Managing Clinical Images: The Infrastructure Inside
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| Ken Kupetsky (center), CIO of Burke Rehabilitation Hospital, in White Plains, N.Y., says the facility virtualized its digital radiology image management system as part of an effort to streamline the flow of information into its EMR. Source: Burke Rehabilitation Hospital |
Driven in part by the need for a better image management and integration with the EMR, Burke Rehabilitation Hospital, a 150-bed inpatient acute care facility in White Plains, N.Y., virtualized its storage network. The results: Faster image pull-times and simplified management for the hospitals already stretched IT staff, says CIO Ken Kupetsky.
Virtualization also helped Burke attain HIMSS Stage 6 EMR Adoption Model last year. Stage 6 criteria include having a full complement of radiology PACS implemented—in other words, all images are available to physicians via a secure network.
Burke has 500 clinicians and more than 1,000 IT devices on its network across 15 buildings, spanning a 60-acre campus. Its image management and recovery system was siloed, and its server-attached storage was "on its last legs," with no real disaster recovery or virtualization capabilities in place, Kupetsky says. The network uses a PACS (Merge) to concentrate on housing its images.
He sought to break down the IT walls by implementing a system that could provide quick, efficient image retrieval, yet also could be easily managed by an IT staff that was already spread thin. (Burke has an IT team of 10.)
Armed with desktop virtualization (VMware) and a three-tiered storage network (Compellant/Dell) to replicate data, including images, the IT team at Burke wrote an internal application to integrate its MediTech EMR and MediServe, Burke's main clinical documentation system. The integrated application pulls information out of the two systems so clinicians can quickly access scanned images, x-rays or any images associated with the image repository, says Kupetsky.
"The virtual desktop allowed us functionality to work better than the previous siloed image access environment. It's also a better disaster recovery setup because snapshots are created on the back end, and we're able to recover those images with a couple of pushes of a button."
According to Kupetsky, Burke clinicians now can bring up clinical database images in 15 minutes—whereas it used to take 10 hours on tape. Currently, 90 percent of the data center infrastructure at Burke is virtualized, and the system sports 110 virtual servers and desktops that serve as a foundation for the organization's image management strategy, he says.
The three-tiered storage system pushes seldom-used data deeper into the system so that frequently used data and images are quickly accessible. This structure allows the system to free up server space. The new system has made for tighter integration and improved performance for critical applications including imaging, according to Kupetsky. The time needed to transition between programs and screens have been cut in half.
"If images are not accessed frequently, they move to lower disks. But if [clinicians] want to look at an x-ray, they would click on the virtual desktop application and pull the image pretty quickly, even though it had been moved to a slower disk array," says Kupetsky.
"Pairing storage and server virtualization provides a flexible, efficient foundation for DR," he adds.
The big build
Some imaging departments not only buy a new image management system, but get a new building as well. Palomar Pomerado Health System, which includes the 319-bed Palomar Medical Center in Escondido, is anticipating the opening of Palomar Medical Center West (PMC West), a new center that is slated to be completed next year.PMC West's image management strategy is built around a large-scale image cache with sub-3-second response time and direct SAN-attached archive architecture, according to Pat Dillon, director of technology at PPH.
"PPH hasn't tiered out to a third level of storage, so our long-term fetching is fast as well," Dillon reports. Referring to document imaging in the current environment and, in the future, all other compatible modalities and digital studies, Dillon says, "We don't separate our long-term plan for PACS images from other images, so in the larger context, we can stay fast on all image retrieval. Our goal is to have all the imaging accessible to the clinicians." While all the imaging is accessible currently, he plans and hopes it will all be on the same storage platform within two years.
While all the images are accessible currently, Dillon plans for all images to be on the same storage platform within two years.
Currently, PPH is setting up and testing a new PACS (McKesson). PPH selected wireless capabilities using a Cisco network and will be testing wireless portable x-ray capabilities later this year, Dillon says.
He says image management considerations during a big build include:
- Looking at the clinical workflow and seeking to catch problem issues early. For example, urgency drives the requirement in the emergency department (ED). All images and reports must be nearly instantly accessible to ER radiologists and clinicians.
- Designing in detail, including decisions such as which rooms will receive which kind of displays.
- Ensuring that the business case for all technical requirements is thoroughly articulated to justify the cost.
Image exchange in the cloud
Although an image-sharing strategy can be an integral component of enterprise-wide image management for healthcare organizations of every type, the picture can get complicated for medical centers that receive a significant number of consultations and second opinions.Virginia Commonwealth University Medical Center (VCUMC) in Richmond is an academic medical center that serves as a tertiary medical center and provides a large number of second and third opinions. VCUMC receives a large number of transfer patients and provides consultations on imaging exams performed at other facilities as well. Advanced images are critical, but storing and sharing them was becoming an issue. In 2010, VCUMC implemented a cloud-based image exchange tool (eMix) to facilitate viewing and sharing imaging exams and reports with referring facilities before patients get to VCUMC.
Currently, 17 referring facilities use the eMix tool to send images to VCUMC, and another 40 will do so in the near future, according to Ann S. Fulcher, MD, chair of the department of radiology. "This technology is important. When patients are transferred from another hospital or facility, our radiologists are able to review and interpret the images prior to the patient's arrival. This allows our receiving physicians to formulate a treatment plan often before the patient leaves the other facility," she says.
"In the past, patients brought filmed images for review, but now that imaging is DICOM-based, they bring images on CDs. However, CDs may not always be compatible with our system. This system allows us to receive images in an efficient manner," she says, because images arrive electronically before the patient does.
There has been a direct correlation between a reduction of the number of CDs being imported and the increase in the number of eMix studies transferred, says Sharon Gibbs, MSHA, CRA, director of radiology. "The workflow is improved and processing time is reduced by about 15 percent," Gibbs added.
Cloud-based image sharing strategies are another tool in the box for healthcare organizations, especially in critical access areas, to better manage incoming patient referrals, she says.
With imaging showing no signs of a slowdown in volume per study, and the possibility that some images will be part of meaningful use requirements for EMRs in Stage 2 and 3, more facilities will be assessing their image management needs and building out, swapping out or virtualizing to meet new demands.