Monday, May 22, 2017

Is cloud-based medical imaging archiving the future of PACS?

Ed Marshall, CPO,
Ambra Health
Ed Marshall is chief product officer at Ambra Health, a provider of healthcare cloud services. Before Ambra, Ed held roles as senior vice president and general manager of the Services Industry business unit at NetSuite, as well as vice president of sales and marketing for OpenAir, which was acquired by NetSuite. A seasoned speaker, Ed has presented at industry events such as the Gartner Symposium/ITxpo, the annual Technology Services World (TSW) conference, and the CFO Leadership Council.

Are PACS administrator attitudes about cloud-based image archiving changing?

Attitudes toward cloud-based workflows are changing across the board and PACS administrators are no exception. Highly innovative and technology-driven practices have always had an eye toward the future, but cloud-based image archiving will quickly become more mainstream with growing pressures on organizations to operate more efficiently. 

The new reform rules require health centers to be more efficient and eliminate the duplication of imaging studies that put patients at risk for overexposure. PACS administrators are also now dealing with more imaging than ever, as they may be part of an organization acquiring new organizations (or being acquired themselves), and facing significant risks when imaging lives in multiple different systems. 

Patients themselves are becoming much more active in the healthcare space, demanding access to their health records and imaging. For an organization to have success in the new marketplace and consider itself patient aware (and HiPAA conscious), easy access to medical imaging is a must. The cloud enables an organization to securely store imaging, to easily query/retrieve imaging across disparate locations, and to reliably enable patient portals. Progressive PACS administrators want those benefits, and therefore they want cloud-based image archives.

What have been objections to it in the past and how have cloud providers overcome those?

Acceptance of the cloud remains an ongoing educational challenge for cloud providers. Objections to the cloud have included speed, reliability, and security. Today’s cloud providers are addressing those concerns with robust solutions.

On-premise software within a VPN, where all storage is local, provides the speeds to which practitioners are accustomed for retrieving and viewing imaging. Improved internet speeds and modern cloud technologies have eliminated the gap between on-premise and cloud for managing imaging inside a hospital. Many cloud vendors support hybrid storage models and local cache, enabling doctors with the speeds they want, while leveraging the flexible and low-cost cloud technologies. Furthermore, replacing CD’s with cloud image exchange eliminates the delays caused by missing CD’s, unreadable CD’s, and damaged CD’s. So, the overall impact of cloud is a more efficient imaging solution for IT staff and doctors. 

Reliability of internet-based cloud solutions has also been an objection, but that objection is no longer valid.  Cloud vendors support up-times in excess of 99.9 percent. That’s often better than the uptime of traditional health system IT networks. And as more imaging needs to be exchanged beyond the facility’s four walls - to urgent care facilities, referring physicians, trauma transfer - cloud based systems are more reliable than outdated hospital networks and CD couriers.  Plus, cloud vendors are experts in cloud storage, utilizing state-of-the-art facilities and redundant architecture.

Data security in the cloud has historically been a major concern across industries, and the healthcare industry is no exception. And once again, cloud vendors often surpass older hospital IT systems in security operations.  Cloud vendors host their solutions in modern data centers, with the best physical security available. Cloud vendors also monitor their solutions with penetration testing, intrusion detection, and other always-improving industry tools.

In general, most of the historical objections to cloud solutions have turned into advantages for cloud solutions.

What are some of the factors driving medium to large health systems to reconsider cloud-based solutions?

New requirements and regulations like the Health Information Technology for Economic and Clinical Health Act (HITECH), and Meaningful Use regulations aim to protect patient information and improve data accessibility. The problem is the majority of departmental PACS archiving or disaster recovery systems fail to fully support these initiatives. Combined, these challenges and initiatives demand a more holistic approach to image archive and management.

In the world of value-based care, enterprise image management has boiled down to a critical cost item – we can’t duplicate medical imaging. As regional networks expand and facilities acquire new organizations, they’re increasing risks to both patients and providers when prior imaging can’t be easily accessed in a timely manner or when images live in multiple different systems. A single source of truth for imaging has to stop being elusive. We’ve seen many facilities turning towards cloud VNA (vendor neutral archiving) as a method of safely storing data that acts as a central repository for all imaging, so priors are easily exchanged using the cloud when needed, and all imaging across the health system is shared, regardless of where the imaging was done.

In addition, cloud systems better support future initiatives like interoperability among imaging vendors, integration with EMR’s, Health Information Exchanges (HIE’s), and patient portal enablement. So cloud vendors provide superior functionality, lower costs, higher reliability, and a future-proof architecture. 

What are the advantages of cloud-based systems for:
  • Image volumes?
Leading cloud vendors have invested in scalable architectures, so there is no performance degradation as volumes increase. Cloud customers can pay in an “on demand” fashion, allowing predictable pricing with no large upgrade or “storage refresh” costs. Managed and secure cloud providers offer replication and archiving automatically in data centers, providing a powerful foundation to underpin continuity plans. 

  • Security, safety?

Cloud providers can often enable the whole stack - storage, software, and accessibility so security and safety are not afterthoughts. Security and safety are core to the cloud offering, with cloud providers understanding evolving security concerns better than even most hospital IT staffs. For example, one of the most secure methods of storing patient data in the cloud is split-merge technology. This technology anonymizes image studies by removing protected health information from the imaging data. The protected health information is then separately encrypted and stored, creating an Internet-safe image study.

  • Acquisitions of practices by hospitals causing the merging of multiple PACS systems?
Mergers can be complicated, leading to multiple PACS systems and limited communication among silos of information. A leading cloud vendor can provide a complete range of consultative migration approaches, from moving an entire library, to a phased migration.  And with an elastic cloud architecture, you can accommodate ever-increasing image volumes, systems, users, and organizations without the need to worry about provisioning more infrastructure and resources.  Furthermore, cloud based systems can operate beyond a VPN, enabling the integration of partnering and acquired facilities in a rapid low-cost fashion.

  • Integration of imaging sources including non-DICOM systems?
Managing all image types - both DICOM and non-DICOM - is important for an imaging archive.  Cloud archives can manage non-DICOM storage, either with or without DICOM wrappers. Non-DICOM imaging can be stored side-by-side with DICOM for a holistic view of all patient imaging. 

  • Increasing maintenance issues, including purging, troubleshooting?
Cloud based systems are generally updated seamlessly and frequently, so you are never stuck on an old version of the software facing significant costs and overhead to achieve version upgrades.  Maintenance issues are therefore minimized.  Also, troubleshooting is far easier for cloud vendors as there are no version controls, and bug fixes can be patched without most customers realizing there had ever been a bug.
Purging can be achieved through flexible “Purge rules.”  So you can manage data storage in a manner that matches your purge protocols. Ironically, many customers are viewing their imaging as an asset that they might not want to purge, as imaging becomes important for artificial intelligence and deep-learning applications.  Cloud storage is perfect for managing such large volumes of storage for an indefinite amount of time. 

  • Legal considerations?
The ultimate goal is to strike a balance between risk mitigation and utility. If information is too hard to share, users may seek out highly risky ways to manage image transfer. The cloud offers a secure and HIPAA compliant method of sharing studies over the internet.
Flexible cloud vendors can offer data centers in the geography of choice, to support data location requirements, which can be stringent outside of the United States.

What about accessibility, doesn’t the nature of cloud storage suggest longer storage and retrieval times?

No not at all. A Cloud VNA (vendor neutral archiving) acts as a central repository for all imaging, so priors are easily exchanged using the cloud when needed, and all imaging across the health system is shared instantly, regardless of where the imaging was done.  Some cloud vendors offer storage models that can accommodate local caching and flexible storage nodes, enabling the advantages of cloud without sacrificing the speed of local storage

Will any cloud provider do, or is it essential to have a cloud provider specializing in healthcare?

Working with a cloud vendor that specializes in healthcare is important from both a legal perspective (you’ll want a vendor who is HIPAA compliant) and a consultative perspective . You'll want imaging experts to work with your team to establish and identify pain points, solutions, and training suggestions to ease deployment. They’ll want to know items such as, “what is the patient experience like at your organization? Are patients currently having imaging done onsite? Are patients bringing imaging in on CDs for review? Are you a surgical center that collects large amounts of prior imaging and reports and requires complex EHR integrations?”

Standards such as DICOM are truly unique to healthcare, so generic cloud storage vendors might lack the sophistication to effectively manage the details of healthcare imaging.
Finally, a cloud vendor specific to healthcare should also provide an application program interface (API)-first open platform leveraging modern web services that allow for flexible integrations with custom business processes and workflows, in-house apps, patient portals, EHR systems, and more.

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