actually prevail or be displaced over the next few years by DICOM web services, improved WADO or another protocol, remains to be seen.
5.       In with Facebook, Out with MIRC. The RSNA has created an image exchange service called MIRC, which offers the capability to be used for teaching files to describe  image study characteristics, including diagnosis, in a meta-header with this study and providing an exchange service. Based on a survey, it appears that 60 percent of all patients are willing to share their images (with identifiers stripped). However, the image sharing activity between several academic institutions has only resulted in a few thousand studies to be made available. Personal Health Records (PHR’s) are also not used to the degree as expected. It might just take one of the giant social networks such as facebook or others to jump on the bandwagon and provide this type of information.
6.       In with texting, Out with emails. An email is responded to within an average of 90 minutes. By contrast, a text message gets reviewed within an average of 90 seconds. The use of mobile applications may shift the emphasis from radiologists generating reports to “impacting patient status.” More than one out of five results are not being followed up as shown by a poll taken by one of the presenters. Using mobile technologies may allow radiologists to follow up with their referring physicians and ultimately with patients to improve patient care.
7.       In with Video, Out with MPEG. The Mayo Clinic reported that they are currently archiving about one million images per day, resulting in their archive being filled with 1.3 billion images spread over nine PACS systems. For this type of institution, a Vendor Neutral Archive is not just a luxury, but a requirement to allow cross-departmental access. After being able to store successfully the MPEG encoded DICOM files such as generated by endoscopes and other Visible Light modalities, one of their next projects includes storage of “regular videos,” because they found that many departments store DVD’s that have patient diagnostic information acquired for all types of reasons. As an example, filming the “gait” of a patient walking before and after a specific therapy.
8.       In with Image sharing, Out with CD’s. Exchanging CD’s to import images from a patient created by another institution is still an area of concern as there are still users who create non-DICOM compliant CD’s. I believe that one of the main reasons for this is a lack of education. Almost all vendors by now are able to create standard compliant CD’s, however, it might require a non-default setting at the CD burner, as their default might be creating a proprietary CD with images that can only be opened by the embedded viewer. Most third party CD readers are now able to read the proprietary image formats generated by these “rogue” vendors, further increasing interoperability. However, it is clear that electronic exchange of the information is far preferred, which is where the image exchange services come in. These services allow users to exchange through a “cloud” where information is stored and to which they can connect in a secure manner through a plug-in or edge server. A good way of thinking about this service is that they act as an “ad-hoc” HIE. There are now several third party companies who provide this service.
9.       In with middleware, Out with tag morphing. Tag morphing was a big deal over the past few years as it was portrayed that without a lot of header modifications, it would be impossible for a VNA to exchange information with a PACS system. However, based on feedback from VNA vendors, this was apparently grossly over-rated. Without the changes, basic image viewing has proven to be possible, and whatever change is needed can easily be included in the migration process.
10.   In with RWF, Out with SWF. The traditional “Scheduled Work Flow” sequence specifies how an order is placed, filled and scheduled, followed by generation of a work list, retrieval by a modality, image acquisition and storage, and finally retrieval and reporting. Using all this information it is useful to perform business analytics showing how a department is performing. However, what is needed instead, is clinical analysis whereby the sequence is reversed, hence the title of “Reverse Work Flow.” To make a clinical impact, the result should be fed back to the next order, the image characteristics and diagnosis should impact the image processing for the next procedure of this patient and/or patients with similar characteristics. The same applies for creating the modality technique. For example, if a radiologist would decide that for a follow-up exam the technique could be reduced by a factor of two, this would impact the radiation dose that a patient would be subjected to, resulting in better care.
This year’s new health care imaging and IT technologies are mostly just a new “creatology,” some are just an evolutionary step, but in my opinion, the single most disruptive technology is the usage of mobile devices such as smart phones and tablets along with the proliferation of new applications and the capturing a new group of users. It will be interesting to see how this will evolve and how regulatory agencies and trade organizations will react and whether they will be able to facilitate it rather than choking it.