imaging in the cloud: a new era for radiology

Imaging In The Cloud: A New Era For Radiology

Doug Rufer – Region Business Manager –Radiology Solutions, US&C

Introduction

Approximately 7,300 Carestream employees serve customers in more than 150 countries worldwide

We hold more than 1,000 patents for technology and patents for technology and intellectual property

Our products are at work in 90 percent of hospitals and clinics worldwide

We have a customer centric culture

Who We Are…

When you think of the world’s first proven wireless digital

radiographic detector, the first packaged X-ray film, the

first digital dental detector, or the first medical dry laser

imager…healthcare professionals around the world think

of Carestream.of Carestream.

We are a world leader in:

• Medical imaging … digital and film

• Healthcare information solutions

• Dental imaging and dental practice management software

• Molecular imaging

• Non-destructive testing

Our Industry In Transition

Think Back a Few Years…

Remember when there was film? And Processors?

To Get This?

Things Changed and Today Looks Like This…

But Change Brings New Challenges -Consider:

• Data is growing exponentially demanding new storage solutions

• Organizations are managing multiple silos of storage which increases

costs significantly

• Location/department focused vs. patient driven workflow

• Strict legal, retention and security requirements – how do I keep my

data safe, yet share it?

• Data Neutrality and Interoperability

• High demand for Image Exchange and Access

What’s Next On the Horizon?

Site C

Site D

Site A

HL7

DICOMSite D

Site B

DICOM

HL7

DICOM

•Centralized vendor neutral archive•Storage in the “Cloud”•Improved mHealth through access•Higher standards of interoperability•Focus on patient centered workflow

CentralArchive

RIS

PACS

Cloud Services are Changing Old Mindsets

Cloud-Based Services….

Ownership Usage

Do-It-Yourself

Services Rendered

(SLA)

Capital Expense

Fixed Asset

Operating Expense Service

And Future Financial Models



Do-It-Yourself

Services Rendered

(SLA)

�� Pressured by demands for lower costs, quality, safety, and care integration, the industry has embarked on a fundamental transformation

� This paradigm shift in care and financing has driven senior executives to rethink how they do business, where they do business, and how they connect with others

� This information revolution is focused on the goal of more informed, patient specific decision-making



Do-It-Yourself

Services Rendered

(SLA)

�The demand for IT skills is increasing rapidly

� Regulatory efforts like Meaningful Use and ICD-10

� Strategic EHR implementations, connections to HIEs and necessity to join ACOs

� Demand is spiking while budgets are shrinking – focus on driving costs down while improving outcomes



Do-It-Yourself

Services Rendered

(SLA)

� The infrastructure modifications required to resolve storage growth challenges for “Big Data” and PACS images must also produce new healthcare IT solutions that can evolve as disruptive innovations

� The developing trend in IT is away from buying technology and towards buying the results that technology delivers and communicating these results to their internal customers



Capital Expense Fixed AssetOwnership

Operating Expense Service

Services Contracts • Cash Purchase• Bond Financing• Loan Financing• Capital Lease Financing• Pay per Procedure Payments

• Services Contracts with predictable Unit Price/Study and a defined SLA

Organizations will continue to struggle with growth financing

Cloud Services is a FASB-13 Compliant method fororganizations to grow while staying nimble and managing their cash as well as their balance sheet

Rise of the VNARise of the VNA

•A VNA is a standards-based archive that works independent of the

PACS provider and stores all data in non-proprietary interchange

No clear cut or widely accepted industry definition

What is a VNA (Vendor Neutral Archive)?

formats

•A VNA also provides context management so that information can

be transferred seamlessly between disparate PACS via DICOM and

HL-7

Different Archive Types

•DICOM Archive – supports storage of radiology images in a DICOM format; most archives available today

•Multi-department Archive (radiology/cardiology) – serves multiple department’s imaging needs

•Multimedia Archive – expands the DICOM archive to •Multimedia Archive – expands the DICOM archive to incorporate other data types, such as JPG, MPEG, DOC, PDF, etc. files

•Enterprise Archive – Becomes the backbone of a health network and incorporates an MPI

•VNA – Patient-centric, open architecture archive that supports cross document (XDS) protocolsOosterwijk, Herman. What Is a VNA, Anyway? Publication. N.p.: Www.Healthimaginghub.com, n.d. What Is a VNA Anyway. OTech and Teramedica. Web. 28 Mar. 2014.

A “True” VNA:

1. …is a medical device

2. …is scalable

3. …provides image, information, and lifecycle management

4. …manages both images and related information in a patient centric 4. …manages both images and related information in a patient centric manner accompanied by cross departmental workflow

5. …supports open standards and multiple departments with infinite expandability

6. …maintains patient privacy and is highly secure

7. …does not require PACS migrations, new interfaces, or data conversions when technology changes

8. …offers cloud access capabilities and works with universal viewers

Oosterwijk, Herman. What Is a VNA, Anyway? Publication. N.p.: Www.Healthimaginghub.com, n.d. What Is a VNA Anyway. OTech and Teramedica. Web. 28 Mar. 2014.

Vendor Neutral Archive

� Provides a centralized, redundant, clinical information management control and archiving solution that is:

� Fast, secure, independent, and scalable

� Provides for patient centric workflow

Radiology: DICOM / HL7

Other Clinical:“Other” data, XDSCardiology:

DICOM / HL7 / “Other “dataLaboratory:“Other” data

Interesting Facts…

1. 1/3 of US hospitals have a VNA1

– Today’s cost is barrier for smaller facilities

– Need to adopt cloud-based VNA solutions to contain costs

2. 1/3 of all imaging produced in the US will reside on a VNA by 20162

3. Global Cloud computing market was valued at $1.8B in 2011 and expected to grow to $6.79B by 2018 –that’s a 21% growth rate!3that’s a 21% growth rate!3

4. Medical Images are expected to require 30% of ALL storage globally and represent 10% of US healthcare costs4

5. 2012 KLAS survey said VNA would be central strategy of 27% of respondents5

6. Global VNA market is estimated at $165.3M in 2013 and expected to grow to $335.4M by 20186

7. Enterprise PACS purchase decisions are outpacing departmental PACS decisions7

1Vendor Neutral Archives: Strategy for health info exchange, by Ifetayo Freeman - http://www.auntminnie.com/index.aspx?sec=sup&sub=pac&pag=dis&ItemID=1052152Benchmarkes: Imaging IT sees a sea of change, by Mike Miliard - http://www.healthcareitnews.com/news/benchmarks-imaging-it-sees-sea-change3,4Cloud PACS and mobile apps reinvent radiology workflow, by Cristen Bolan - http://www.appliedradiology.com/Issues/2013/06/Tech-Trends/Cloud-PACS-and-mobile-apps-reinvent-

radiology-workflow.aspx5,6,7A view of the future image exchange - http://www.appliedradiology.com/Issues/2013/11/Tech-Trends/A-view-of-the-future-image-exchange.aspx

Site C

Site A

CARESTREAMAgent

HL7

• Central, consolidated archive across disparate sources

• Endless number of data sources

• Unlimited storage volume

VNA Benefits

Site D

Site B

DICOM

HL7

DICOM

DICOM

HL7

“Other” Data

XDS

CARESTREAMXDS Registry

Clinical DataArchive

• Data replication and complete security

• Vendor Neutrality: Data format, platform, PACS�No more data migration costs

• Integrates data from disparate clinical vendors via:�DICOM, HL7, IHE XDS Framework, XDS-I, Other

• All data types managed through one centralized system

• Patient centric view of data with clinical lifecycle management

• Backbone to true mobile healthcare

An Interesting Thought….

So…is PACS as we know it dead?

Will the VNA become the be-all backend infrastructure for your enterprise?infrastructure for your enterprise?

Will “PACS” simply be a universal viewer with tools specific to the specialist (referring, radiologist, etc.)?

Only time will tell….

So is this technology taking So is this technology taking off?

Healthcare Technology OnlineTop Health IT Trends

p.24

Are We Ready for Imaging in for Imaging in the Cloud?

Seems like the Cloud is Everywhere…

Cloud Based Cloud Based PACS ServicesPACS Services

License Software vs. SaaS

Purchase a software license

� Install software on a local server� HW compliance

� OS requirements

� Maintain software� Apply security patches

Purchase Software as a Service

� Register on-line with a browser� No HW risk

� No OS requirement

� Software maintained in the cloud� No security patch � Apply security patches

� Upgrade software� Downtime

� Potential compatibility issue

� Sharing documents by sending� Multiple copies / Version control is

difficult

� Data protection depends on user (backups)

� No security patch

� Upgrade in the “backcloud”� No downtime

� No compatibility issue

� Sharing docs by on-line access� One copy

� Data protection depends on service provider at data center

CIO’s biggest issueswith imaging IT

• Ensure Availability of Patient Data over a Lifetime

• Manage Unpredictable TCO with Unexpected Capital • Manage Unpredictable TCO with Unexpected Capital Expense

• Protect Regulated Data (PHI)

• Enable Physicians Collaboration across Sites & Systems

On-going Cost of PACS (Archive)…

• Continuous expansion of storage capacities to absorb the exploding production of imaging data

• Upfront capital investment in capacities which stay unused and idle during most of their lifetime

• Unpredictable Total Cost of Ownership over the lifetime of data (Investment, Maintenance, Expansion, Migration, Replacement)

Yet the Need for Collaboration…

• Ever frequent demand to get faster results on-site or on-the-go delivered to the caregiver at the point of care

• Disparate legacy imaging systems across multiple distant locations.

• Difficult single-point of access across the continuum of care

On-demand and Ad-hoc Collaboration• Referring physicians can access enterprise imaging patient portfolios, including comparison

of images, reports and other supporting data

• Enables real-time collaboration between clinical users

Physician Directed Exam SharingOr Disruptive Innovations for Access

Simple to deploy and maintain• Zero overhead for high-speed performance

• Latest enterprise-access technology without replacing legacy PACS or archives

Easy to Use• Simplify workflow as an independent viewer or

embedded within EHR or HIS

• Simple, easy to adopt, intuitive user design that doesn’t require dedicated training

Patient Directed Exam Sharing

Patients will control their individual health information portfolio.

A patient may be interested in sharing their exam information with another person (physician or non-physician). The person with whom the exam data is shared would have access to all the tools available for manipulating images.manipulating images.

Report Information …

Access to Full Patient History, Reports, and Notes

Market Demands are Creating Transitions

� There are initiatives to fuse legacy Imaging IT (PACS) and Healthcare Information Exchanges (HIE) for patient data without fork-lifting the existing infrastructures

� There is a growing number of healthcare � There is a growing number of healthcare organizations with a need for an information hub supporting global workflow & ad hoc demand for access to mobile portals for comprehensiveenterprise review and collaboration

� There is a consolidation of healthcare organizations with a need for Vendor Neutral Archives (VNAs) to replace disparate archives and provide business

continuity with disaster recovery protection

Meaningful Use – The Basics

What it is – simplified…

• Guidance for health entities and providers to use medical information in a meaningful way to improve patient outcomes

How we will do this…

• By digitally transforming our paper based healthcare system through the adoption of EHRs• By digitally transforming our paper based healthcare system through the adoption of EHRs

– Providers (Eligible Professionals)

– Hospitals (Eligible Hospitals)

• Exchange key patient information through Health Information Exchanges (HIE)

– Benefits

– Better physician collaboration

– Reduce repeat exams

– Track key data within a population

• HIPAA – Health Insurance Portability and Accountability Act – sets standards and assures patient data communication is secure via electronic exchange

Why CIO’s are Considering Cloud

77%Reduce costs

• Pay only for what we use• Software License Savings• Lower outside maintenance costs

• Hardware savings• Lower labor and

support costs

To what degree would each of these factors induce you to acquire commercial OpEx Cloud Services?

1

Respondents could rate multiple drivers items

50%

72%

Improve reliability

Faster time to value

Source: IBM Market Insights, Cloud Computing Research, July 2009. n=1,090

2

3• Improve system reliability• Improve system performance

• Take advantage of latest functionality• Simplify updating/upgrading• Speed deployment• Scale IT resources to meet needs

Functionality & Workflow in the Cloud

Sharing Data and Workflow

Consolidated Patient Portfolio, across multiple departments, sites and IDNs

Single, Shared Global Patient Worklist

Common access from any location

Patient Access

Mobile Access

Medical ConsultAccess

Superior Clinical Imaging Functionality

Common access from any location

On site and remote Diagnostic and Clinical Review

No fork lifting existing Imaging IT infrastructures

Data Consolidation and Central Management

Industry consolidation to replace disparate archive infrastructures with Scalability and Redundancy

Integration with multiple systems and sites

Multi-format, flexible content Multiple Ingestion Points

Imaging Considerations Considerations of the Future

Imaging 3.0

What is it?

•Change process led by the ACR to ensure radiologists play a key role in healthcare delivery and quality patient care

•Mandate to ensure radiologists remain relevant in tomorrows healthcare delivery and not irrelevant

•healthcare delivery and not irrelevant

• Initiative to focus on being a key consultant in the delivery of a patient’s care once the decision has been made that imaging will play a role

• Pre-exam consultation

• Post exam interpretation with improved recommendations

• Assisting with the care plan of the patient and consultation with the referring physician

Source: Allen, Bibb. Speaker Toolkit Imaging 3.0 Overview and Script. Reston, VA: American College of Radiology, 14 Feb. 2013. PPT.

HIE – Why This Initiative Matters

1. Created as a collaboration between HIMSS and RSNA organizations

2. Sought to improve the way computer systems in healthcare share information

3. Provide data to the clinician when/where it’s needed and all patient information can be searched based on specific standardscan be searched based on specific standards

4. Addresses areas outside of medical imaging (for example, Cardiology, Opthamology, Pathology, Dental imaging, IT infrastructure, Pharmacy, Patient Care Devices, etc.)

Source: IHE.net/FAQ/

Interoperability – XDS-I; Your VNA Must Support This

What is XDS-I?

• XDS

• Created by IHE (Integrating the Healthcare Enterprise)

• Refers to a family of profiles that support document and image exchange in healthcare • Refers to a family of profiles that support document and image exchange in healthcare systems

• XDS-I specifically addresses medical image communication between healthcare systems

• But What About DICOM and HL7

• Both are part of the XDS profile.

• Consider this example: DICOM and HL7 are the vocabulary and basic grammar of integration; XDS provides the technical framework for how the language fits together and is communicated to others

Source: Mik. “What Is The Difference Between XDS, XDS.a, XDS.b, and XDS-I?” What Is The Difference Between XDS, XDS.a, XDS.b, and XDS.I? Healthcare IT Systems, 22 May 2012. Web. 28 Mar.2014

Why is Interoperability Important?

Optimal Patient Care

• Requires access to all relevant information at the right time

• Necessitates the need to share information openly to those who need it

• Eliminate redundant data entry

For IT

• Standardizes the way systems will communicate via strict adherence from vendors for communication protocols

• Allows for best of breed solutions to be purchased while ensuring standards based integration and communication

• Improves and simplifies system implementations and support

What you will get out of all this….What you will get out of all this….

Business Intelligence

For Radiology?

• Radiology practices have turned from “cash cows” to “cost centers”

• Outcome based models of care (like those previously mentioned) are forcing providers to slash costs due to declining reimbursement of Medicare payments

•• There is urgency today for radiologists to understand where inefficiencies exist in their radiology operations; all while boosting quality and cutting costs

• Analyze 3 key areas:

• Clinical – what exams are more urgent; catching duplicate studies; educating other care providers on best practices

• Operational – understand your modality utilization to effectively manage staffing

• IT – monitor your IT systems to be pre-emptive and avert disasters

• Start now before your CIO finally gets around to radiology

Source - Fluckinger, Don. "RSNA 2013: Radiology Survivors Will Embrace Business Intelligence." RSNA 2013: Radiology Survivors Will Embrace

Business Intelligence. TechTarget, 04 Dec. 2013. Web. 28 Mar. 2014.

Business Intelligence

So why is this important?

• In 2012, about 500 petabytes of data exist globally; that will expand to greater than 25,000 petabytes by 2020*

• That much data will require tools to better analyze the stored data so healthcare providers and facilities can make better, more informed decisions – with the ultimate goal of reducing healthcare costs while improving patient – with the ultimate goal of reducing healthcare costs while improving patient outcomes.

• If medical images will truly represent 30% of all data stored electronically, there is huge opportunity for BI to be used to improve patient care, length of stay, etc.

* Source: Gardner, Dana. "Healthcare Turns to Big Data Analytics for Improved Patient Outcomes." ZDNet. HP, 12 Dec. 2013. Web. 28 Mar. 2014. /

VNA: Why Invest; What to Invest; What to Look For

Why Move to a VNA?

Top 5 Reasons to Purchase a VNA

• Long Term Storage Format: A Vendor Neutral Archive is based on the DICOM industry standard file format and protocol and XDS-I protocol.

• Reduces Risk of Data Migrations: Data migrations will be a thing of the past since a proper VNA will mitigate the need for a site to perform one in the future due to the standards based approach of this solution.standards based approach of this solution.

• Prevents Vendor Lock In for PACS Vendors: No more proprietary data formats. You are free to choose what vendor/viewer/etc. best meets your organizations needs.

• Long Term Redundancy: Data replication, redundancy, life cycle management, and business continuity. All offered when coupled with a cloud based solution. The benefit to you: rent the long-term storage, instead of invest in storage that may not be used for years, requiring upgrades downstream.

• Integration: A good VNA will allow for easy integration to virtually any system you have, be it HIS, RIS or PACS solutions plus utilize open standards such as HL-7, DICOM, etc. and be patient centric to deliver all patient information to the caregiver where and when they need it.

Source: DeepWellArchive. "Vendor Neutral Archive: Top 5 Reasons Why to Implement a VNA." DeepWell Archival Services Electronic Medical Record

Storage Powered By ClvrTv. DeepWell Archival Services, 04 May 2011. Web. 28 Mar. 2014.

A Few Considerations

Look for Vendor Neutral Archives that:

•Offer an on-site and off-site (cloud) architecture

•Benefits:

�Prevents your data from being in a “silo”�Prevents your data from being in a “silo”

�Disaster recovery built in

�As technology changes, so does your archive

�You don’t have to “own” the technology to move forward since the cloud vendor makes those investments for you

�Moves capital expense of an archive to an operating expense

� “Own” your on-site storage for current studies and “rent” the rest

Source: Calhoun, PhD, August. "Don't Create a Vendor-neutral Silo: Why Your Image Archive Should Include the Cloud." Healthcare IT News. Healthcare IT News, 04 Nov. 2013. Web. 28 Mar. 2014.

Checklist

� What departments will store data on the VNA?

� Have you considered workflow for all those departments when querying or accessing data?

� Will your VNA be local or in the cloud – or both?� Will your VNA be local or in the cloud – or both?

� What are your plans for disaster recovery?

� Does your vendor support open standards?

� How does your vendor index patient information on the VNA? Remember, now all departments use accession numbers and order exams for images?

Checklist - Continued

� What universal viewers will you use to access the data on your VNA?

� Does your vendor support XDS and XDS-I protocols?

� How will you manage document/image life cycles? Does your vendor support this for long-term strategy?this for long-term strategy?

� Will you connect your VNA to a local registry for cross enterprise document and image sharing?

� How will you manage access and security? Mobile access and security in compliance with HIPPA and PHI?

� Are you planning to replace your PACS? If yes, have you considered a VNA as a driver to do that so storage and migration costs are no longer a concern for the future?