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VNA And the Centralization of Clinical Data

Medical Dealer Magazine | Cover Story | VNA And the Centralization of Clinical DataBy Matt Skoufalos

At the advent of PACS – the picture archiving and communication system associated with the storage and transmission of medical images – hospitals and health care providers were less concerned with the movement of patient data among different internal departments, or even between different institutions, than with the movement of patient data from the site of its capture to a central, in-house repository.
CIMmed - Medical Grade Mounting SolutionsThe medical imaging market has become more complex, more demanding, more competitive, and certainly much bigger since that time, however; and is now bound by various standards and strictures that govern not only the security of those images, but their portability as well. Complicating the picture is the ubiquity and variety of personal mobile devices in the health care setting, those used by practitioners and not, as well as their connection to that central data network responsible for storing, accessing, and cataloguing those images sourced from different medical devices. The technological solution to those problems that has emerged is an overlying framework to network that information: a vendor-neutral archive, or VNA.
VNAs have been on the market for about six years, estimates medical imaging consultant Michael Gray. Although the concept is fairly straightforward – an image viewing, retrieving, and catalogue system that’s interoperable with software and hardware from various developers – implementing one is a complicated task that involves connecting proprietary technologies that competing vendors have been producing for some 30 years.
“VNAs facilitate the exchange of data,” Gray said. “Let’s figure out how to exchange images among disparate systems so they look the way they’re supposed to look, and since we’re spending a fortune, let’s figure out how to never have to do it again.”
Medical Dealer Magazine | Cover Story | VNA And the Centralization of Clinical DataThe ubiquity of various medical imaging modalities across multiple health care segments, each with its own demands, has complicated the management of patient data throughout organizations of every size and specialization. When multiple practices are purchased and consolidated, so is their data. That information must be accessible securely, reliably, and distributed to various users across a variety of platforms, particularly in support of institutional transitions to Electronic Medical Records (EMRs). Unfortunately, Gray said, when many organizations migrated to EMRs, they may not have considered how their new, digital infrastructure would handle imaging workflow, diagnostic display, or archiving; as a result, piecemeal solutions emerged that could handle each, allowing “best-of-breed” developers to dominate the current market.
“Large IDNs that have good IT departments and are reasonably smart and can see their way to managing a three-piece PACS system are doing it,” Gray said. “The core of that PACS out of pieces is the VNA.”
It wouldn’t necessarily be if PACS itself weren’t subdivided into various and sundry categories comprising images captured in different formats from radiology, cardiology, endoscopy, and other departments. But a true VNA must not only manage images sourced from those various entities, it also must handle “informal” or non-PACS images from mobile devices, digital cameras, and tablets – usually, JPEG and MPEG files.
“Images in three sources need a common denominator [and] a viewing application that’s able to see them all and find them,” Gray said. “A VNA, a universal viewer for EMR, and a diagnostic display application that pushes all the boundaries. You put them all together, and they become an application that is really an enterprise-class system.”
The best-of-breed approach is equally useful for EMR early adopters as well as for health care systems that manage their own PACS systems because it augments rather then precludes installed technology, Gray said. A comprehensive system will use a VNA to bridge the gap between a viewer that handles “80-85 percent of the images and a few specialty apps for nuclear medicine and others,” he said.
“You like your PACS system?,” Gray said. “Good, we’ll plug it in. You don’t? We’ll throw it away and get one you want. Everybody has a problem of some sort. They’ve got a really good PACS system for radiology or cardiology, and whether they’re happy or not, they’ve got a contract.”
Medical Dealer Magazine | Cover Story | VNA And the Centralization of Clinical DataAs VNA developers continue to develop various advanced features and functions into their software – as well as the ability to turn each of these off and on, depending upon the sophistication of the system and the client’s price point – shoppers in turn must know the ends they’re trying to achieve before they buy, Gray said.
“If you don’t have a good description of where you’re trying to get, you’re more than likely going to make some mistakes buying pieces today that should have had that endpoint in consideration,” he said. “That generally applies to everyone – a five-guy radiology practice and a five-hospital IDN.”
Although purchases of standalone VNA systems are “cost-plus” for facilities that have already invested in PACS systems but need a standalone archive, and despite the fact that data migration is “a rather daunting task,” every health care system will be headed toward the eventual roll-out of a VNA because “you can’t manage these things in interfacing systems,” Gray said.
“After you’ve realized that you’re making a decision that is basically a career challenge, the only other thing you have to worry about is looking at the quality of the interfaces available from that vendor to the outside world,” he said. “Can you communicate change back and forth from the studies? How far along are your various vendors?”
“Early on, it became obvious that even though it was difficult to track, we saw PACS as being an efficiency improvement,” Gray said. “Today you walk into a department that doesn’t have PACS, and it’s not in business. VNA is now a brick-and-mortar decision.”
For someone like Keith Dreyer, DO, Ph.D., FACR, FSIIM, who’s vice chairman of radiology at Massachusetts General Hospital and an associate professor of radiology at Harvard Medical School, VNA represents the intersection of his job duties in both informatics and enterprise medical imaging – even when those duties don’t run parallel.
Medical Dealer Magazine | Cover Story | VNA And the Centralization of Clinical Data“It was always the responsibility of the department of radiology to make images available to folks via film, hard copy, or electronics,” Dreyer said. “It wasn’t until the rapid growth of EHRs that people were looking for a way to deliver these in a consistent and common way across the enterprise. People needed to deconstruct PACS to say what needs to happen in the department and along economies of scales.”
Of the image acquisition, routing, storage, and display functions of a PACS system, the data repository is “essentially a commodity” that Dreyer said can be handled as part of a broader storage system within the walls of a health care provider. Acquisition and workflow, however, are departmentally specific demands that require individual autonomy, and therein lies the test of a worthwhile VNA.
“You really need to look at what functionality is necessary within a department from a computational standpoint,” Dreyer said. “There’s the display for the purposes of workflow inside a department, and there’s the display for clinical review, patient access, HIE, image sharing. If you split it that way, there is a core component that’s necessary inside the department.”
“We read 2,200 cases a day at Mass General alone,” he said. “That doesn’t necessarily mean that’s what the 5,000 physicians or 3 million patients we serve need to be able to take a look at those images. So you need to abstract a solution that probably has less functionality but works on more devices.”
Wholesale changes to the operations of health systems only transpire through federal mandate, concerns over risk or compliance with such mandates or financial motivation. Dreyer believes that creating a centralized patient data center is a financial issue; creating a common, enterprise-wide visualization tool is too, but more because efficiencies of scale can be derived from the workflow improvements of multiple departments able to access their imaging data in any format and whenever needed.
“The best VNAs need to be able to input from any image source,” Dreyer said. “Then they need to be able to communicate to a master patient index so they can handle various sources from multiple departments, but also multiple hospitals. Then, they need to have their own form of cache to be able to have a storage facility behind them.”
“Ideally, they would provide a cloud solution for that storage as either backup or primary,” he said, “and then they would need to be able to abstract that data as a common access point. Then, they need to have a thin visualization tool or be able to support outside visualization.”
Although the task of uniting such disparate interests can be daunting, Dreyer agrees with Gray: that resolving it will involve giving consideration to “the final evolution of what medical imaging informatics is going to look like.” Whether cloud-stored data is cheaper and safer than locally stored data; whether an enterprise-wide VNA does or doesn’t support an enterprise-wide PACS system; whether modalities bypass a PACS system altogether and go straight to the VNA.
“Technology evolves, and so you really have to think through, now that it’s 2015, what’s the best way to design this technology,” Dreyer said. “It probably isn’t to have it come off a modality, sit in a department, get stored; maybe it just goes to a central storage instantly, then it goes to the departments for primary interpretation, but it can also go directly for clinical review. Right now, it goes from a CAT scan to a PACS system to a VNA.”
Medical Dealer Magazine | Cover Story | VNA And the Centralization of Clinical DataMach7 Technologies CTO Eric Rice said that the chief goals of VNA developers, which includes his company, are to create enterprise imaging platforms that consolidate data while allowing clinicians to have better control over it.
“Specialists want to be able to choose best-of-breed

; CIOs want to be able to consolidate,” Rice said. “We have to make a solution that can store any kind of data object, that can communicate any kind of data object, but we spend time with R&D making sure clinical applications can plug into it as well.”
Health care technology vendors feel pressure to implement interoperability standards, Rice said, be they are related to federal standards or incentives around meaningful use, or from customers who want additional functionality, better pricing, or more reliable uptime.
“The biggest pressure of any singular vendor is a customer saying, ‘If you want to continue to live within my ecosystem, you need to do X, Y, and Z,’ ” Rice said. “It’s tough for a vendor to say, ‘We’re not going to do that.’ They will often commit to it, and as they commit to it, that standard becomes less of an issue for the next one.”
The future of the VNA market isn’t going to be driven exclusively by particular customer demands, however, as much as it is by an institutional consolidation of unstructured health system data – not just images, but patient reports and interviews, Rice said. This “federated approach” will create federated repositories of structured and unstructured data, the fluidity of which vendors like Mach7 will be tasked with enabling, for the benefit of providers and patients alike.
“As patients are getting more control of their purchasing decisions, they’re going to be a little more picky about which health care provider they go to,” Rice said. “It’s beneficial knowledge to the patient that they can exchange their data from one repository to another and vice versa.”
For providers, he said, capturing more patients equates to more revenue at a system level. As patients get more access and control over how their information is shared, Rice believes they are going to be able to assist more in their own diagnoses, treatments, and scheduling.
“The consumerization of this data and how patients get access to it, as we have these bigger repositories of data, we’ll see more around prescriptive analytics, whether in the hip pocket of your iPhone or elsewhere, and from that, give you some kind of treatment plan that your physician can work through,” Rice said.
“The one thing you can predict is that there’s always going to be change,” he said. “New standards will come out in the future, but we should be able to grow with the industry as these new trends, new application, new data emerge. As these institutions are consolidating through mergers and acquisitions and building up their patient populations, the interoperability at play is really, really important. The technology is really a good core differentiator for us.”