In the Navy: The DoD and the Future of PACS
The US Navy deployed its first PACS—a military-specified system with limited functionality—in 1996. Since then, the Navy has operated multiple PACS from a variety of vendors, all selected through a contracting process monitored by the US Department of Defense (DoD). “Our purchasing process enables us always to select the best of breed,” Edwin Doorn, logistics management specialist with Naval Medical Logistics Command, Fort Detrick, Frederick, Maryland, explains. “We’re not locked into using a single product. We can shop for what works best for our needs.” 
Edwin Doorn Doorn should know: He’s one of the people charged with selecting the best PACS for a given naval facility, a task made no easier by the rigorous security requirements of the DoD. In 2007, the Navy deployed its first Synapse PACS from FUJIFILM Medical Systems USA Inc, Stamford, Connecticut, at a naval hospital in the Pacific; soon, the system was installed at seven sites, including Naval Medical Center Portsmouth in Virginia, where it replaced a slow-running legacy PACS. “It can be challenging to install anything from a new vendor in a DoD facility,” Doorn notes. “We have an extremely stringent network, and FUJIFILM was able to meet our security needs. That was the primary driver behind our decision making at the time.” Doorn explains that this is a key differentiator in his health system, where the need for data security applies as strictly to DoD communications as it does to medical equipment. “We need to be sure there are no vulnerabilities in the technology we put in our hospitals, and that can be difficult because medical equipment, by its nature, is vulnerable,” he says. “When we started making ourselves network capable, that portion of security wasn’t really examined. Now, the DoD is the driving force in making sure these systems are secure before they become a part of our network.” The Navy’s needs, however, extend far beyond the security requirements imposed on its network by the DoD. In fact, they resemble the needs of any powerful, geographically diverse health system processing millions of images a year. “The military is very transient,” Doorn notes. “We move folks all over the world, and we do it often. Having continuity of care is very important to us.” Portsmouth is the Navy’s biggest and busiest hospital for radiology; 800,000 images a year pass through its PACS. As Doorn observed, "If a sailor and his family are treated at one hospital and are later transferred to Europe, it’s important to have the data available at the other facility.” In order to ensure continuity of care, the Navy only acquires systems that use open architecture and standards-based communications. “All of our PACS are in communication with one another,” Doorn says. “We can do DICOM Query/Retrieve from all of our systems. Now, when we move that sailor to Europe, his previous studies and records follow him instantly. In the old days, there were cases where the films didn’t get transferred and studies were repeated; of course, we don’t want that.” In addition, all of the Navy’s FUJIFILM PACS can communicate with one another using a proprietary feature called CommonView™. “We used to use a third-party product to relay images back and forth,” Doorn says, “but that’s very cumbersome for workflow. After we implemented Synapse at multiple sites, we were able to use the CommonView feature to connect the remote databases so that our physicians reading at remote sites could stay at the PACS workstation, click on a tab for that site, and type in their reports.” Like other major US health systems, the Navy has been in the process of transitioning from analog to digital mammography, and this was another factor in its decision to install Synapse. “Instead of waiting to replace all of our analog systems, we decided to go with CR technology,” Doorn says. “When we rolled out our PACS initially, we didn’t have digital mammography in mind. To support digital mammography, we rolled out Synapse to support soft-copy reading, and it’s been extremely well received.” The Navy’s disparate PACS not only communicate with one another, but also communicate with Armed Forces Health Longitudinal Technology Application (AHLTA), the DoD’s electronic medical record (EMR), which was first deployed around seven years ago. Though implementation of AHLTA will not be complete until 2011, the system currently gives military providers access to data on patient conditions, prescriptions, diagnostic tests, and other essentials. “We get the patient data from AHLTA to feed into the PACS, and then the reports issued by the PACS wind up back in AHLTA,” Doorn says. AHLTA is often cited as a model for the kind of national EMR system prescribed in the American Recovery and Reinvestment Act of 2009. Its statistics are impressive: in any given week, AHLTA currently supports 2.2 million prescriptions, 642,400 outpatient encounters, and 19,600 inpatient admissions. “If, for instance, we had a major-trauma case come into one of the Pacific hospitals, the patient would be stabilized there and then sent via medical evacuation to the next level of care,” Doorn says. “It might not even be a Navy hospital, but the patient’s images and data would follow along with him or her.” Doorn says that the integration between the Navy’s PACS and AHLTA has saved the military’s health system both time and money. “We make the best use of the physicians’ time,” he says. “There’s no need to go searching for these studies; they’re immediately available.” Although the DoD’s medical system currently enjoys functionality that is still just a far-off fantasy for most commercial health systems in the United States, Doorn’s goals for the Navy’s PACS and EMR will sound very familiar to those in the radiology community. In the future, he hopes to realize further operational efficiencies as a result of the integration: “In the early days of teleradiology, we needed third-party middleware to send the images back and forth,” he says. “One thing that the deployment of our modern PACS has allowed us to do is that we can now accomplish this without the middleware, so we see ourselves getting to the point where we’re exclusively doing PACS-to-PACS communication. That’s not always easy, and we receive data from other sources, like Veterans Administration or civilian hospitals; we’re hoping that the implementation of these systems will help facilitate that process.” Doorn’s goal is for all of his PACS databases to be aware of one another, eliminating the need to perform manual query/retrieve. “If we need to push studies between PACS now, we can do that,” he says. “In the future, though, if a patient comes from one hospital and goes to another one, instead of the staff at the original hospital pushing information to the new facility, it will come over automatically, whenever a study is scheduled.” In addition, Doorn envisions a future when PACS/AHLTA integration will enable geographically disparate facilities to share radiologists. “We can’t share staff across hospitals yet, but it’s one of our goals,” he says. “What we’re finding is that we could possibly connect all these Synapse servers to support teleradiology efforts. We see that our PACS could support a majority of our teleradiology needs, and we’re aggressively exploring that.”
Edwin Doorn Doorn should know: He’s one of the people charged with selecting the best PACS for a given naval facility, a task made no easier by the rigorous security requirements of the DoD. In 2007, the Navy deployed its first Synapse PACS from FUJIFILM Medical Systems USA Inc, Stamford, Connecticut, at a naval hospital in the Pacific; soon, the system was installed at seven sites, including Naval Medical Center Portsmouth in Virginia, where it replaced a slow-running legacy PACS. “It can be challenging to install anything from a new vendor in a DoD facility,” Doorn notes. “We have an extremely stringent network, and FUJIFILM was able to meet our security needs. That was the primary driver behind our decision making at the time.” Doorn explains that this is a key differentiator in his health system, where the need for data security applies as strictly to DoD communications as it does to medical equipment. “We need to be sure there are no vulnerabilities in the technology we put in our hospitals, and that can be difficult because medical equipment, by its nature, is vulnerable,” he says. “When we started making ourselves network capable, that portion of security wasn’t really examined. Now, the DoD is the driving force in making sure these systems are secure before they become a part of our network.” The Navy’s needs, however, extend far beyond the security requirements imposed on its network by the DoD. In fact, they resemble the needs of any powerful, geographically diverse health system processing millions of images a year. “The military is very transient,” Doorn notes. “We move folks all over the world, and we do it often. Having continuity of care is very important to us.” Portsmouth is the Navy’s biggest and busiest hospital for radiology; 800,000 images a year pass through its PACS. As Doorn observed, "If a sailor and his family are treated at one hospital and are later transferred to Europe, it’s important to have the data available at the other facility.” In order to ensure continuity of care, the Navy only acquires systems that use open architecture and standards-based communications. “All of our PACS are in communication with one another,” Doorn says. “We can do DICOM Query/Retrieve from all of our systems. Now, when we move that sailor to Europe, his previous studies and records follow him instantly. In the old days, there were cases where the films didn’t get transferred and studies were repeated; of course, we don’t want that.” In addition, all of the Navy’s FUJIFILM PACS can communicate with one another using a proprietary feature called CommonView™. “We used to use a third-party product to relay images back and forth,” Doorn says, “but that’s very cumbersome for workflow. After we implemented Synapse at multiple sites, we were able to use the CommonView feature to connect the remote databases so that our physicians reading at remote sites could stay at the PACS workstation, click on a tab for that site, and type in their reports.” Like other major US health systems, the Navy has been in the process of transitioning from analog to digital mammography, and this was another factor in its decision to install Synapse. “Instead of waiting to replace all of our analog systems, we decided to go with CR technology,” Doorn says. “When we rolled out our PACS initially, we didn’t have digital mammography in mind. To support digital mammography, we rolled out Synapse to support soft-copy reading, and it’s been extremely well received.” The Navy’s disparate PACS not only communicate with one another, but also communicate with Armed Forces Health Longitudinal Technology Application (AHLTA), the DoD’s electronic medical record (EMR), which was first deployed around seven years ago. Though implementation of AHLTA will not be complete until 2011, the system currently gives military providers access to data on patient conditions, prescriptions, diagnostic tests, and other essentials. “We get the patient data from AHLTA to feed into the PACS, and then the reports issued by the PACS wind up back in AHLTA,” Doorn says. AHLTA is often cited as a model for the kind of national EMR system prescribed in the American Recovery and Reinvestment Act of 2009. Its statistics are impressive: in any given week, AHLTA currently supports 2.2 million prescriptions, 642,400 outpatient encounters, and 19,600 inpatient admissions. “If, for instance, we had a major-trauma case come into one of the Pacific hospitals, the patient would be stabilized there and then sent via medical evacuation to the next level of care,” Doorn says. “It might not even be a Navy hospital, but the patient’s images and data would follow along with him or her.” Doorn says that the integration between the Navy’s PACS and AHLTA has saved the military’s health system both time and money. “We make the best use of the physicians’ time,” he says. “There’s no need to go searching for these studies; they’re immediately available.” Although the DoD’s medical system currently enjoys functionality that is still just a far-off fantasy for most commercial health systems in the United States, Doorn’s goals for the Navy’s PACS and EMR will sound very familiar to those in the radiology community. In the future, he hopes to realize further operational efficiencies as a result of the integration: “In the early days of teleradiology, we needed third-party middleware to send the images back and forth,” he says. “One thing that the deployment of our modern PACS has allowed us to do is that we can now accomplish this without the middleware, so we see ourselves getting to the point where we’re exclusively doing PACS-to-PACS communication. That’s not always easy, and we receive data from other sources, like Veterans Administration or civilian hospitals; we’re hoping that the implementation of these systems will help facilitate that process.” Doorn’s goal is for all of his PACS databases to be aware of one another, eliminating the need to perform manual query/retrieve. “If we need to push studies between PACS now, we can do that,” he says. “In the future, though, if a patient comes from one hospital and goes to another one, instead of the staff at the original hospital pushing information to the new facility, it will come over automatically, whenever a study is scheduled.” In addition, Doorn envisions a future when PACS/AHLTA integration will enable geographically disparate facilities to share radiologists. “We can’t share staff across hospitals yet, but it’s one of our goals,” he says. “What we’re finding is that we could possibly connect all these Synapse servers to support teleradiology efforts. We see that our PACS could support a majority of our teleradiology needs, and we’re aggressively exploring that.”