Fulfilling the VNA Promise - How to Get the Most Out of Your Facility's Vendor-Neutral Archive

In the not-too-distant past, picture archiving communication systems, or PACS, were the backbone of every image capture and storage strategy. However, the tide is turning as some healthcare providers gravitate toward vendor-neutral archives (VNAs), in which images and clinical data are stored in a standard format and with a standard interface that make them accessible by systems from disparate vendors.

The VNA market will hit $210 million by 2018, driven by an increasing need to more easily share imaging information among healthcare providers, acording to Frost and Sullivan. Moreover, while the VNA market remains considerably smaller than the PACS market, data from Frost and Sullivan reveal that the latter is demonstrating slow growth, but the former is seeing a rapid compound annual growth rate of about 15 percent.

“All of this really isn’t surprising, given the increasingly complex amount of data from multiple sources that must be exchanged and manipulated, as well as today’s more sophisticated workflows,” says Don Dennison, president of Waterloo, Ontario-based medical imaging informatics consulting firm Don K. Dennison Solutions, Inc. Dennison, who currently serves on the Board of Directors of the Society for Imaging Informatics in Medicine (SIIM) and chairs the ACR Connect and Informatics Industry Activities committees for the American College of Radiology, says the vendor-specific nature of PACS often means they are not up to the above-mentioned challenges.

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Solving major problems

Dennison notes that the most effective VNAs—and those that yield the greatest benefits and ROI—are those that offer hospitals and other healthcare providers a system for storing and managing imaging data being generated by every department, rather than radiology alone or radiology and perhaps cardiology. By deploying VNAs in a “highly available configuration,” he asserts, end-users have the advantage of solving a wider breadth of problems and offering image management service for all departments.

Also falling under the “most effective” umbrella, Dennison says, are VNAs that integrate with electronic medical record (EMR) systems—for example, by having EMRs provide patient information in HL7 ADT messages. In these cases, VNAs can function as image repositories for EMRs, with patient and physician/visit data completely in sync between the two systems. Just as significantly, performing enterprise image management and viewing tasks utilizing systems other than the radiology PACS—namely, a VNA—permits the resources of radiology department PACS to be dedicated to their primary function: acquisition and reading workflows.

Louis Lannum, director of enterprise imaging at the Cleveland Clinic in Cleveland, knows this all too well. In early 2011, Cleveland Clinic implemented a VNA—or a “medical image library,” as Lannum prefers to call it—to replace a legacy radiology PACS. Soon afterward, it became evident that more than 60 percent of the data Cleveland Clinic physicians required at the point of care, including such unstructured data as images, were missing from patients’ medical records. Instead, these data were stored in different silos throughout the organization, which encompasses 10 hospitals in Northeast Ohio and one each in Florida and Abu Dhabi, United Arab Emirates. Cleveland Clinic’s VNA now extends to all 11 U.S. hospitals.

“Finding out about the ‘absent’ data, and knowing what access to that data could mean from a clinician and patient care standpoint, triggered a strong interest in leveraging the VNA outside the radiology department to do more,” Lannum says. “It was clear we would benefit more from having an organization-wide strategy and platform for cataloging and storing images, no matter which department had generated them.”

Over the past few years, the medical imaging library has been expanded to span 30 vastly different departments, from women’s health (an enterprise-wide internal fetal medicine stores ultrasound images) and bariatrics to dermatology/wound care, endoscopy labs, and a large ophthalmic practice, to name a few. In addition to storage, it has been augmented to include workflows and central image management.

“We’ve gone way beyond storage,” Lannum reports, noting that “everything is normalized to patient records and available to the EMR system.” Six months ago, Cleveland Clinic developed an exchange program through which patients and outside clinicians can send images captured outside the system (for example, at another healthcare institution or outpatient imaging center) to one of its facilities. Appointment reminders sent to patients incorporate a link patients can use to send their “outside” images to the appropriate Cleveland Clinic hospital prior to the day of their visit.

In addition to facilitating image management and eliminating previous barriers to image access by removing data silos from the equation, in turn conserving “considerable costs,” the VNA is contributing heavily to a better caliber and continuum of patient care, Lannum states. For one thing, it affords clinicians the opportunity to harness a wider range of image capture devices. Case in point: A wound care specialist treating a patient for a wound could request that the person take photographs of that wound during different stages of treatment and send them in for incorporation into the VNA. The physician could then pull and compare the images over time, using them as a visual frame of reference to assess the progression of healing and determine whether a change in wound care is necessary.

“Depending on the specialty, data have a huge impact on patient treatment,” Lannum states.

The University of Miami Health System (UHealth) in Miami, Fla., is also solving a multitude of problems and reaping rewards from the implementation of a VNA whose scope goes beyond radiology and cardiology and has an EMR integration element. UHealth includes a medical school, three main hospitals and more than 30 outpatient centers, with new satellite locations on tap. It has formulated a specialty-by-specialty deployment plan that is part of an over-arching imaging data management strategy, according to Dawn Cram, director of enterprise imaging.

UHealth’s VNA archives and presents all enterprise-wide images from disparate PACS, specialties and sites. To date, the VNA extends to the dermatology, internal medicine and ENT service lines; “several more,” including surgical services, will come online this year.

Physicians can harness a consolidated patient record to access current and historical images at the point or care. The image viewing and sharing solution allows for the viewing of DICOM or XDS documents, depending on departments’ individual needs. “XDS is especially valuable because many devices aren’t DICOM-compliant, and because we don’t have to worry about future interoperability,” Cram says.

She cites the streamlining of workflows as a major benefit afforded by the VNA, offering dermatology as an example. To create this workflow, UHealth melded the VNA with a standards-based mobile camera app that sends images directly into the enterprise archive, along with a description, rather than compelling clinicians to place orders. They also can launch the image viewing and sharing solution through the EMR or via a direct login. “Clinicians really like this not only because it is more efficient, but because it also enables them to see the specific work performed on their patients, not just a photo label or generic description,” Cram says.

On the whole, she adds, “the VNA eliminates cumbersome workflows that are created when [as is the case today], different service lines use different equipment—like scopes, smartphones and cameras—to perform a large volume of imaging exams that [surpasses] radiology and cardiology, and when images are stored in multiple places—on CDs in cabinets, on acquiring devices, on different PACS and elsewhere.”

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Maximizing ROI

VNA deployment also can bring a financial gain thanks to the “technical and operational” benefits of replacing a PACS archive with a VNA, Dennison notes, as well as the advantages of integrating a VNA with an EMR system and frequently reducing a hospital’s dependency on its PACS vendor. This puts the hospital in an excellent position to renegotiate existing PACS service and maintenance agreements (SMAs) to reflect changes in service, with the decrease in SMA expenditures partially offsetting the cost of VNA projects and making a “positive” contribution to ROI.

Dennison emphasizes, however, that without a request for proposal to replace an existing PACS, a hospital’s current PACS vendor will have little reason to make concessions during SMA renegotiations. Consequently, he says, realizing any savings and subsequent portion of ROI is contingent upon understanding which functional areas of a PACS can be successfully replaced by a VNA and which probably cannot. The complexity of replacement in each functional area merits consideration as well.

VNA solutions available on the market today feature proven methodologies that make it feasible for them to handle long-term archiving and image lifecycle management, according to Dennison. He deems the complexity of transitioning from a PACS to a VNA for this type of functionality low; other than the need to keep the VNA copy of a given study in sync with the one cached by the PACS, “the archival and retrieval functionality is fairly straightforward,” he says.

The same is true in situations where a VNA is used for image distribution and is integrated with the EMR system. While there are some security and privacy considerations brought on by the need to offer access to images within multiple applications (for example, the EMR portal) or in standalone fashion, Dennison says, the remainder of deployment and integration activities are uncomplicated. “State-of-the-art” solutions have the full capability of assuming image distribution and transmission of images to EMRs.

Meanwhile, although most major VNA solutions can perform routing and image pre-fetching functions, some factors can limit the cost savings and ROI to be gleaned from them. One factor is the degree of rule-definition flexibility, which varies by vendor. Another is a solution’s ability or lack of ability to express sophisticated relevancy rules, especially across multiple terminology domains. Replacement complexity here is moderate, Dennison says, because the performance of relevancy detection can make study routing and pre-fetching, whose transactional nature otherwise renders them straightforward processes, more complicated tasks.

He adds that the picture becomes a bit murkier with acquisition and quality control workflow organization functions. “VNAs’ ability to perform in these two areas is the major product differentiation areas among current vendors,” he says. But the cost savings may be tempered by a high degree of replacement complexity, since a large number of acquisition modalities will often have different associated configurations. Moreover, for large hospital systems, quality control workflows may be very complex, entailing automatic and manual activities alike. Efforts to recreate all these workflows, accumulated over the course of many years, could be quite significant.

For some hospitals, a more rapid ROI can be achieved by converting a PACS to a VNA, as is the strategy for Toledo, Ohio-based ProMedica, a 13-hospital system serving northwestern Ohio and southeastern Michigan. The project links the PACS and EMR, opening up image access across the enterprise. Cardiology, pathology, and ophthalmology are online; dermatology, wound care, and myriad other service lines will soon follow, says Free Beck, PACS administrator, PACS/VNA enterprise image management.

“In addition to supporting image-sharing across the enterprise—making our EMR system a single source of all images—this is a much more cost-effective storage and workflow solution” than a PACS, Beck says. Implementing multiple PACS for multiple service lines—an option that was raised when the ophthalmology department requested its own PACS—would, in addition to precluding the desired image-sharing, have been cost-prohibitive. “And just hardware to support a VNA system would have been a $1 million investment.”


Best practices

Other best practices are key, not only to support an adequate ROI from VNA investment, but also to maximize the potential of the VNA as a whole. At the top of the list, Lannum puts the standardization of body part descriptors and ordering and naming conventions used with any VNA. Equally essential, he contends, is labeling images so that they are associated with specific clinical events and individual patients.

“Failure to standardize descriptors and conventions, or to associate images only with patients rather than with events, partially defeats the purpose of moving into the VNA realm and negates the benefits,” Lannum says. “Having different ordering and naming conventions for the same thing can cause as much confusion as working with disparate PACS, which isn’t what anyone wants.”

Cram advocates careful assessment and handling of risks and liabilities “outside traditional imaging departments”; risk aversion and data security should be high priorities, she emphasizes.

 “You need to look at security in terms of how images are captured, stored, managed, and distributed—and nothing is too basic,” she says. “For example, physicians capture images with smartphones—but are the phones and SD cards really encrypted? What about data stored in scope towers? It goes on and on.”

Among other precautions, such as checking for encryption and restricting the way data stored in such systems as scope towers can be accessed, UHealth limits the ability to obtain images to a need-to-use basis. The latter has a side-benefit: it maximizes system bandwidth and accelerates image transmission and display.

All said, VNA adoption is not necessarily easy, but it is worth the effort.  “It can be a long road, but we’ll all get there and get something from it,” Lannum says.