Imagine. Automatic access to a patient's full clinical history across all providers. Electronic medical records (EMRs) enriched with radiology images and reports. Streamlined communication of diagnostic-quality medical images. Upgrading to a new picture archiving and communication systems in just hours. Welcome to the VNA-enabled world of medicine.
Small wonder that VNAs (Vendor Neutral Archives) are predicted to store 31% of all new imaging studies across the globe within four years, according to a major new report by InMedica, the leading independent provider of market research and consultancy to the global medical electronics industry.
Currently, the VNA is one of the most talked-about new healthcare IT technologies. And while definitions vary, most experts agree that a primary benefit is allowing sites true control of their own healthcare data. Others include interoperability among IT systems, easy medical record sharing and analysis and use of information in ways never before possible. In short, the VNA enables imaging sites to declare their data independence from the proprietary IT systems that so often restrict the value of important medical information.
The VNA-Adhering to True Standards
Unlike most PACS and other healthcare applications, a VNA follows storage methods and data formats that objectify healthcare information by adhering to industry standards. Additionally, IT applications are no longer tied to physically addressed storage and communication with other systems through proprietary integration.
Underlying many of these benefits is a consistent metadata format, which enables identification of all data for a particular patient, wherever the information entered the IT system.
This patient-centric data presentation eliminates today's convoluted, costly and clumsy IT interfaces and home grown workarounds that attempt to fill in the gap among systems. Any application using the archive requires only a single point of integration to a standardized service for access.
VNAs typically unify data from HIS, RIS, PACS, EMR as well as information from numerous specialty departmental systems into a single archive.
Key Attributes of a Vendor Neutral Archive
Key attributes of a VNA include:
■ Patient-centric storage.
■ Open standards.
■ Management of images as well as related information.
■ Support for query, storage and retrieval.
■ Support for multiple departments, enterprise and regional architectures.
■ Audit trails that maintain patient privacy and security.
■ Allows PACS and other IT solutions to be interchangeable.
■ Elimination of future data migration and/or conversion of data formats.
■ Hardware agnostic.
■ IHE compliant and certified.
Solving the Problems of Proprietary PACS
Because diagnostic images and reports are among the most frequently shared information across the continuum of care, the isolated and often proprietary PACS archive has long posed a particular problem to hospitals-and to radiology departments that wish to upgrade to new PACS applications. The VNA provides an elegant answer to PACS problems with implications across the enterprise and beyond.
Perhaps surprisingly, many PACS difficulties are actually rooted in the longstanding Digital Imaging and Communications in Medicine (DICOM) standard itself, which isn't actually all that standard. DICOM fails to fully specify the metadata tags (fields) used to identify and annotate data. Unfortunately, this gives PACS vendors plenty of room to retain vestiges of their older proprietary systems. Additionally DICOM permits the addition of private tags, which will not read across vendors. It also permits empty relational data fields, with other negative consequences. In short, DICOM provides ample opportunities to keep data tethered to a specific application, making cross-vendor communication difficult and migration to another vendor's system often an arduous process.
As if all this were not enough, the promise of an EMR enabled with DICOM images and related information is even more complex. This can require custom interface engines to link unrelated systems and possibly data transformation. It may even require the duplication of entire archives. Interfaces are costly to acquire, implement and maintain and create security risks and scalability issues. Data duplication astronomically multiplies the storage and maintenance costs.
The entire situation is even more unmanageable due to the nature of the DICOM beast. Imaging files are enormous and becoming larger-and therefore are complex, costly and cumbersome to share.
Moving all information to a truly standard DICOM eliminates most of these problems. With a VNA, sites can share images across systems, migrate to a new PACS and manage their data much more easily.
PACS Beyond Radiology and DICOM
The VNA's benefits do not stop with images-nor do the problems of PACS. Currently, a PACS is often called upon to store a growing variety of data-both DICOM and non-DICOM-from within radiology and from other medical specialties.
DICOM data stored may include cardiology, neurology, and an ever-growing list of the ologies. The departments that generate this data often have their own identification numbers, requisition systems and even accession numbers that all must be reconciled and managed within the PACS just to create an integrated record in this single application.
Radiologists are increasingly adding non-DICOM data objects-such as scanned prescriptions and reports-to the PACS archive. And cross-departmental data also may not be in DICOM format.
Without an accepted metadata management standard to help reference this information to a specific patient, it remains tied to the PACS archive and to the department that created it. With VNA standardization, management becomes far simpler and sites have a platform for cross- application viewing.
Whether or not information from the other ologies-both DICOM and non-DICOM-is managed in a PACS, it is of course managed or stored somewhere. If archived in a separate IT application with even more department-specific formatting, the difficulties of introducing it into any standardized system or an EMR are even greater. If stored on isolated hard drives or on CDs casually tossed in desk drawers, it is probably not even managed in any meaningful way.
Again, the VNA again provides a powerful way to fill in the gap.
The VNA -Strict Adherence to IHE Standards
A VNA takes advantage of standards developed by the widely recognized Integrating the Healthcare Enterprise (IHE) initiative. In addition to DICOM, these include XDS and XDS-I, HL7 and others. Using this shared data format, the VNA provides one comprehensive archive as the single point of information access for all the healthcare IT applications connected to it.
Naturally, existing non-standard data will have to be transitioned to this formatting as part of the data migration process. Many VNAs provide sophisticated built-in tools for this migration and data standardization. Medical sites weary of the ongoing cycles of data conversion that accompany a move to a new IT application will be pleased to know that this will be the last data migration they will ever have to perform.
Because the VNA contains diagnostic images, image-enabling an EMR and other IT systems becomes far less challenging than with a siloed PACS archive. Providing this patient-centric storage and information sharing will put a facility on the road to Meaningful Use.
Once the VNA is active, if slightly non-standard data enters the system, many VNAs stand ready to help. Through DICOM tag morphing, advanced systems can neutralize proprietary data, reconcile and manage patient identifiers from multiple sites and resolve inherent metadata discrepancies. Some systems can also maintain the original tagging so that the data can interact with both standard and non-standard systems.
Standardizing Non-Imaging DICOM Objects and Non-DICOM Data
As noted, in addition to DICOM images, a VNA stores non-imaging DICOM data. This includes DICOM Structured Reports, containing CAD and measurement data, and DICOM Presentation States with user manipulations such as shutters and overlays.
The VNA also stores and manages non-DICOM information from other specialty IT systems across the healthcare enterprise. This typically involves such files types as JPEG, PDF, waveforms, various video and audio formats, and MS Word-in short whatever modern medicine sends its way. In particular, these versatile storage capabilities make the VNA an appropriate repository for data from specialties as diverse as lab and ophthalmology to speech pathology and dentistry.
Some VNA providers can store non-DICOM data in native format, which provides for easy exchange of the originating system and allows departmental IT systems to retain some autonomy. Whether and how this is accomplished may vary significantly with the VNA vendor and has important implications for the true neutrality of the archive.
Whether for DICOM or non-DICOM objects, once the object header is formatted with consistent patient identifiers as defined by the IHE, a simple search in the appropriate fields will gather the information necessary to create a comprehensive patient record. To facilitate this, the VNA includes a master image manager database, which captures information from the header such as patient name, patient ID, accession numbers and more. Information is recalled against the database using a standard storage query and retrieve protocol.
In addition to storing and retrieving data, an intelligent VNA also can route and pre-fetch studies and manage certain functions based on user-determined rules.
Enabling the EMR
Often, a key goal of the VNA is to provide access to complete, accurate and timely patient data at the point-of-care, typically through an EMR system. A VNA simplifies the task. A simple link to the standards-based VNA archive will bring up all these images and imaging-related data for a particular patient. Embed a lightweight DICOM viewer, and the result is an easy and elegant hospital-wide image viewing solution.
Naturally, this same link and viewer can bring VNA information to any physician portal connected to the archive with a simple click.
Streamlining PACS Migration
As a result, a site also has the ability to elegantly switch to any new standards-based PACS or other clinical system without costly data migrations or significant data reconciliation and cleansing. The VNA ends the era where a medical facility was tied to a particular vendor simply because their data was held captive in a proprietary format. Typically a new PACS can be connected to the VNA with a simple plug-in with little interruption of department functions.
Benefits of the Vendor Neutral Archive
When a site truly owns its data with a VNA, it also realizes a full range of advantages that will enable:
- ECONOMIES OF SCALE: A reduction in data storage silos can cut storage management costs and improve data security (HIPAA compliance) by using standard IT policies and principles for managing enterprise data.
- ENTERPRISE DATA MANAGEMENT POLICIES: Standardized enterprise data management rules greatly decrease storage costs and reduce or eliminate legal liabilities using institutional data purge policies or data tier policies (hardware/compression rules).
- REDUCED INTERFACE COSTS: Using a shared archive platform to store clinical data and distribute it, IT management can reduce complex system interfaces to the EMR, enterprise information systems (EMPI, patient registration, etc.), and departmental information systems (RIS, CVIS, etc.) within the enterprise.
- OPTIMIZED IT INFRASTRUCTURE: Allows IT to select best tools (PACS, workstation, etc.) for clinicians to meet job requirements. The VNA reduces difficulties involved in migrating large volumes of image studies. In addition, reducing vendor dependence can decrease new or replacement PACS expenditures by creating a more competitive bidding environment.
- IMPROVED DATA AVAILABILITY: A centralized image archive allows for an easier and less expensive implementation of a highly available data storage management solution.
- ENHANCED CLINICAL INFORMATION LIFECYCLE MANAGEMENT: Managing clinical data based on its clinical value over time in a tiered clinically-aware archive improves availability of information (via different QOS tiers) and reduces storage management costs (using intelligent compression or purging techniques).
- ENHANCED PATIENT CARE: By simplifying the sharing of imaging studies and clinical content between PACS, departments, and facilities, clinicians can have access to additional relevant patient information. This, in turn, can positively affect clinical efficacies.
- FACILITATE COMPLETION OF ELECTRONIC MEDICAL RECORD: Placing more information into an EMR context allows broader distribution of content to physicians and clinicians. This results in greater acceptance of the EMR by both physicians and allied staff.
- CREATE AN INFRASTRUCTURE FOR DATA MINING AND OUTCOMES RESEARCH: Smartstore's enterprise basis solution allows for broad-based analysis of clinical data usage patterns. This information can be used to potentially reduce costs and improve efficiencies at the department, facility, or enterprise level.
Medical sites implement a VNA to achieve a wide range of goals, and the technology varies widely. Careful planning and an examination of competing VNA solutions is the best way to assure optimal outcome for a VNA conversion.
Greg Strowig is Vice President of Client Services, TeraMedica.