Cloud PACS and mobile apps reinvent radiology workflow

 While cloud computing has been around for more than a decade, health care is finally embracing it today. A recent market study¹ reported that the global cloud computing market in the health care industry was valued at US$1.82 billion in 2011 and is expected to reach US$6.79 billion by 2018, growing at a compound annual growth rate of 21.3% from 2012 to 2018.¹

The rapid adoption of cloud computing in health care presents opportunities and challenges. Cloud-based PACS along with mobile apps promise to simplify image and data sharing and cut costs, yet one challenge is secure storage. Medical images are projected to require 30% of the world’s storage and could soon represent 10% of all of U.S. healthcare costs or about 1.5% of US GDP.¹ From an IT perspective, the average 100-bed hospital, performing 40,000-50,000 radiology exams annually, is adding 5 terabytes of data to image storage.¹

There are several approaches to building a cloud-based PACS or image exchange, which offer feasible solutions to managing enormous volumes of readily accessible data.

Why choose the cloud?

How do cloud-based solutions affect radiologists? It is becoming more practical from an efficiency and cost perspective for radiology to share images and reports across a secure cloud network.

As more health care providers and hospitals invest in electronic health records (EHR), they are integrating image viewers into EHRs—essentially building a bridge between referring physicians and radiologists. These infrastructures are increasingly using cloud-based networks as the backbone.

Cost is a major factor driving the rapid adoption of cloud-based infrastructures in health care. According to the Government Accountability Office, 75% of all imaging procedures are performed outside of the hospital setting where picture archiving and communication systems (PACS) are practically nonexistent.² Currently, the National Healthcare Information Network (NHIN) requires a PACS to share medical images,² which means 75% of medical images will not be available to providers without PACS. A cost-effective solution to the problem is Software-as-a-Service (SaaS) or on-demand software. Since applications are delivered as a service over the Internet, users can pay on a pay-per-use model.

With on-demand applications, such as radiology information systems (RIS), PACS, remote image review software (teleradiology), advanced 3-dimensional (3D) apps, and billing software, facilities avoid paying huge upfront costs.³ Multiple hospitals can share standard software, infrastructure, storage, and processing power. Cloud computing can help imaging [networks] rapidly scale and descale operations and avoid huge spending on maintenance of costly applications and storage.³

Additionally, the flexibility of anywhere, anytime access to medical data allows radiologists to report remotely from outside the hospital.

These factors—low upfront costs, cost-effective scalability, and flexibility—are driving the migration to cloud-based PACS.

Cloud-based models simplify image sharing

One of the true marks of genius is making something technically complex seem simple. This was the approach Steve Jobs took when introducing the concept of the personal computer.

In health care, what seems simple is actually quite complex. This is the case with image and data sharing. A recent survey found that outside images were handled in emergency departments where approximately 20% of images were hand carried or emailed directly to physicians; about 90% of images were entered into the hospital PACS, while about 10% were managed through the departments treating the patient. Several of the physicians and IT staff in the survey noted that images were frequently lost and exams had to be redone.⁴

Using zero-footprint software, applications that do not require end users to install any software,⁵ is very cost-effective since it only requires a browser and runs on any platform. Some PACS claim to be zero footprint, yet if they require plugins, only run on specific browsers, and do not support tablet or mobile device capabilities, then the true advantage of a zero footprint, such as decreasing cost of ownership and deploying data with minimal IT support, is diminished. On the other hand, many zero-footprint implementations in the market are very basic and do not support full diagnostic viewing needed in a PACS.

A notable zero-footprint viewer is Nil solution by Claron Technology, which is just as powerful as a standalone workstation with support for multi-monitor, rule-based hanging protocols for exam viewing according to physician preference. As a pure zero-footprint viewer, there is nothing to install and there are no restrictions on browser use.

Improving referral services

Establishing a solid referral base is the life-blood of radiology and poses a particular challenge for private practices. It is no longer enough to provide accurate radiological reads with quick turn-around times; referring physicians want radiologists to play a more collaborative role by reviewing a case at a moment’s notice and must be notified of critical results.

Growing private practices like Sand Lake Imaging, Orlando, FL, a high-volume freestanding imaging center with 350 patients a day, need to communicate with local referring physicians as well as with those located nationally and internationally. By converting their RIS to MedInformatix and CoActiv’s cloud-based PACS, the imaging center increased its productivity by 30%, improving its service to referring physicians.

“The CoActiv PACS has resolved our challenges to expand our practice capabilities to interface with physicians across the continuum of care. It’s a cloud-based system that is easy to set up, to get all of the doctors set up onto the system in a manner that is HIPAA compliant and nonintrusive to their own practices,” said Stephen M. Bravo, MD, Medical Director, Sand Lake Imaging.

With the new system, subspecialists can now view 3D reconstructed images and cine images of the heart and PET/CT examinations. “That has significantly helped us service these subspecialists in ways we weren’t able to in the past,” said Dr. Bravo. The program also provides a feature for subspecialists to view the records of those patients whose primary care doctors initially sent them to Sand Lake Imaging.

Another challenge is effectively communicating urgent results to referring physicians. It can take 10 to 15 minutes and several administrators to connect the radiologist with the referring doctor for a 2-minute conversation, says Sid Prakash, MD, DABR, a diagnostic radiologist at Total Radiology at Bainbridge MRI, in Bronx, NY, where they recently installed RoentgeonWorks by BRIT Systems.

The RoentgenWorks DICOM Cloud is a browser platform for uploading medical imaging studies and reports. Users can upload, view, and share studies and reports 24/7 from any https connection. Users can also send out email invites to colleagues and patients, allowing them to view images via Brit’s WebWorks browser-based viewer or the DoctorWorks iPad application.

“Today you need to report critical results to the referring doctors. I was looking for a PACS vendor focused on communication, not just on the PACS user interface,” said Dr. Prakash. “The fact that it tells you there’s an urgent finding is great. If you dictate an urgent study on acute fracture, for example, it picks up those words and knows if it’s urgent and gives you options to call and leave an automated voice message on the doctor’s phone and also send information on the urgent finding.”

Dr. Prakash was also looking for a PACS that supported mobile apps to share images with physicians. “It’s huge to be able to have reports on iPads, in particular because more doctors want to see reports on their mobile devices. When I provide a doctor access to reports on a mobile device he will remember that my practice was able to do that while others were not. In the private practice space, it makes a huge difference—it’s a competitive advantage. Whatever you can do to make it easier for them is important,” said Dr. Prakash.

Cloud supports the VNA model

One of the advantages of the cloud-network is scalability. A network can add on services and capabilities through the cloud. One way to create an enterprise imaging strategy is to use a vendor-neutral archive (VNA). A VNA is a comprehensive cloud-based image storage and management solution. Images are archived on a short- and/or long-term basis and the archive can grow as capacity requirements increase. VNAs help health care providers consolidate imaging data from multiple PACS.

In fact, Colorado Telehealth Network (CTN) built the CTN Colorado Imaging Exchange on a cloud-based VNA network. The concept was to store all of the images in a central cloud repository to facilitate sharing imaging studies. As part of the service, Acuo Technologies and Client Outlook provide vendor-neutral archiving services and diagnostic-quality medical image viewing, and GNAX Health hosts and manages the cloud. The network enables hospitals, imaging centers, clinics, and other health care providers in Colorado to safely store and share medical images through a private cloud.

“We want CTN’s Colorado Imaging Exchange to be interoperable. The solution demonstrates the power of an alliance,” said Ed Bostick, Executive Director, CTN. The platform is a private point-to-point network with built-in encryption for securing data.

“One of the benefits of the VNA is that radiologists often like the workflow of a specific PACS, but their IT doesn’t like the way the infrastructure is deployed and managed,” said Toria Thompson, Consultant to CTN. “Because our solutions take care of the archive piece of the PACS, it takes that heavy lifting off of the PACS. Now, the PACS can go back to being primarily a radiology workflow management tool, and all of the archiving is in a standard system.”

One of the pain points for radiology reading groups is getting priors, noted Thompson. “With CTN’s Colorado Imaging Exchange, you can grant access to radiology groups to the priors that they need or push priors to the radiology group so that they have them waiting. So in many ways, it’s an easier workflow for getting priors,” she said.

Reducing the total amount of storage required is another advantage of a VNA. By having studies in a central place, it eliminates storage redundancy. Users can view images directly from the unified cloud-based viewer. Because the data is not sent by Internet to different locations but viewed from one location, there is no change to the data, which contributes to data integrity.

The universal viewer has a collaborative benefit as users can manipulate studies and view them in real-time. “One of the things that we were missing with PACS was the collaboration in radiology. The unified viewer gives you that collaborative effect,” said Thompson.

The unified viewer includes an iPad capable app and Android download that is 510(k) cleared. “Many radiologists choose to look at images first in the viewer because of the speed with which you can get to studies with a Universal workflow app,” said Thompson.

Another leading VNA provider working with large hospital networks is Siemens Healthcare. Siemens is deploying its VNA to Intermountain Healthcare, a 22-hospital network based in Salt Lake City, UT. Siemens Image Sharing & Archiving (ISA) VNA will handle Intermountain Healthcare’s enterprise imaging needs by storing images in the Siemens Healthcare Computing Center (HCC), which is redundantly hosted in a Dell data center. The archive is managed with Dell’s clinical data management software, federating images to the Dell Cloud Clinical Archive (DCCA).

“Our costs for managing images would scale with our utilization – but not in a traditional way,” said Marc Probst, Vice President and Chief Information Officer, Intermountain Healthcare. “If our volume expands, we would expect our costs per study to go down, [and] if our imaging volume actually goes down, we have an opportunity to reduce our overall costs. This type of budget certainty is a key factor in making this solution our long-term answer to enterprise image management.”

ROI on the cloud

As the saying goes, if you can’t measure it, you can’t manage it. This begs the question—what are the true savings on a cloud-based PACS?

Through a Philips Pilot Program, medical facilities can identify their return-on-investment based on workflow efficiency and savings. After installing IntelliSpace PACS by Philips Healthcare, The University of Pittsburgh Medical Center reported realizing a 43% decrease in study management costs across its 18-hospital network, which translates to an estimated savings of $14 million annually.

IntelliSpace PACS interfaces with the hospital or imaging center’s existing HIS and RIS, and can image-enable EHRs. Specific to radiologists’ needs, it generates work-to-do lists and an order/protocol; schedules exams for modalities; provides referring physicians a full view of their patients; and supports patient ward-specific worklists for critical care units. MD Anderson Cancer Center, another participating hospital in the Philips Pilot Program, expects to save $30 million over 8 years.

Managing cloud security

An ongoing threat to cloud-based networks are data hackers and viruses. Although cloud storage has been around for a long time, in a recent survey of health care professionals, 47% of respondents indicated significant security concerns with cloud-based image sharing.⁴

One reason Patrick Ward, CIO, Central Illinois Radiological Associates (CIRA), chose Visage 7 was that it did not require moving patient imaging data from the hospital data center (Figure 1).

“What Visage does is differential streaming of the images,” said Ward. “The actual DICOM data allows us to keep the data file on the hospital’s network – it does not leave the boundary of their security that they manage and administer. Visage does graphical processing to stream the data to the physician. The file is never actually transferred just the visual data—it’s very fast and it’s full-fidelity.”

The platform at CIRA, a large radiology group with dozens of hospitals, IDNs and centers across Illinois, combines Visage 7 as its viewer, Nuance PS360 for workflow/reporting, and Acuo for managing the data. This integrated environment now provides network-wide access to images, regardless of where their radiologists reside, with a single enterprise worklist.

In a recent study,³ researchers identified several steps radiology departments can take to secure data:

• Store data remotely in virtual compartments in the storage media;
• Encrypt data during storage and transfer;
• Connect with the server using a secure URL, such as URLs beginning with https (s stands for secure);
• Use biometric checks to protect access to data;
• Employ mirror servers to avoid service disruption; and
• Develop a long-term archival strategy to protect the security and integrity of data.

Impact of mobile apps

It used to be that radiologists went to a dedicated workstation to access images. In the post-PC era, images follow radiologists wherever they go.

Some of the primary features mobile devices provide radiologists with are remote desktop access, DICOM viewers, file upload, and screen sharing and consulting with referring physicians in real-time.

“The ability to use an iPad or mobile device to download information will improve communication between radiologists and referring doctors as they can instantaneously gain access to medical information for their patients. I think it’s going to increase turnaround times and make the entire system more efficient because physicians will no longer need to wait over the weekend, even for non-stat findings,” said Dr. Bravo.

Mobile devices have already transformed patient care at leading institutions like Mayo Clinic Arizona, located in Phoenix and Scottsdale, AZ. The hospital has implemented a pilot program using mobile software for diagnosis.

“We had a need for clinicians to access images almost immediately after they completed a scan and before the radiology report was finalized in order to make clinical decisions. So the main driver was our telestroke program with our stroke neurologists and neuroradiologist who were on call. They needed to make clinical decisions as soon as a stroke patient presented in the emergency department,” explained Amy Hara, MD, Professor of Radiology, Mayo Clinic Arizona.

Doctors there deploy Calgary Scientific’s ResolutionMD, which acts as a mobile PACS workstation, streaming data from imaging modalities to devices on both Android and iOS platforms, yet the data is never stored on any device.

Although the emergency setting prompted the inception of the program, today all of the radiologists, several of the surgeons, neurologists, oncologists, and gastroenterologists are on the mobile platform.

“The radiologists mainly use the mobile imaging solution for after-hours and weekend coverage when they are asked to give an opinion on a case. We have even had a radiologist on an airplane connect to Wi-Fi and render a second opinion using ResolutionMD,” said Dr. Hara. “Mobile imaging is breaking down a lot of physical barriers to get an opinion or diagnosis rapidly.”

She added, “We are also looking to use the technology for physicians to collaborate from remote locations. With ResolutionMD, both the physicians and radiologists can interact simultaneously, allowing them to collaborate in real-time. It’s a much more efficient and accurate form of communication when you’re not in the same location.”

Mobile devices for imaging are transforming the way physicians deliver bedside care. Orthopedic physician assistants at Mayo are now able to show patients their intraoperative images to explain the surgery while the patient is in the recovery area. “It has transformed the way they can communicate with patients; it’s much more effective to show patients their own images. It has really helped improve patient communication,” said Dr. Hara.

Radiology apps also provide advanced visualization tools. TeraRecon provides iPad support for its Aquarius iNtuition advanced visualization server-based software suite with the release of AQI 4.4.5. The app is designed to provide a convenient and expedient way to obtain access to images, advanced visualization, and other advanced techniques, through an intuitive, mobile, multi-touch and image-centric user interface.

Radiologists can benefit from multiple image viewing apps, such as OsiriX HD, Intel AppUp Center, RadSnap, ClearCanvas, AbbaDox Rad, and many more. Residents can tap into teaching files like Radiology 2.0: One Night in the ED, iRadiology, MIRC Viewer, and Surgical Radiology. GoodReader and iAnnotate-PDF are useful for reading and making annotations. Clinical radiological journal apps, such as the Applied Radiology Mobile Edition, are DICOM-enabled, allowing readers to launch a DICOM viewer and scroll through full DICOM datasets right on a tablet or smartphone.

Getting to the next level

Cloud-based platforms are key components to bringing medical communication to the next level. One can only imagine how workflow might change in the era of mobile devices that use augmented reality like Google glasses, or with collaborative social networks that deploy cloud-based services. According to Athenahealth CEO Jonathan Bush, the big break in cloud-based adoption will come with the introduction of a proprietary network where doctors access services by “friending” a laboratory, specialist, or pharmacy to allow the entity to start paying for and receiving online clinical information [as a] cloud-based service. Essentially creating a bridge to the cloud.⁶

“Mobile devices may empower radiologists to play a critical real-time role in the health care continuum,” said Dr. Bravo. “In the end, the requirements for meaningful use and the increasing requirements for efficiency within the entire health care system are going to push this technology to the forefront.”

References

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2. Heart IT and Johns Hopkins Medicine announce the Award of NIH Grant to include images in the Nationwide Health Information Network (NHIN). Heart Imaging Technologies. http://www.heartit.com/index.php/news?start=5. Posted November 30, 2011. Accessed May 2, 2013.
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4. New survey finds: Hospitals see need for streamlined management of medical images from beyond the enterprise. ETIAM. http://www.etiam.com/new-survey-finds-hospitals-see-need-for-streamlined-management-of-medical-images.html. Updated April 22, 2013. Accessed May 13, 2013.
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