When Duke University Health System (DUHS) in Durham, North Carolina, goes live with its full-blown Epic electronic health record (EHR) implementation in June 2013, another equally important transition will have happened in the background: the installation of a new vendor-neutral archive (VNA) that will eventually contain all 135 terabytes of image data currently housed in the department of radiology’s PACS.
That’s not the endgame, though, according to Christopher J. Roth, MD, radiologist and vice chair of radiology for health IT and clinical informatics at DUHS. Roth also serves as the enterprise director of imaging-informatics strategy. The plan is for the archive to host almost every DICOM and non-DICOM image generated by all specialties, now and in the future.
“Looking at it from the health-system perspective, the three-to-five–year vision is to get as many of the other clinical specialties as possible up where radiology has been for years now, to provide a high level of functionality and security around the images that they create, and to accommodate emerging needs in medical imaging,” he explains. With an Epic implementation imminent, increasing government health IT requirements, and an ambitious plan to accommodate the imaging IT needs of all specialties, Roth and the IT department at DUHS were looking for a highly flexible, nonproprietary, simple approach to enterprise image-archive needs.
“Many of the applications—and the whole spectrum of health IT, at this point—are moving in a direction of seamlessly integrated, enterprise-level solutions, and that is what this is intended to be.”
—Christopher J. Roth, MD
Duke University Health System
Living in an EHR World
More than one factor drove Roth and DUHS in the direction of the VNA. To begin with, there is the new way that radiology is viewing PACS. “We are beginning to look at PACS as something to be deconstructed and rebuilt in best-of-breed component parts,” he says.
Typically, PACS is being disassembled into three pieces: The archive and image-management components (including life-cycle management, security, storage and distribution); the viewer; and functions related to radiologists’ workflow, such as worklists, incorporated peer review, and critical-results review and reporting. Just as one might migrate all data off a desktop or laptop to be decommissioned, existing images in a PACS archive are best migrated to vendor-neutral storage in the event that an institution is considering a new PACS, Roth believes.
Clinical imaging-informatics apps are developing rapidly, and there is a growing need for the interpreting physician to be able to use the tools of choice to do, for instance, 3D reconstructions, quantitative analysis, and functional imaging—using the best tool for the job. Radiologists and other physicians do not want their choices limited by the storage medium, Roth adds.
Aside from diagnostic imaging, clinical images being generated at DUHS include patients’ headshots, operative and educational videos, and digital pathology. “There are a lot of different storage needs required of a health-care system that didn’t exist when PACS was being developed,” Roth remarks.
“A few years from now, everyone in the health system will have needs for storage,” he says. “Many of the other clinical specialties also are performing their own imaging, and they are performing imaging well, at the point of care, to make immediate decisions. Because their solutions evolved locally for a given department or clinic, however, what they are doing (inconsistently, in many cases) is maintaining a broadly and easily accessible longitudinal record of images taken.”
Roth continues, “In many cases, ophthalmology and dermatology departments are taking images, but they don’t have a great way of doing anything with them. They may be sitting in a shoebox somewhere; they may be sitting in someone’s desk drawer. They may be printed out on a piece of paper and put in someone’s chart, which doesn’t do anything in an EHR environment.”
The clock is ticking when it comes to digitizing patient information, Roth says. “These are things that ultimately need to be changed in the fairly near future, and radiology has been doing this for more than a decade, easily,” he notes. He believes that radiology has a partial responsibility for sharing what it knows with other specialties, particularly concerning the operational aspects of managing and distributing images (as well as making