Thursday, July 28, 2016

Enterprise imaging, what to look for in a VNA

Phil Wasson is Healthcare Industry Manager and Consultant at Lexmark Enterprise Software and has been involved in health information technology since the 1990s. Over the past 15 years, he served as CIO and CEO at Tri- Rivers Health Partners, which provided IT support for Swedish American Health System in Rockford, IL and FHN, formerly Freeport Health Network in Freeport, IL. A year-and-a-half ago Mr. Wasson joined Lexmark to provide the Global Healthcare Industry Team with product marketing expertise to expand Lexmark’s understanding in the healthcare space to offer exceptional customer engagement, industry expertise, and deep technology capabilities through an extensive portfolio of product offerings in both enterprise imaging and healthcare content management.

Q. What are some of the reasons healthcare organizations are moving to
vendor neutral archives (VNAs)?

Healthcare organizations are pursuing VNAs after years of trying to get their historical PACS vendor to support a higher level of system availability. Every time the storage infrastructure changes, which in healthcare happens pretty frequently, PACS studies must be migrated to a new storage platform. There are costs associated with every one of these migrations. A VNA approach to medical image management allows an organization to migrate studies to a common long-term archive under an enterprise approach, which reduces costs and adds value.  I first pursued a VNA solution back in 2007 when our organization implemented the Acuo Universal Clinical Platform. After that day, we never again had to worry about paying a PACS vendor to allow us to migrate data to a new platform. 

Our experience was that the Acuo VNA offered significant cost savings while supporting high availability access to enterprise images. Other benefits with Acuo’s VNA also emerged, including: the ability to federate between different PACS systems; leveraging image viewers that could directly access the VNA; and supporting the capture and management of images from departments beyond radiology, including cardiology and pathology. I learned that many different service line units could benefit from an enterprise image management solution.

I often explain the benefits of a VNA like this: Imagine I have this terrific camera I can sell you. It takes wonderful pictures; the best pictures you can get. However, in order to look at those pictures, you have to buy the software from me, and by the way, if you want to send that image to your mother, you have to buy the transfer software from me as well. Oh, and also your mother needs to also buy my software in order to look at that image. How much interest are you going to have in a solution like this? Probably not so much.

Of course, you'd never buy a camera from me if that were what I was selling. If you think about traditional PACS, that analogy in essence is how it works. Unfortunately, these proprietary systems lock you in. I call it a vendor lock and block model. Frankly, for the archive to be vendor neutral it not only has to be neutral across different systems but it also has to be neutral to itself.

One of the reasons I joined Lexmark is because of the remarkable capability of the Acuo VNA software to eliminate the proprietary approach to image management and create vendor neutrality. Along with that are also other opportunities to integrate imaging with unstructured clinical documents under a Healthcare Content Management “HCM” model. This is very appealing to healthcare clinical and IT leaders. There are a lot of things to consider for true neutrality. It's needed at the image storage management layer, the workflow and worklist layer, and at the visualization tool layer. Also, a host of functions is needed to support this well so that the customer can take full ownership of their enterprise imaging solution and the management of all clinical content.

The other advantage of the VNA approach is that it provides a great deal of flexibility for allowing all the different ‘ologies’ to manage medical images within a common, vendor-neutral environment while also enabling the use of specialized viewers. An oncologist, for instance, might need a specialized oncology viewer while a pathologist might need another type of viewer. Why should you have to replace your PACS every time you want to add a different type of viewer? In the vendor neutrality world, you are able to go out and select whichever visualization solution you need and connect it directly to the VNA and multiple viewers for different needs can be pursued. It’s the same way your mom will look at the pictures you send her, imaging neutrality, it is the same concept.

Q. What is one of the first questions a potential VNA buyer asks? And is it the right question?

Well, I think a lot of them talk about the vendor’s implementation track record. Most prospective customers want to know how many implementations we've done. That is a very appropriate question. Today, every vendor out there seems to have a VNA offering all of a sudden. A vendor’s implementation track record is a pretty important validation of the technology, especially when you consider the migration of imaging studies from different PACS systems into the VNA. It’s a critical piece of evidence that a vendor is the real deal. The other thing you must have to go along with that migration experience is a built-in migration toolset that will support your ability to migrate those studies yourself and then take ownership of the migration process as you go forward. This is true vendor neutrality. When we sign a customer agreement, we never hold their images hostage. If they ever decide they need to move off of our product, we assist them in doing that.

Q. Healthcare reform is driving a large number of partnerships and mergers, including the development of huge health systems spread over wide regions. Is this trend also accelerating the move to VNA solutions for these large provider networks?

Yes, we see that within our provider customer base. Many of our VNA customers have either already proceeded down the path of acquiring entities or are positioning themselves to be able to do it down the road as the market consolidates. The ability to aggregate and federate multiple, disparate PACS systems, both initially and on an ongoing basis, is important. This is something we support as part of our solutions. The ability to easily migrate data from acquired entities and to support federation of clinical content using the VNA will be essential as the healthcare ecosystem evolves. Interoperability of clinical content on a large scale will be crucial for success in supporting patient population health management.

Q. As I understand it, VNAs have become much more sophisticated over the past five years. What are some of the ‘must haves’ a PACS or IT administrator should look for in a mature technology?

We asked ourselves that question last Fall before RSNA and started listing out all the capabilities we felt were critical features of a fully-functional, mature VNA. Before we knew it, we had created a list of more than 30 capabilities we believe are absolutely critical for success. We compiled them all into a document called the Lexmark Definitive VNA Checklist, which includes all of those things our VNA does today. If you look at this document, you’ll see many of the things we’ve been talking about today. It has all the things purchasers should be reviewing, like PACS aggregation and federation and other important functions of a truly mature VNA that have been validated in many diverse healthcare IT environments. The VNA must be able to interoperate with any application, encompassing all disparate systems and silos of patient information, including both DICOM and non-DICOM content. It is important to be able to dynamically tag and morph your DICOM tags so that as you migrate objects into the VNA, you have the opportunity to update these DICOM tags and you should be doing that as part of your migration. You can bring in metadata from existing systems and then retag and re-morph the DICOM tags as they get stored permanently into the VNA. Those are things that are critically important. It’s likely some of the vendors out there that suddenly say they offer a VNA may not have all of these essential capabilities and may not be truly neutral to themselves. Our VNA technology emerged primarily from the world of radiology and we have more than ten years of interoperability validation at the Integrating the Healthcare Enterprise (IHE) connectathons in the U.S. and in Europe. We have a long history of supporting all the items listed on this definitive checklist.

Q. What are some of the other items on that checklist?

If you want to move toward PACS redefinition, you must have the ability to pre-fetch and auto route and do post-fetching on images that exist within the VNA, as well as being able to bring those into any visualization tool quickly, as part of your workflow. This is a pretty important feature. At one of my previous companies, we made the mistake of purchasing a highly proprietary PACS system that required us to duplicate five years of proprietary, historical PACS studies in the system. I said to the vendor “I only want you to store 90 days of cached imaging data.” We wanted to minimize our storage requirements. If there was a study older than 90 days, we wanted to be able to prefetch from the VNA into the cache and after 90 days have it removed from the cache. 

Although that traditional PACS vendor said they could support this, ultimately they didn't have the software capability to adequately support this workflow. The pre-fetching times were so inadequate that the solution was basically unusable. The vendor couldn't support multi-tasking within the application infrastructure, so it blew up our whole decision around that PACS vendor. The ability to prefetch as a basic function is really important.

We talked about the importance of the implementation track record and the migration capabilities. Those are really important components. As we begin to merge DICOM and non- DICOM data together under an HCM model, the IHE integration profiles become critically important. For instance, deploying an XDS and XDS-I solution within your enterprise will enable you to take advantage of a host of emerging opportunities. We have a considerable number of European deployments today and the majority of them include XDS. This enables non-DICOM documents to be available on the same viewing platform as DICOM. You might have a DICOM viewer that can ingest non-DICOM documents to support your workflow. 

In other cases, we see organizations in the EU that don't have EMRs, but they have patient care systems on the front end of a significant electronic content management system that includes non-DICOM data stored in the XDS repository. Over time I think we are going to see more and more XDS deployments in the U.S. because as the U.S. healthcare delivery system approaches that standard, costs can go down significantly and the ability to exchange documents inside and outside the organization goes up significantly. We aren’t replacing an organization’s EMR; we are optimizing it by surrounding it with an HCM model, which provides ways to easily access and manage unstructured clinical imaging data and other documents. So expecting a strong level of IHE participation by your VNA vendor I think is critical. 

Again true independence, I can't emphasize that enough. If the vendor doesn't have a good track record of migrations and won't contract with you to make sure your data remains truly independent, then you should probably walk away from that vendor.

Q. In a 2014 survey, one of the issues PACS administrators had with VNAs was usability and user interface. How has that been improved?

As we’ve rolled out our solutions for redefining PACS at an enterprise level, we’ve included our recently acquired line of visualization solutions. Lexmark acquired a company called Claron Technology, and Lexmark now offers the NilRead family of referential and diagnostic image viewers. Like many of our products, NilRead is a fully vendor neutral, zero-footprint viewer that can run against anyone's PACS or anyone's VNA. The diagnostic viewer is FDA-approved. We are able to deploy this viewer into a radiology environment as part of a solution to redefine or eliminate proprietary PACS. Lexmark felt the need to have a very functional and capable viewing technology of its own.

Regarding the worklist management aspect of PACS redefinition to support radiology workflow, Lexmark has a formal relationship with a company call Clario that we can deploy to support this critical function. We also acquired a company called PACSGEAR that has multiple software modules that provide a host of PACS imaging connectivity and capture options. I believe that about half of the hospitals in the U.S. run one or more PACSGEAR modules. Included is PACS Scan Mobile, which provides an easy and secure way to capture and view patient content from a mobile device. PACSGEAR wraps that in DICOM. We also have an industry-leading enterprise content management (ECM) solution that does not wrap content in DICOM. This content can be managed within our Perceptive ECM product or directly within our XDS registry and repository.

Q. What unresolved challenges remain that a PACS administrator might be looking at regarding VNA implementation?

I think it is a sales job within your organization, specifically with the radiologists. They associate everything with speed, visualization capabilities, high availability, and the ability to do your due diligence. So their buy-in is critically important.

Q. Is security a challenge with VNA?

We haven't had any of those (breaches) that I can recall. We provide all the typical security requirements, especially on our ECM side. These are required through a mandate within the ONC certification process. Our ECM products are ONC-certified by Drummond and we're talking about undergoing module certifications for our VNA and visualization solutions as part of the next phase. But overall from a security perspective, we tag onto the security components any
organization must have available.

Q. Cloud storage is becoming more common. Is that a solution people are moving to and does your system support that?

Our next release of Lexmark Acuo VNA (6.03) is significant and is the first broad release of our VNA web capability. It supports the ability to deploy the VNA within a cloud option. We haven't seen a lot of that yet. There is a lot of discussion going on, and I think over time it will continue to gain acceptance. But we have a solution capable of that where we can bundle an offering of services and VNA software that can support a public cloud-based deployment option.

Q. What does a good VNA do to enhance patient care?

Coming from the IT side of things, one of the big objectives from my perspective is high availability and the ability to have a scalable framework necessary to support whatever an organization needs. Increasingly what we're finding is that you have to bring more financially responsible, value-based systems to the table. One way to do that is to put a migration solution in place where you can migrate one time and move on. If your storage system changes, there should be no cost to move your imaging studies to a new storage platform. Creating more value is a key component of what Lexmark Healthcare does and may be the biggest thing we're trying to leverage into healthcare organizations. Bringing the ability to redefine PACS, reducing costs while providing more flexibility in a vendor neutral way is extremely important to Lexmark Healthcare. 

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