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| Dan Trott, Dell EMC |
Q. What are obstacles for medium sized hospital to implementing enterprise imaging?
A lot of the PACS systems for hospitals were purchased in the early 2000s and it is often times very difficult, when they continue to be functional, they still to the things they did in the 2000s quite well, but it is challenging with all the other demands on hospitals’ capital to modernize in a lot of different places, including all the other clinical applications that are coming along to justify the cost of completely updating into a fully blown enterprise PACS solution.
Consequently what ends up happening is that the radiology PACS ends up staying the same that it has been for a long time and new solutions like ophthalmology PACS or Pathology PACS or some of these other imaging driven solutions take on higher priorities for boards of directors than updating. What ends up happening is we have a whole series of imaging silos with data stored in PACS that don't talk to each other or don't equally provide imaging into the EMR, or we end up with a lot of Band-Aid fixes that are not very efficient. I think that is a big challenge. I think in healthcare we are all trying to shoot for the longitude patient record and in order for us to do that we need to get all these different imaging devices to have their outputs standardized and their solutions connected into an EMR in a format that can be used down the road for content management and analytics. If you're stuck in a bunch of old siloed storage environments you can't do that.
Q. Are radiology PACS administrators pushing the enterprise solution forward in small hospitals?
I would have to think that is case by case. The PACS administrators in many instances are responsible for keeping things up and running, but not necessarily for strategy. In some places they are but in those places it tends to be much more the larger systems that have R&D responsibilities the PACS administrator may have a bigger role. But particularly in your community hospitals that decision tends to be much more with radiology and even that that is migrating more and more into the realm of the CIO over time.
Q. Are PACS administrators in community hospitals becoming part of the IT department?
Not the PACS administrators, because they remain consistently responsible for making the user interface in the radiology department work correctly. The office of the CIO in so many hospitals is becoming responsible for all IT provisioning and the system itself and the strategy for IT management regardless of who provides the application, those are becoming much more the responsibility of the CIO to manage. Now the CIO still has to be responsive to needs of clinicians, but when it comes to what hardware infrastructure and what solutions are being purchased, the decision tends to have a lot of weight in terms of what GUI they (clinicians) want, but how its run and connected into the EMR tends to be the responsibility of the CIO. Or at least it is trending in that direction, let's say.
Q, Do the CIOs rely on radiology PACS administrators for advice and expertise in broadening the whole base?
Yes radiology in particular that is the case because in almost all cases the PACS solution was the first truly digital clinical application out there so in many cases that PACS administrator has grown up in the system of that hospital as a critical resource because they know more about it than anyone else, so the remain an important member of the strategic team but they don't run it. They are contributors and influencers.
Q. Can you elaborate a bit on why you advocate for a cloud-managed system?
I think across all of healthcare, and one of the advantages I have as a healthcare field director, is that I go out and talk to people with a lot of different systems across the country and so many systems are looking to get out of the data center management environment wherever they can and whenever they can.
That is as a result of healthcare moving in a significant way toward a hybrid cloud management solution that I think that within the next several years is likely to become the predominant way that applications are run. Having a strategy of incorporating hybrid cloud and the confluence of on-premise data center environments, on-premise cloud environments and off-premise public to private cloud environments, a mix of those different structures is a really good model for driving costs down and create efficiencies across the board in the healthcare IT space.
We're constantly trying to help our customers understand that cloud is a strategy not a destination. It is a thought process for management of clinical data, not just someplace that is out there that you are going to throw stuff. It is not a Dropbox and unfortunately that's the way a lot of people think about what the cloud is.
The reality is with the systems we're delivering today you have dramatically more control over how to leverage a multi-cloud environment than you ever had before, and its going to get better day by day so that you can pick and choose where you want your information. Maybe you want immediate acute data on patients that are actively being treated in the hospital only in an on-premise environment, maybe patients that have recently left the hospital to be in an on-premise or private cloud, and then data that is really now being held as disaster recovery or compliance data to be out in a public cloud environment where the costs strategically decreases as you go.
That used to be a hard thing to do. You had to build your own data centers and put them out there in a separate location and have the people to manage and maintain those and that is a high-cost environment. But today with the ability to deliver the kind of security that we have and with a significantly enhanced networks that are available in bandwidth, leveraging all three of those clouds can be a much more effective way of doing it.
In small hospitals that may be critical, because not only do you get space back from helping to get rid of stuff that is not critical that you are now managing in your data center or in a co-lo that you rent from someone, you are able to leverage the cloud to get all these resources back. If you are trying maintain storage for medical imagery in a disaster-recovery model in an on-premise space, every five or six years you are going to have to replace a lot of those spinning disks and that will require you to migrate all this data from the old ones to the new, which consumes so many resources that could be better used in other places modernizing your infrastructure.
Cloud offers a lot significant advantages across the board and we're getting to the point now where PACS vendors are appreciating that and providing much more sophisticated archiving capability and they are signing up to be able to either support public cloud environments from Amazon, or Microsoft or Google or whomever so that they are more responsive to those capabilities or providing those capabilities.
Q. You seem to be saying that archiving and retrieval times and security issues have been overcome for cloud storage?
There are solutions for virtually every one of those problems. Obviously with all of the challenges we've had this year alone managing security attacks one could question that, but reality is that in most cases most of the time the people who were affected could have potentially protected themselves from these with tools that are available today. It is a matter of priority use of your capital. At Dell we have solution called SecureWorks that is a managed solution for intrusion protection and the folks at SecureWorks defray over 300 billion security intrusions a day across all the different customers that we support. Part of what is happening is that solutions like SecureWorks and others that have been leveraged to protect federal government data in critical areas like military and others, those tools are now being spun off and becoming available commercially for people in healthcare.
I did a focus group at CHIME 7 0r 8 years ago, and we asked that question, what are the things that are keeping you from considering cloud? Among the CIOs who were attending said the number one thing was security and cost. We asked the same thing four years later and those two things were reversed. CIOs were more concerned about cost and felt that security was being handled effectively. If asked it today, I think security might be even further down the list. Tools are becoming much more appropriate, block chain is a good example, the advent of block chain has created the ability move data around in a secure environment that we simply didn't have five years ago. Step by step, day by day we're beginning to be able to deliver it.
As for the cost of data center infrastructure, the cost of bandwidth, all of those things continue to fall off dramatically. If you think what it would cost to implement cloud environment today versus even five years ago, there is just a significantly improved capital impact on healthcare and it gives them the ability to move from a capital-based environment into an operating environment where they have much more control over their budgets.
Q. Is that what Dell offers as a hybrid cloud solution?
Clouds can be configured in several ways. The two most significant ways are private clouds and public clouds. A private cloud is an architecture that provides cloud-like functionality but can be located anywhere, on the premises of a hospital, or in a nearby data center or be provided by a vendor close by. That adds significant advantages, the hospital has more control over security and it can be closer to you so that from a retrieval perspective the data can be retrieved back into the EMR a lot more quickly, in seconds, as opposed to having to use longer distance bandwidth. At the same time because that cloud system is local it is also typically more expensive, and it is private, the cost is not being shared by other institutions.
Now the public cloud, whether it is Dell EMC, or Microsoft or Google or whoever, these are large systems that have dramatic cost-efficiencies due to volumes and those costs are shared across a lot of users consequently it provides a very cost efficient way of managing your data, but it typically is not as quick in response, it is a little harder to get to and the security is provided by that vendor, you are not managing the security, you have to trust that vendor to deliver that security.
Dell introduced cloud-based medical imaging in 2010 and when we introduced that we completely wrapped it in our Dell SecureWorks solutions so we felt we could guarantee security would meet HIPAA requirements. At that time public cloud vendors didn't provide that guarantee at all, they wouldn't sign anything to ensure shared liability with regard to security, they wouldn't sign VAAs (vulnerability analysis assessment). Today all of them do, and they have really stepped up security to be able to provide that and also have segmented private data storage within the context of your system where an AWF (adaptive web framework) will segment off a section of storage where you will only your individual presence in this space. All of those things have changed, it has become infinitely more capable.
What a hybrid cloud system does is it builds a solution set, you orchestrate software in that hospital that allows you to control which of these different entities your data is going to be in at a specific time in its life cycle. That enables you to now say ok, the data coming out of this application is going to go local on hardware managed by the department for two months, to give the patient time to get out of the hospital, then it is going to go into a near line environment at a co-lo, a cloud-based co-lo for two years and at the same time, we're going send a copy out to the public cloud and that is going to be our long-term disaster recovery model to comply with HIPAA. Along the way we'll have multiple copies at multiple locations, it will always be protected against any natural disaster, which I'm sure the people in Houston, in Florida and Puerto Rico all hope they have now.
That mixing and matching is the hybrid cloud environment. As I said before it is not just the locations, but also the strategy for how you want to manage that data with the greatest security and greatest cost-effectiveness. It is a strategic decision, and people like Dell EMC are capable of delivering these solutions now, and not only are we capable of doing it but we aggressively suggest that is a very effective way of building the kind of IT infrastructure you need to position yourself to deal with the future.
We know there is a big herd of clinical applications and massive data is just around the corner for clinical pathology, and we're just getting to a point where the FDA is approving the soft copy review of slide data, and those (file sizes) are infinitely greater than the average radiograph, and as more and more hospitals are capable of providing personalized medicine with genomics, and it moves outside of the realm of R&D hospitals and Children's hospitals and more people are leveraging this tool, that data is also massive, how are you going to manage all that. The impact of localized infrastructure that we've historically used is not going to be effective, consequently clouds make sense as a strategy.
Q. Moving on to employing advanced analytics, can you elaborate on that?
There are two parts to that, one is preparing yourself to take advantage of what analytics provide and then the other part is leveraging the analytics. To prepare yourself to be able to leverage analytics of the clinical and medical imaging data that you have, there are a couple of things that have to happen, one of them is you've got to find ways to bring the medical imaging that is not generated in the classic DICOM format into the EMR that is searchable.
Radiology, cardiology, ultrasound have all leveraged DICOM to standardize the format that makes it significantly easier to look at where the data comes from, who is it about, what are the diagnostics codes so that in the future it can be managed in a content management software solution that allows you to search for things.
But there are a lot of images generated in healthcare that are not in standardized formats. One of the common examples is when a nurse uses her phone or tablet to take a wound care image in the patient's room. You can store that in an EMR but what you have is an image that has a name and a file capture date and that is all the metadata you're going to have for that image, which is perfectly useful for the diagnostic process and therapeutic process while the patient is in the hospital but as inclusion into some predictive analytics tool it won't be helpful because you don't know what it is, or any of the other information about that patient or disease. You need to be able to format that. There are solutions that are being introduced that are truly enterprise software that give you a workflow tool that allow you to add metadata to those images so that they have the same ability to be searchable.
Once you have that and its available and accessible then there are wonderful analytics tools that are being introduced into healthcare right now at a rapid rate that says ok now let's look at this massive data lake of information that has been generated by all these patients that we see and let's use algorithms and analytics to give us specific predictive tools. For instance you can say, I'd really like to be able make quicker diagnosis in an emergency room environment where I maybe managing these patients with residents or interns.
By having that an being able to look at all of the data for all these patients across every kind of demographic that we see in the ER and search for the same sets of characteristics as this patient that is currently being admitted and then be able to say here are the top three things I need to do to diagnose this and what are the top three things I need to do from a therapeutic standpoint. What a wonderful tool, leveraging predictive analytics to be able to provide enhanced diagnostic tool sets to make everyone who touches that patient be better based on all the accumulated information over time.
Now today there are a lot of tools to do that. The computing and management capability for that data is now becoming much more readily available, as a result that high-performance computing that once the province of someone like a genomics lab, is becoming available at a price most people can afford, and the software that does this kind of predictive analytics specific to healthcare is being adapted from other things. We don't make that software at Dell, but we have partnerships with people who do. We're providing them with high performance computing and rapid access storage to make all that data manageable so that those predictive analytics algorithms can be used across the board for a wider variety of healthcare settings.
Q. What is Dell EMC's approach to helping smaller hospitals implement enterprise imaging?
From the Dell perspective we have four pillars of focus. Working within those pillars we're developing tools that we can extend across healthcare, not just the big guys but the little guys and everyone else. The four pillars are IT transformation, and within that we're trying to help our customers modernize and automate their data center environments so that they have the ability to not only manage the mass volumes of data flowing into the hospital in a more cost effective way but also giving them the tools to transition into that modern space.
The big problem is no hospital anywhere, except maybe the best endowed ones have the capital necessary to do a forklift upgrade of everything in their data center. We're creating and leveraging a modular, flexible way of moving our healthcare customers from older systems that they haven't been able to replace for a long time just because of cash flow into a much more modern, less expensive system and to do it in a incremental way so they can bring some of their data into a new software driven hyper-converged infrastructure model that is more cost effective, faster, and provide dramatically better access to data but doing it block by block over time.
Our second pillar is what we call connected health, the connected health transformation is specific to helping them get all this data from all these disparate sources whether it is different clinical applications, or incorporating all the internet of things, tools that are now out there, whether it is wearables that are popular or remote monitoring devices so that you get people out of the hospital and into there homes and still take care of them and avoid readmission by monitoring their blood pressure, blood sugar heart rate and all of that stuff but then bring that data into data analytics boxes that provide a dashboard for the care giver that they can easily see when the patient is going beyond the benchmarks, the warning flags that tells them that they need to send a home health nurse out to take care of them. That connected health capability is critical over time.
Then the third pillar is precision medicine to make it easier and less expensive for our healthcare customers to be able to manage all the data that results from genomics, whereas today probably in smaller hospital environments that is pretty much limited to pediatrics because genomics is becoming critical in terms of being able to manage pediatric oncology, but also all of the things that are likely to flow out of that. We just partnered with a company with a simple server that has a board with 200 compute nodes built into one board, the result is that we take the time to do a person's complete genome down from about 20 days to 20 hours. It offers a huge high performance-computing environment in one server that can make that happen at a very reasonable cost. You don't have to go out and buy a Watson you can do it with real world tools.
The fourth pillar is security. Providing security transformation across the board and across all health care by leveraging tools that we can bring to bear on our own or through partnering to give our healthcare customers the ability to leverage things like a hybrid cloud environment to lower their costs and become more efficient without the fear of unnecessary HIPAA violations or security intrusions.
Those are the four things Dell EMC is doing to really focus hard on delivering specific solutions that address the needs that healthcare customers have.
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