VNA or ANV? Lessons From the Health System-Vendor Transition

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Following years of experience working on the enterprise IT team at Iowa Health System as an infrastructure architect, Tom Coppa takes a strong stance on the terminology used to refer to enterprise-wide image repositories—what some have taken to calling vendor-neutral archives (VNAs). “The idea of a VNA makes a lot of sense—it remains a very solid and very good thing to have,” Coppa, who today serves as a technical consultant for McKesson, says. “But the reality is that there is nothing neutral about the vendor you’re going to deal with as a health care organization.” Tom_CoppaCoppa observes that the term “VNA” is, at its core, a play on words. “I might even argue that when you reverse the acronym, things start to get more interesting,” he says. “Most companies today are actually archive-neutral vendors, which is to say that they avoid proprietary aspects of their solutions, or if they do have something proprietary, they still maintain the core essence of the data.” From Silos to the Enterprise In his role at Iowa Health, Coppa led the charge toward an enterprise-wide solution for image data management—five years ago. “I had a top-down view of the technologies and the solutions,” he says. “For me, PACS crossed networks, storage, servers, and datacenters, our entire WAN. We were distributing it across an entire state, and when we started looking for an enterprise PACS, it was a multidisciplinary selection process involving the financial team, executives, clinicians, and IT.” The experience was eye-opening, Coppa says, and not just because the health system’s initiative to implement an enterprise PACS was somewhat unique at the time. “At that time, a vendor would traditionally be working with radiology, cardiology, or some other department in the hospital, and that department would get indirect or tacit blessing from IT for its solutions,” he notes. “This was very much the other way around.” Today, Coppa says, most health systems are evaluating enterprise image management solutions in much the same way he and his colleagues at Iowa Health were. “There are strong strategies and financial directions an organization wants to take, and they seek to find solutions that fit into those strategies,” he says. “The solutions can’t break the bank, however, and there still needs to be value put on workflow.” DICOM Metadata and Beyond Coppa defines the “archive-neutral vendor” as one whose enterprise image repository can handle image data regardless of its point of origin. This represents a challenge when dealing with DICOM images, he says, because modality vendors leverage the private DICOM tags contained in the image metadata in a variety of ways. “There are some vendors who put certain pieces of information in private fields, while other vendors may use those same fields for completely different information,” he says. “This creates the need for tag morphing, which recognizes the public standard tags while changing the private tags to put all the expected data in the expected fields.” Hence Coppa’s reversal of the VNA acronym. “It’s a play on words, but it gets people thinking about which vendors have truly been neutral,” he says. “PACS vendors who also have modalities tend to use DICOM metadata in different ways, and storing their data becomes more cumbersome for someone who’s attempting to be a neutral vendor.” The challenges of the enterprise archive are further complicated by the introduction of non-DICOM image data, he notes. “Most people have gravitated toward the idea that what you really need is an archive that can accept and store all kinds of image data, whereas for a long time, the assumption was that the data would be all DICOM—you’d send it to the archive and it would be regurgitated back exactly as it was received. That won’t work anymore.” Behind the Transition The main force driving the transition from PACS to enterprise repositories is the crippling storage burden caused by medical images, Coppa says. “It’s not surprising to talk to large organizations right now that are managing a petabyte of data, or are on the cusp of it,” he says. “As a result of that conversation, to understand the landscape of the amount of data available, you get the attention of the C-level executives. They want to know how this is being managed, what it will cost, how the EHR will access it as they prepare for meaningful use, and at what point we will start to balance diagnostic information with images.” With that in mind, McKesson has developed its own enterprise image repository to include core VNA capabilities as well as the ability to extend those capabilities using the XDS cross-enterprise document sharing standard. “We’ve opened up our back end,” Coppa explains. “We’re unbolted from the front end of the PACS, because we have the back end repository with the DICOM and XDS standardization to support any entity that might be sending our archive information.” As consumption of storage continues to increase faster than the price of storage can decline, Coppa sees enterprise imaging coming into its own as a priority not just for clinicians or IT, but for all of the stakeholders across the health care continuum. “This is an issue that has become financial, clinical, technical, and legal,” he says. “There is a desire among customers to have a broad representation of their own businesses, and that makes the approach, as a vendor, much more consultative. The health care organizations are looking for partners who can maintain the workflow and the value of the data through the system. This is a collaborative effort to solve the problem without breaking the bank.” Cat Vasko is editor of HealthIT Executive Forum.