Putting the Digital Spin on the File Room
Once Y2K issues are finally put to rest, hospitals are expected to turn their IT resources and attention to digital storage of radiological images, so the experts predict. And when it comes to archival media and storage solutions for this need, there are almost as many options as there are images produced annually in the U.S. – an estimated 500 million in 1999 alone. Whether its microfilm or magneto-optical, digital tape or RAID, PACS or outsourcing, choices abound and costs vary.
Industry experts predict the use of imaging across all diagnostic modalities will continue to grow – and with it the need for larger capacity, more accessible, and less expensive storage solutions. There is virtually unanimous agreement that whatever the solution is it must be extremely reliable and offer high performance and storage density at a cost-effective price-point.
New Spin on an Old Technology
For years many patient records, including text and images, were kept in manila folders or consigned to microfilm for long-term storage. Microfilm proved hardy with a 500-year shelf life when stored under ideal conditions. This more than met the need to maintain records up to the life of the patient, but it was hardly convenient. Retrieving records from microfilm was time consuming and labor intensive.
These days more and more hospitals, specifically the ones that can afford it, are turning to more accessible, more expensive digital means of storing images. Microfilm, also known as film-based imaging, is not yet a thing of the past, however. Recently there have been three improvements in the use of microfilm imaging that “have taken an old, antiquated technology – film – and brought it into useful life today,” according to Mike Oris, director of marketing at Fuji Photo Film USA Inc. (Elmsford, N.Y.) and member of the Film-Based Imaging Member Council (F.b.I.).
“One is that films today are scanable and can produce a digital image of the same caliber, clarity and detail as the original document,” Oris says. “Second, there are scanners on the market that can scan 16mm microfilm and bring it back to electronic files for residing on networks or backing up imaging systems. Third, there are ‘desktop-com’ devices, which are computer output microfilm devices, that can take digital images and write them -whether they be just data or text and images – to microfilm.”
A “hybrid imaging concept” is available as hospitals and imaging centers migrate their records to new updated storage systems. The hybrid solution combines electronic or digital storage for online and near-term needs with microfilm for the long-term archives and offsite storage. Oris believes this hybrid approach is the best way to secure images over the long haul. “When something is stored on microfilm,” he says, “it can be read at any time – 10, 15, 20, 50, 100 years from the time of filming.
“There is information [on microfilm] in excess of 60 years that is still readable, still retrievable, still printable, still accessible,” Oris adds. “You can’t say half of that about information that is stored electronically.”
To Film or Not To Film
While film and microfilm have served us well, electronic or digital is the way the industry is going, however. Of the estimated 500 million radiological images produced last year in the U.S., upwards of 30 percent were completely digital from the initial shoot, through the viewing and diagnostic process, and to eventual storage. They never once touched a piece of film. Industry experts predict this practice will accellerate into the new century, and with it costs of digital storage should come down.
Digital is the “enabler,” says Bill Springer, a partner in the Healthcare Consulting Practice and member of the National Leadership Team for Healthcare Consulting at KPMG (White Plains, N.Y.). “Price points are costly but coming down to the point where more and more clients are investing in PACS and related systems,” he says. “One of the major drivers is the ability of these digital systems to serve their offsite centers – be they freestanding imaging centers, physician groups or other hospitals in their network.”
“Some facilities have great capabilities in their radiology departments, and by being able to read these images real-time, they save money, speed up the cycle time, and get results out quicker,” Springer adds.
There are 700 facilities in the U.S. equipped with some form of a picture archiving and communications system (PACS), according to the Concord Consulting Group (Concord, Mass.). But not all hospitals, particularly small, community-based institutions, can afford the estimated $600,000 to $1 million price tag to get up and running with a PACS. For some institutions, digital tape libraries using digital linear tape (DLT) and “pay-as-you-go” solutions, as well as hybrid models, provide attractive, effective and more affordable options.
The Scalar 1000 DLT library from ADIC accommodates 12 DLT tape drives and 118 cartridge positions.
DLT to the Rescue
One such digital hybrid model is in place at the University Health Network and Mt. Sinai Hospital in Toronto, Ontario, Canada. The network of four hospitals is fully digital with a PACS and digital tape library. The facility has two 4-terabyte digital linear tape (DLT) libraries which filled up in just eight months, and is adding a third 50-terabyte system with room for additional growth, according to Greg Couch, the hospitals’ manager for Medical Information Systems.
The four facilities archive 20 to 40 gigabytes of images a day. Two copies of each image are made – one for the onsite, near-term library, the other for offsite, long-term and back-up storage. Couch says the DLT system, purchased from Advanced Digital Information Corp. (ADIC of Redmond, Wash.), is very active: “We have a pre-fetching mechanism for patients that are due in clinic or OR for the next day, so every night we pull back approximately 70 gigabytes of information.”
These images are routed automatically to the appropriate physician workstation in a digital format and physicians are not permitted to get film from any of the digital imaging modalities. Couch says this is a hospital mandate and it is meant to enhance the ease of access of images across all four facilities, not necessarily to save money on the purchase of film.
This is a point often misconstrued, according to KPMG’s Springer. He says it is a common misconception that savings from reduced film usage will help pay for a digital system. While proliferation of digital technology and high-resolution monitors to view images creates pressure to avoid printing, old habits die hard, Springer notes. “Many healthcare providers still want to touch hard copy, not just view it on a high-resolution monitor.”
?Software and servers to support the DLT libraries at the University Health Network and Mt. Sinai Hospital in Toronto were developed in-house, and getting the library up and running took less than one month. Couch says the hospital found it necessary to write its own software: “Typically what’s packaged with a tape library is some sort of hierarchical storage management, HSM, software, which is more suited towards the typical commercial application found in banking. The cost of it was quite prohibitive, so we decided we needed something simple and decided to do it ourselves.”
According to ADIC, the DLT libraries it sells are not “specifically designed and labeled as a medical product.” In most cases, just as it was in Couch’s, medical information professionals are creating their own front-end databases for organizing digitized images, according to Steve Whitner, marketing director at ADIC. To more directly service the medical community, the company works with medical products manufacturers, such as Siemens Medical Systems, Inc. (Iselin, N.J.), which serve as high-level integrators of ADIC tape libraries, he says.
Automated digital tape libraries, which range in dimension from tabletop to room size, are essentially large reservoirs of tape with several different kinds of drives or recorders and an electronic-mechanical interface, according to Whitner. “They’re basically robots that move tapes from a reservoir into drives and then back again.
“The libraries that ADIC makes can handle several different types of media,” Whitner says. The most common used in medical applications are DLT made by Quantum Corp. (Milpitas, Calif.) or AIT 8mm data cartridges made by Sony Electronics Inc. (Park Ridge, N.J.) – media Whitner describes as “high-capacity, high-throughput and relatively modest in cost.”
The longevity of digital images stored on tape is approximately 10 years, so every decade or so the images need to be copied onto new media. Whitner says this is “relatively easy to do” and that many large systems offer “automatic, over-time file replication.”
Optical media, from companies such as Hewlett-Packard Co. (Palo Alto, Calif.), is an option as well. Whitner says optical storage systems offer long-life and fast access, but “tend to be much more expensive unit per unit and the capacity is not as high as it is with tape.” ADIC makes automated storage libraries that offer both optical and tape in the same unit. This offers hospitals a way to protect certain records over the long term with less volatility and without the need to re-copy in a period of years. At the same time, the bulk of their images can be stored more cost-effectively on tape. Whitner also notes that images can be transferred easily between the two media.
Prior to installing the DLT library, the Toronto hospital network used CD-R, which the facility outgrew. Couch says CD-R technology could not accommodate the volume of images generated by the hospitals, which has been doubling every eight to 12 months, and in addition, the cost of adding the jukeboxes to hold the disks was prohibitive. “One DLT with compression can hold 70 gigabytes. One CD-R holds less than one gigabyte,” Couch says.
The bill for the DLT libraries: $98,000 for the initial two 4-terabyte units, and $140,000 for the new 50-terabyte system.
The Marriage of Acquisition and Storage
One system on the market today combines acquisition and storage in one unit. The Clarity 7000 from Cares Built, Inc. (Keyport, N.J.) acquires radiological images using a digital detector and stores them in a digital archive on CD-ROM. According to company founder and President Tim Telymonde, CD-ROM was the medium of choice because of its affordability and reputation as the industry standard.
Although the Clarity 7000 accepts images from all DICOM-compatible equipment, Cares Built has optimized the system to work specifically with X-ray equipment. The digital detector slides into the X-ray table or wall unit and with the help of a built-in photo timer captures the exposure at the time it is taken. It is then displayed automatically on the monitor in the control area.
The system can be networked from the X-ray room to the physician’s viewing room, which can accommodate as many as nine monitors. Each monitor permits the doctor to view a single patient study or multiple patient images, up to 24. The system also accepts electronic dictation and operates with the advantages of touchscreen technology. “It’s almost as simply as an ATM,” Telymonde says. “We call it DICOM made easy.”
No costs were available. But Telymonde says, “We are competitive across the board.”
Alternative to PACS
A new “pay-as-you-go” service is being billed as a hospital’s alternative to PACS. This new service offers online access to DICOM?-?based radiological images, near-term offsite storage, plus an offsite back-up archive. It permits a hospital to bypass the incremental approach that typifies a PACS set-up and get established quickly with a digital storage solution. Built on a service model, it provides unlimited storage and access, along with ongoing maintenance and upgrades. By outsourcing this vital record-keeping task, hospitals invest in no hardware, training or personnel, and maintain no long-term image library onsite.
Wam!Net offers offsite image storage at sites in Minneapolis and Las Vegas.
Two companies – InSite One, LLC (Wallingford, Conn.) and Wam!Net Inc. (Minneapolis, Minn.) – are fine-tuning this new service for anticipated availability this quarter. Pricing was not immediately available, but InSite One says its offering would be priced “competitively.”
“Pay-as-you-go” storage is based on a three-stage model consisting of online, nearline and offline components. InSite One Chairman and CEO Rick Friswell defines the terms as they relate to his company’s product, InDex (Internet DICOM Express): “Online means storing the image within the facility or within the network of facilities. Nearline is the archiving warehouse located in Wallingford and linked back to the hospital by high-speed line. Offline is what we do with the image once we receive it at the warehouse, and that is to make yet another copy and store it in a second location geographically distant from Wallingford.”
The Wam!Net set-up is similar. The approach to offsite storage is called “regional replication,” according to Mike Schad, medical service engineer of Wam!Net’s Medical Division. “We store every image that we take into our system in Minneapolis and we also replicate to our facilities in Las Vegas.”
Schad says storing offsite still means hospitals have immediate online access to images, plus “they get redundancy automatically by being offsite.” There are financial advantages to the service when compared to traditional storage options such as DLT libraries, Schad points out.
“The first megabyte that you put into that tape archive, if you buy for example a 20-terabyte system, you have to pay for that entire 20 terabytes the first day, even though you’re only storing one megabyte. With Wam!Net you just pay for that first megabyte as you store it,” he says.
As part of the “online” configuration, InSite One plans to provide customers with a patented proxy server, which consists of RAID storage and database. It will reside in the hospital to take images directly off DICOM-based modalities as they are being produced for immediate available to clinicians. The server will provide “instantaneous access” to up to 45 days of stored images, according to Friswell.
Customers of Wam!Net will get a “purple box” which “acts as a gateway between the customer’s network and Wam!Net’s wide area network,” according to Schad. “We expect our customers to have some amount of online RAID to handle the first 30 to 90 days of patient data onsite – the images they’re retrieving quite frequently.”
RAID generally consists of a series of hard drives set up in parallel that accepts real-time images without buffering, and offers high throughput and built-in redundancy.
When the image hits the server and RAID system, it is immediately duplicated offsite for nearline storage. In the case of InDex, images are aged automatically and purged from the server within approximately 30 to 45 days. At that point, images reside “nearline” in the Wallingford warehouse. InDex uses “lossless” image compression, which returns images from the archive to the hospital in their original state, according to Friswell.
Offline images are stored on DVD from Pioneer Electronics (Long Beach, Calif.), selected by InSite One for its “capacity, durability and speed,” Friswell says. With Wam!Net, back-up copies go onto a RAID system offsite, “but there are plans in place to do some nearline and offline storage with tape eventually,” Schad says.
Retrieving an image from nearline storage should be virtually instantaneous, but is contingent on such variables as the backbone of the hospital’s network and the demands on the network at the time the image is being recalled. “Our stated goal to our customers is in the 15 second range, and in actual scenarios with our customers we’re looking at sub-five seconds right now,” Wam!Net’s Schad says.
Friswell says strategies such as ‘pre-fetching’ can help ensure that images are retrieved as quickly as possible. “If we understand what the hospital’s patient schedule is for the following day, we have the option of downloading the images back to the hospital’s server during off-peak hours to be available to the clinical team the next day.”
KPMG Consultant Springer says hospitals are asking about external storage solutions because they don’t necessarily want to invest in all the hardware, but “the key will be the price-point, is it going to be cost-efficient for them.”
Hospitals don’t necessarily have $1 million to spend on a PACS and are increasingly concerned with issues of capital expenses, space, film and labor costs, maintaining and improving quality, and efficiency, according to Robert Sandler, a healthcare consultant who handles business development for the Connecticut Hospital Association (CHA of Wallingford, Conn.) and is president of the Sandler Group.
CHA’s Shared Services Program, an 11-year-old group purchasing program, recently negotiated a contract with InSite One and endorsed the InDex service for its members, consisting of about 200 hospitals and imaging centers throughout New England. Speaking on behalf of the group, Sandler says InSite One’s service will allow hospitals “to use cutting-edge technology without having to have large capital outlays.
“Taking a look at what InSite has to offer, there’s a potential impact on quality of services and the way they’re delivered with respect to the patient,” Sandler says. “So, not only do we have a new service which will help hospitals become more efficient at a time when capital resources are becoming scarce, but we also have a service that has the potential to improve the quality of patient care.” 
