It’s Murphy’s Law as applied to health IT—just as PACS platforms are reaching maturity, image storage needs have exceeded their capabilities, says Alexander Towbin, MD, Neil Johnson Chair of Radiology Informatics at Cincinnati Children’s Hospital, Cincinnati, Ohio. “There’s more and more interest in storing other images outside of radiology,” Towbin says. “Add to that the fact that MU [meaningful use] is encouraging sharing of patient data between two hospitals, including images, and the traditional PACS archive quickly becomes outdated.”
Towbin views radiology as “the tip of the imaging iceberg” in the hospital setting. “Radiology is the most organized in terms of imaging informatics, but other specialties are catching up,” he notes. “Cardiology is approaching the same level, while dermatology and pathology, among others, are just beginning to work on digital imaging and imaging workflow. A lot of times their images are just sitting in someone’s office on a shared drive. There are best practices that radiology has applied that can help, but we know our workflow doesn’t necessarily match up with theirs.”
Transitioning to Enterprise Archiving
At Cincinnati Children’s, the transition to an enterprise archive has been pitched internally as one of two pillars of a complete patient medical record. “At the patient level, there are two classes of data, textual or numerical, which do well and live well in an EMR, and images, which don’t do so well in EMRs,” Towbin says. “They do, however, do well in vendor-neutral archives overlaid with a viewer. You have to be able to launch images from the EMR, and once you can, the EMR and enterprise archive combined create the patient’s medical record.”
Changing the hospital’s image archiving destination from a PACS to a VNA is a mild technical challenge, Towbin says. More difficult is migrating data previously stored in a PACS to a VNA for permanent storage going forward. “A full DICOM migration takes a lot of planning,” he notes. “We’re still dealing with that. Migration can be tough.”
Most challenging of all, however, are the politics associated with implementing an enterprise archive, not the IT wrinkles. The move to a VNA can ignite long-simmering tensions between radiology IT and hospital IT. “Sometimes that relationship is frosty,” Towbin notes. “With enterprise IT, the image archive becomes a hospital resource, where before, you could argue that it was just a radiology resource. Decisions that the radiology department was making exclusively now need to be vetted differently, and there are questions about who is going to support the archive: Can radiology IT provide all that support? Does it even want to?”
Radiologists as Leaders
From these questions, naturally, come questions about image ownership—and data ownership in general. “When you start talking about large hospital systems moving to an enterprise archive, you can use a VNA, but how do you federate that across multiple hospitals?” Towbin points out. “There are politics involved here as well. For example, if there are multiple hospitals with separate IT staff, who provides primary support for shared systems such as the VNA?”
Participation in a health information exchange, such as those encouraged by the meaningful use program, complicates the question even further. “When you have all the hospitals in one region communicating, and they all have very different agendas and levels of expertise, how do you aggregate all of a patient’s images in one place?” Towbin says. “How can we make it so that radiologists from anywhere can see a patient’s images no matter where that patient shows up? That challenge is ultimately more political than it is technical.”
For Towbin’s part, he foresees a future in which the patient is the center of his or her own data, while the hospital acts as the storage “steward.” “No department or hospital should own the images,” he says. “In radiology, we’ve decentralized our images for so long that we don’t even think of this as a concern anymore, though it was in the early days of PACS. The patient as owner of his or her own information is still a new concept for a lot of the other specialties.”
For this reason, he says, radiology departments are natural leaders as their hospitals transition to enterprise imaging; their departments can and should help set the direction, Towbin says. “Imaging informaticists are uniquely positioned to be leaders in this new technology and new way of displaying information,” he says. “Radiology should play a big role in providing the expertise to hospitals.” Ultimately, he says, “If a patient from anywhere in the city comes here, no matter what hospital they normally go to, we should be able to take care of them with full knowledge of their prior medical history—including images.”
Cat Vasko is editor of HealthIT Executive Forum.