Saturday, September 19, 2015

Truths and myths about a deconstructed PACS.

The term of deconstructed PACS has been floating around, which might be
confusing and/or new to many, therefore this attempt to shine some light on this topic.

In the past, there have been other adjectives used for the PACS system, which came and went. For example, the terms of the integrated PACS, the RIS (Radiology Information System) driven or PACS driven, and several others. In the meantime, the RIS is pretty much dead as most hospitals now have an EMR (Electronic Medical Records) with order entry capability in the form of a CPOE (Computerized Physician Order Entry) function, so there is no use to talking about integrated RIS/PACS or RIS driven PACS anymore.

So, what is the deconstructed PACS in my opinion? It is nothing other than using a best-of-breed approach or commoditization for the individual PACS components. It is a logical evolution of what has been happening since PACS started all along.

Going back in PACS history, the initial PACS systems were a “package deal” containing hardware and software for the archive, viewing stations, including dedicated expensive video cards, and monitors. This was true until the hospital IT departments got involved, especially from the large providers, who had a contract with for example, HP, Dell or IBM to provide all of their hardware, which could amount to literally thousands (or more) computers a year. Most of them can buy the hardware much cheaper than the PACS vendors, and therefore wanted to provide their own hardware for the viewing stations.

The same thing happened with the archives, for example, an IT shop who had all EMC hardware with its support and maintenance agreement, would be very hesitant to bring in another vendor just for the PACS. Remember that the PACS from a hospital perspective is just another piece of their healthcare IT puzzle together with the other department systems, HIS, billing etc. To make a point, when I visit a hospital IT room I can appreciate their perspective, as the PACS servers take up just a few of the many computer cabinets in one of the several rows of hardware of their computer room.

Some of the first vendors very smartly addressed that requirement and started to sell PACS software licenses only while specifying minimum hardware specs such as required CPU, memory and OS version, which did shake up the industry and pretty much everyone started to follow. We are now at the point that you can provide your own hardware, including the medical grade monitors, video boards, computers, servers and storage devices for all PACS components.

After that, VNA or Vendor Neutral Archives were introduced. Users were getting tired of having to migrate data every time they changed PACS vendora, so they wanted to take control over their data and purchase the archive from a different vendor and use the PACS archive mainly as a cache to allow for fast access of the most recent studies.

In the meantime, more “ologies” wanted to manage their images electronically and again, the CIO’s were not allowing a department to buy yet another archive for let’s say cardiology, dentistry, surgery and other images. The users also found out that not all images are in a DICOM format, for example, speech pathology, physical therapy and dermatology were all storing native JPEGS and MPEGs, and ophthalmology has been creating pdf’s containing very detailed and specific results. Moreover, the push to share this information in a standard manner with Health Information Exchanges (HIE’s) forced these VNAs to become a gateway to the outside world using standard protocols such as XDS. And if you need to have access to all of the patient images creating a patient centered view, you might as well access the VNA instead of all the individual PACS systems while using a zero footprint viewer.

An additional problem with uncoupling the archive i.e. VNA from the PACS is synchronization. If an image has to be modified or deleted on the PACS, you don’t want to have to do that twice, voila, the IHE IOCM (Imaging Object Change Document) profile that provides that functionality. So we arrived at an archive device (VNA) that supports DICOM, non-DICOM, can talk XDS, supports the PACS synchronization and has a standard DICOM viewer interface. At least this is a “true VNA” in my definition.

So far we have deconstructed the PACS hardware and software, the archive and the viewer, which actually caused some “experts” to announce that PACS is dead, which is definitely a misstatement. Therefore, myth number one that the deconstructed PACS is the same as “PACS is dead,” is definitely a misstatement. We still need PACS systems that manage the department workflow, providing very fast access to images and efficiently providing very specific tools and image presentation in the form of hanging protocols to deal with specialties such as cardiology, mammography, dentistry, nuclear medicine, and last but not least, general radiography. This is in addition to features such as peer review capabilities and critical results reporting.

Going down the path of deconstruction, we also need so-called workflow managers that manage the workstations. These started out as a solution for radiologists who are serving multiple hospitals, each one might have a different PACS system. Instead of having to log into different worklists for each individual PACS, the workflow manager would combine or aggregate these worklists and create a single one, while synchronizing the reading between multiple users and PCS systems. The step from different PACS systems to a single archive (VNA) that has images from different sources is not that hard to make, hence we have the next step, i.e. a workflow manager from a different vendor. The step to use a best-of-breed viewer is now easy to make, yet from another vendor.

So far we reconstructed the archive, workflow manager and viewer, however, we need additional middleware to make this work. In particular, we need to clean up the data as it comes from different sources, such as series and procedure descriptions, especially if the images are created at different institutions with their own terminology. For this a DICOM cleaner or “tag morphing” software is needed. In addition, if you don’t have a universal ID, you need the Master Patient Index or MPI capability. Last but not least, to get some of the details needed from the orders, you need an interface engine that consolidates all of the HL7 feeds.

As of now we have five components, the VNA, workflow manager, viewer, DICOM router, HL7 interface engine and an optional MPI provider. You can purchase each one of those from a different vendor, which is the best-of-breed approach.

This brings us to myth number 2, which is that a deconstructed PACS is less expensive, which is not necessarily true. The reason is the effort involved with integrating, testing and maintaining such a diverse system. Assuming that you have a strong IT department, and educated imaging and biomedical engineering resources, it could definitely be less expensive and provide best of breed, i.e. a solution that better meets your specific requirements and workflow. The truth is that for many institutions this is not an option. They might want to deconstruct the PACS only to the level of the VNA, and even in that case they might be better off to purchase the VNA from the same vendor as their PACS provider. However, if you do so, I would strongly recommend requiring standards support at each level so that you can replace any of the components for either business reasons or if the vendor simply does not keep up with new developments. As an example, you would be surprised how many vendors still don’t support 3-D breast tomosynthesis images, or even the new enhanced multi-frame CT and MR for their viewer, in which case you might be better off to look for a different solution.

The last myth is that a deconstructed PACS is something new, which is incorrect. It is just a logical evolution of what started 15 years ago by opening up the PACS by using standard interfaces and allowing the replacement of the several parts by the different vendors. So, the truth is that there is nothing new under the sun, which might take some of the marketing hype away from the vendors, but that is OK, they just have to come up with another term to sell what is basically the same old thing.

In the meantime, as a user, it is important to make sure that any new PACS purchase allows for the deconstruction by requiring standard support, and verifying and testing these, and continue to get educated and stay knowledgeable to provide the more sophisticated support needed for these systems.

Thursday, September 10, 2015

What's new from HIMSS ASIAPAC15

There was a pretty good size exhibition
hall and it was well attended
The HIMSS ASIA Pacific was held Sept. 6 to Sept. 10 in Singapore this year and, despite a good attendance (1,700 professionals), most of the attendees were local, which might not have been such a surprise if you looked at the speaker roster as most of the speakers were from the local region as well. 

In my opinion, it would have been better to call it HIMSS Singapore, as it would have reflected the venue more accurately. The good news is that I learned quite a bit about the initiatives and challenges in Singapore, which basically come down to the fact that there are going to be too many elderly people too soon to be supported by too few workers, which will require a smarter approach to how they conduct their business. Hence the term “Smart Nation” was introduced by the Singapore government as of last year, which includes smart transportation, infrastructure, and homes, but foremost smart healthcare. However, even though the incentive for implementing digital technologies in healthcare is different than in the US and other countries, the objective is identical, i.e. doing things smarter and therefore more efficiently, safely and effectively, and we can use the same solutions.

Singapore still has a long way to go with regard to electronic health record implementations they are about five years behind where the US is right now. In addition, with regard to imaging (PACS) implementations, they are about 2-3 years behind. They have home grown EMR systems that are not interoperable, and they are just starting to think about enterprise image archiving using Vendor Neutral Archiving. The standards-based approach to healthcare IT implementation using IHE is still not well understood and/or appreciated. The good news is that they can learn from implementations in the US as well as countries that have advanced health care IT implementations such as Canada, the UK and other western countries, and use the lessons learned to jump-start their implementations, which will very likely start happening in the next one to three years, which would be expected if they are serious about “smart healthcare.”

There were three major takeaways from the conference. I learned about the potentially disruptive  impact of wearables, the use of demographic and social overlays onto the clinical data, and the use of “Big data” in a cognitive manner.

First wearables – When people think about wearables, you might think about the Apple Watch and other devices you can wear and measure the number of steps, hours of sleep, and even pulse. But the sensors are now getting very thin and can be incorporated into clothes or other wearables and measure additional physiological parameters such as glucose level. This information can be uploaded into a personal health record and a healthcare practitioner can monitor that data and potentially intervene if needed. With most people now having smartphones, they can be connected in real time and allow for monitoring 24/7. The impact of this could be huge, despite the “big brother” connotation. Sometimes, having a “big brother” watching over you could be a lifesaver or, at a minimum, prevent unnecessary ER or doctor visits. And if a visit is necessary, it could very well be done remotely in many cases.

The second potential disruptive innovation is the use of demographic data and overlaying that over clinical information from the EMR. For example, overlaying the number of re-admissions, diabetes patients, or people with any other condition that might be socially or culturally related on top of a map showing the geographical distribution of the patients can give clues as how to address such health issues. This means that patients are not being treated as individuals anymore but in their social and cultural context. Let’s say that a specific area has a high incidence of diabetes, you might want to do an educational session in the community center about nutrition in that region.

The third thing I learned has to do with the use of “big data.” While the reality hasn’t lived up to the hype so far, there are applications that use big data effectively in a cognitive manner to assist physicians making treatment decisions. A good example is the IBM Watson application, which is used by major cancer centers to assist in the treatment of oncology patients. The patient condition and characteristics which are in the EMR are compared with a database of thousands similar cases and tens of thousands of published articles to come up with a suggested treatment plan. You might think that patients do not always fit the statistics, but then the next step is to take into account the genomics data to come up with a truly personalized treatment. The power of this process is to use the intelligence of the IBM Watson, which runs in the cloud.

So, in conclusion, the HIMSS ASIAPAC15 had some insights to offer and learning experiences and it was good to know what is going on in Singapore. However, it is definitely a regional meeting, and there were a lot of vendor-sponsored presentations that talked about products rather than new technologies. So as an educational event, you might be better off to travel to the HiMSS Annual Conference & Exhibition in Las Vegas, Feb. 29 – March 4, 2016.

Thursday, September 3, 2015

An update on PACS professional certification.

PACS certification for imaging and information professionals has been around for about 10 years.
PARCA was established on January 1, 2005 and the CIIP certification by ABII (American Board of Informatics) was created not too long after that. Since then, it is estimated that more than 2,000 people have been PACS certified, and the certification is still going strong as new people enter this field or experienced professionals look to update their skills and get certified in their profession.
The titles CIIP and CPAS, CPSA and CPIA are becoming well known and used by professionals in this field. When talking with recruiters, they agree that certification is definitely an advantage when looking for a job opportunity as it shows that one has gone through the effort to study this subject matter and earn certification through a rigorous exam.

Certification is a requirement when you work in a clinical field, for example, as a radiological technologist, nurse or physician. Interestingly enough, it is not required when you work in the healthcare imaging and informatics field. However, potential legislation has been considered, in particular in the state of Texas, which would require everyone involved with maintaining and supporting medical devices to be certified. And yes, PACS is a medical device under the US federal FDA guidelines requiring specific clearance to be allowed on the market.

There are several other certifications in the healthcare imaging and informatics field, for example HL7 certification is quite popular for interface analysts and developers. More than 4,500 people are HL7 certified as of now, more than twice as many as those who hold PACS certifications. The CPHIMS (Certified Associate in Healthcare Information and Management Systems) certification is also well known and highly regarded in the IT community.

With the increase of PACS implementations in the Middle East and the Asia Pacific region, there has also be an uptick in the number of PACS certificates issued in these regions. OTech just did the first PACS certification training in Singapore and has performed several in the Middle East over the past few years, responding to the increasing demand for training in these areas. However, the number of PARCA certificates issued is still only about 2 percent of overall certifications, compared with the 23 percent share of CPHIMSS certifications in Asia. The Middle East has an 11 percent share of the CPHIMSS certifications while for PARCA has a 5 percent share. 

The statistics for PARCA certification holders is shown in the table below. 

PARCA Certifications by country (as of 9/1/15)
Middle East
Australia and New Zealand
Latin America

As you can see, 90 percent are in the US and Canada, however the international portion is fast expanding. One of the main reasons for the international following of the PARCA certification is its international board and governance as well as the capability to take a certification exam by on-line proctoring, which makes it accessible from literally any place in the world at any time.

Certification is definitely a good thing to have, and remember, it is not about the piece of paper you can show, which could be an advantage if you want to change jobs, but more about the journey, i.e. the fact that you have to upgrade your skill set and learn about topics that you might not get involved with in your regular day-to-day work but are important to know and understand.