INTEGRIS Health, Oklahoma’s largest healthcare network, recently had to find a solution to a significant problem: its nine hospital PACS were out of space, their software was out of date and the situation was out of control.

Dax Ewbank, enterprise solutions architect for INTEGRIS Health, coins a new phrase when he describes the malady that plagued his organization and continues to dog many others: PACS sprawl. As INTEGRIS grew and acquired hospitals, more PACS were added to the enterprise, but because the system is mission critical, it was difficult to find the time for planned maintenance.

“Patches, upgrades and just basic maintenance were often skipped or overlooked, or done on the fly as needed,” Ewbank says. “Also, while this is all happening, other PACS were added, and sometimes these types of systems were put in without IT involvement. With multiple PACS operating independently across our enterprise, managing them was challenging, to say the least, and planning for the future was almost impossible.”

The main campus PACS archive consisted of an L40 tape library, but the system’s actual tape archive was made up of 160 tapes. At any one time, only 25 percent of the existing tapes were actually online and available for retrieval.

“This, of course, was causing some really great dissatisfaction on the physician level, because when they were trying to pull relevant priors, there was about a 75 percent chance that the study they needed was not online to be retrieved,” Ewbank says. “So a person would have to go and physically pull a tape off a shelf, load it into the library, and load that study. Sometimes the study might not be available. It might take up to a day for that study to be available to the physician.”

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The enterprise IT view

INTEGRIS put the IT department in charge of PACS in 2012, and Ewbank and his team were able to assess the situation.

First, the team brought in “Barney,” an L180 tape library that earned its nickname due to a bright purple exterior. Barney was a basic stopgap that got the remaining tapes online while the overarching strategy was put into place.

At this point, the hospitals had a menagerie of outdated storage options. In addition to Barney, there was a magneto-optical drive (MOD) archive, including over 3,600 MODs, a DVD archive, and another tape archive holding 1.5 million studies. INTEGRIS desperately needed a solution, and with Barney in place, Ewbank’s team went to work to stop the sprawl once and for all.

“Our job was to take this mishmash of different archives, different technologies, different factors, get our arms around it, and turn it into something we could manage,” Ewbank says.

Ewbank and team then devised a strategic plan for what the ideal enterprise image management system would look like and how it would be managed. At the foundation, INTEGRIS implemented Synapse VNA from the TeraMedica Division of FUJIFILM Medical Systems U.S.A., Inc. With Synapse VNA in place, the future of enterprise imaging at INTEGRIS began to take shape.

“We were able to consolidate those PACS archives with disparate media, all into one, more modern media,” Ewbank says. “We actually hired a company to come in and take those MODs off the shelf, load them up one at a time and pull all of that data so that it was now on spinning disks. We were able to then import it into our VNA, and make it available to our different PAC systems. By doing this, we also were able to complete the upgrade of our PACS environment to our current version of software.”

Planning for change

A key part of the team’s plan was implementing a DICOM routing layer, which laid the groundwork for future PACS updates without manually changing several hundred different IP addresses on the modalities. DICOM routers were distributed strategically to maximize their effectiveness. Even adding a whole new PACS would be as simple as “standing the system up and creating a new route within the routing layer.”

Another advantage of this approach is that it allows the IT department to better define its users. “I joke with people and say, physician satisfaction is an oxymoron, because physicians sometimes are really hard to satisfy,” Ewbank says. “But, when we can say we took study retrieval times down from, sometimes, up to a day, to now seconds or minutes, physician satisfaction has obviously improved.”

Ewbank added that INTEGRIS is currently busy implementing Epic with an integrated clinical imaging viewer as a required feature, something that would have been unheard of before deploying Evercore, now Synapse VNA from the TeraMedica Division of FUJIFILM Medical Systems U.S.A., Inc.

“Integrating these third party systems, particularly the planning and integration for Epic, would not have been possible prior to our VNA architecture,” Ewbank asserts. “It simply wouldn't have been done. These systems were too disparate, they didn't talk to each other, and the data was physically unavailable.”

Thanks to improved storage capabilities, INTEGRIS was also able to say farewell to its purple L180 tape library. The stopgap was no longer necessary.

“We were finally able to retire Barney,” Ewbank says. “The organization has been left in a much better situation by going to a VNA. Now we actually have time to plan for the future. It’s not something that we are afraid of doing anymore.”