As the vendor neutral archive market grows, Cincinnati Children's Hospital Medical Center is deploying a long-term strategy for integrating medical images into its mainstream workflow using the latest VNA technology.
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That Ohio pediatrics system's path to the next generation of imaging -- part of a vendor neutral archive market that is consolidating and appears to be gradually replacing older picture archives and communication systems (PACS) -- is starting now.
Cincinnati Children's is launching a Web-based, zero-footprint viewer from Merge Healthcare Inc. -- an IBM subsidiary that is one of leading companies in the vendor neutral archive market -- and adding it to its existing Merge VNA. It is available to any clinician within the system, on any device.
The iConnect Enterprise Archive VNA stores images not only from radiology, but also from cardiology, rheumatology and anesthesia, and will eventually include many other medical specialties, unlike traditional PACS that are essentially confined to individual hospital departments.
Hospital IT planners also expect the VNA -- which is being integrated with the Epic Systems Corp. EHR and existing Merge PACS -- to work in a few years with IBM's Watson cognitive computing engine as a clinical decision support and population health tool.
"We have [pursued] a VNA strategy primarily for enterprise imaging," said Alex Towbin, M.D., director of radiology informatics at Cincinnati Children's and a key architect of the pediatrics provider's VNA ecosystem. "The goal for us is … not to federate radiology images across an enterprise, but to bring all the images from the hospital to one spot."
Streaming images to the clinician
Cincinnati Children's system is structured around a universal, or enterprise, viewer from Merge that uses server-side rendering to stream even the most complex medical images to clinicians' mobile devices or zero-footprint desktops. Zero footprint refers to a terminal without software actually loaded on it.
Similar cloud-based image sharing is also benefiting patients, as well as providers who already make medical images, such as MRIs, available on laptops, tablets or smartphones with no viewer or processing required by the user.
The advent of streaming in the vendor neutral archive market is a significant development that has occurred over the last few years, according to Joe Marion, a medical imaging expert and principal at Healthcare Integration Strategies LLC.
That popular and relatively simply approach and its growing adoption is part of the steady march of VNAs as they supplant PACS more and more when providers are looking to upgrade or replace imaging systems, Marion said.
"They're becoming more accepted. There are more places that are starting to look at them," Marion said of VNAs.
Another driver for VNAs, Marion said, has been the anticipated image-sharing requirements of meaningful use stage 3, which is now being replaced by new federal emphasis on value-based healthcare and Medicare reimbursement.
Storage options with VNAs
Beyond image sharing, storage of the rapidly expanding universe of digitized medical images is yet another force propelling the movement to VNAs.
Marion said one client of his recently turned to VNAs, reasoning, "We're running out of storage capacity on our PACS, and we need more space to store images."
"A lot of [providers] are saying 'Let's just turn to a VNA and do it that way, '" Marion said.
As for VNA image storage, providers generally are pursuing three approaches currently:
- remaining solely with on-premises data center storage and backup under the thinking that it provides greater security, control over images and lower latency than cloud storage;
- relying on a hybrid storage setup that keeps the most urgent images on premises but stores backups in leased cloud space; and
- moving to all cloud-based storage, an option now offered by some VNA vendors, including Merge, which runs a multi-tenant private cloud for some of its clients.
Image formats at the heart of VNAs
Yet another relatively recent trend in VNAs is the move toward the newer XDS (Cross-Enterprise Document Sharing) imaging format as an option for storing patient imaging content, said John Hansen, vice president for interoperability at Merge.
In fact, the latest iterations of Merge's iConnect VNA support XDS because Merge considers the XDS image interoperability framework considerably more "lightweight" than DICOM (Digital Imaging and Communications in Medicine) systems, Hansen said. It is also compatible with the Merge iConnect Access universal viewer that streams images from the VNA server.
DICOM, a mature medical image exchange standard born of radiology more than two decades ago, is an essential component of many VNAs and PACs.
The new Merge XDS-based viewer "is optimized efficiently so there's no image degradation or image skipping," Hansen said. "The primary use case for it is distribution of images across an enterprise and image sharing, but we do have customers using it for primary diagnosis."
Physicians can make diagnoses because the system has clearance from the Food and Drug Administration for applications involving primary diagnosis of medical images. However, this approach is not allowed on mobile devices.
Quick overview of VNA competitors
With a customer base made up largely of big healthcare systems, Merge Healthcare Inc. is competing in the vendor neutral archive market with a handful of other established VNA vendors that have been acquired in recent years by big tech conglomerates.
Major players in this class are the former Acuo Technologies, now part of Lexmark International, and TeraMedica Inc., a subsidiary of Fujifilm Medical Systems U.S.A.
A smaller but feisty upstart, Mach7 Technologies Ltd., entered into a $60 million merger in April 2016 with 3D printing vendor 3D Medical Ltd.
Meanwhile, tech giants already firmly embedded in the hardware side of medical imaging, such as GE Healthcare and Agfa Healthcare, also compete in the space.
VNAs assisting with clinical conditions and billing
Towbin, of Cincinnati Children's, said the hospital system is also starting to use the VNA with a small department in the hospital that focuses on patients with "sunken chest" syndrome. The VNA helps the team produce and share CT scans, ultrasounds and other images to guide surgeons and help them avoid cardiology complications.
Towbin said another value of the VNA, which has been in place at Cincinnati Children's since early 2015, is that increasingly ubiquitous imaging procedures, such as point-of-care ultrasounds, can be accurately documented and billed for. That capability will aid in the transition to value-based care and bundled payments.
Meanwhile, Towbin described a typical real world healthcare scenario and how VNA technology improves the imaging component of care.
"I have a child with congenital heart disease who gets radiology and cardiology for imaging and would have chest X-rays, cardiac [MRI], cardiac echocardiogram," Towbin said.
"In the past, for us, it's been in separate systems -- not always the easiest to access," he continued. "Now, the images will be there side by side and accessible anywhere, so anyone -- radiologists and cardiologists -- will be able to see [them]."
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