f01a.jpg (9492 bytes)Along the southern shores of Florida’s tranquil Lake Okeechobee, about 50 miles west of the hustle and bustle of Palm Beach, sits Belle Glade, home of Glades General Hospital.

Classified by Florida state statute as a “rural hospital in a rural city,” the 73-bed Glades General at the end of April “went digital,” in the words of radiology department director Larry West, a move that included installing the hospital’s first-ever image archive. Its choice? An Inphact (Nashville) application service provider (ASP) system, with provisions for short-term, on-site storage and long-term, off-site storage.

As hospitals and healthcare facilities of all sizes deal daily with the complex, enormous and forever growing task of image storage and archiving, there appears to be no limit to the hardware, software and service options available for managing the job. Depending upon size, needs, budget and in-house expertise, a facility can pick and choose a best-of-breed setup by combining equipment from different vendors or order what several companies claim is a developing trend — equipment and service, a complete package, from one provider.

At Glades General, West chose what Inphact bills as its “full turnkey solution.”

From his first day three years ago as the head of a department that performs 3,200 to 3,500 images a month, West campaigned for some form of PACS (picture archiving and communications system) and storage resolution. Inundated with proposals and “creative financing” structures that ranged from a starter PACS platform to a full-blown PACS and combinations in between, West recommended and received approval for the Inphact arrangement.

“Before Inphact, we were conventional X-ray; the only digital part of our department was the digital capability of nuclear medicine, ultrasound and CT,” West says. “When Inphact came in, they gave us a proposal to hook these modalities up into the PACS system, as well as provide the CR (computed radiography) plates, CR readers and archival storage system on site for everything but mammography.”

The contract includes equipment and service, the whole PACS with archival service, on-site storage for 31 days, and then everything is archived and kept in Nashville indefinitely.

“We’ve got retrieval at the click of a button,” he boasts.

If a Glades General radiologist wishes to recall a procedure taken two or three months ago, he heads into the hospital’s electronic “gateway,” enters the patient’s name and, in a matter of seconds, that image is loaded onto the hard disk for review.

West believes that the ASP option made a difficult financial decision easier for hospital administrators who preferred a monthly procedural cost to an initial million-dollar cash outlay. Both he and Glades General CEO Jim Purcell declined to disclose the monthly fee or any other financial details of the purchase, other than to say the hospital committed to a five-year contract with Inphact.

The choice of Inphact, however, was one West suggested after exhaustive research into other companies’ offers and after talking with colleagues in the field. He also visited Vanderbilt University Medical Center (Nashville) to see an Inphact installation at work.

Inphact uses Agfa Corp.’s (Ridgefield Park, N.J.) Compact PACS.

“I think there were a lot of attributes to the choice of equipment, but I think it had more to do with the accessibility and storage space with the particular model,” adds Purcell, who joined Glades General after the final decision was made. “From the physicians’ standpoint, simple access, the viewing stations, and hospital and Internet access for the physicians at home helped out, too.”

Archiving with ASP
John Lehman, president and CEO of Inphact, prefers to discuss those accessibility and storage features as part of his company’s full suite of services, not as separate components. With its focus on radiology, Inphact offers a turnkey ASP model with radiology information system (RIS), PACS and teleradiology applications, together with its IRIX, RadWeb, RadServ, ImageSafe, Virtual Radiology and TechTeam services.

ImageSafe provides customers with online, on-site storage for a couple of months; central, off-site storage in a large, DICOM-based archive based at Inphact’s Nashville headquarters; backup storage at a location off-site to Inphact; and distribution storage, accessible through the Web. Storage is on RAID disk, linear tape and it cascades from there, depending upon a customer’s access requirements.

Lehman insists that Inphact sees image archiving as just one piece of the large digital puzzle. More and more customers share that view, he says, leading Inphact to conclude that a majority of hospitals and healthcare facilities are looking for a package deal that will take them digital and include image archiving as part of a one-vendor, full-service solution.

Not just a product, anymore
Emageon (Birmingham, Ala.) also sees image archiving as more than just a product issue.

Founded in 1998, Emageon emerged from a University of Alabama (Birmingham) project formed to deal with issues in imaging and archiving in the diagnostic arena. The young company’s claim to fame is the scalability and enterprise-class capabilities of its archives and its distribution network for those images. Currently, it develops and sells a managed archive service, billed on a per-study basis. A fee of $2 to $5 covers the legal life of the study with Web distribution, which Emageon estimates at seven years, depending upon state regulations. Setup and implementation costs run about $25,000 for online, on-site services.

GE Medical Systems (GEMS of Waukesha, Wis.) employs Emageon’s archiving technology as part of GEMS’ new online, off-site, ASP offering. That arrangement became effective June 1.

Emageon also has licensing and marketing agreements with ADAC HealthCare Information Systems, (HCIS of Houston), a division of ADAC Laboratories Inc. (Milpitas, Calif.) and with the healthcare division of BellSouth (Atlanta, Ga.).

Current archive installations include the hospital at the University of Chicago (Illinois) and the Northwestern University (Chicago) Medical Center’s department of radiology.

Gary York, Emageon chief technology officer, credits several forces with driving the market away from massive on-site storage and in the direction of easily accessible off-site storage solutions — price, openness, scalability and performance.

Security also figures in the equation, particularly as it concerns the Health Insurance Portability and Accountability Act (HIPAA) regulations for patient confidentiality and integrity.

“Certainly, price is a driver,” he begins. “Capital budgets have been kept to zero or near zero this year, so many people cannot justify spending money for the technology even if it has the promise of reducing their long-term costs. The time for payback has been reduced substantially for capital projects, so we have a subscription model with no capital costs.”

York says another driver is that people are looking for technology that can function on off-the-shelf, standard hardware. Many people also seeing a kind of technology du jour.

“There is a high-storage 9840 tape system — a lot of people think that is the hot thing for this year,” says York. “Next year, it is probably going to be DVD RAM or DVDR. Because it is changing all the time, it does not make sense to build an archive product that is tied to a particular technology, so we have designed our archives to be open to support a variety of technologies. In addition, we have designed our archives to run across different hardware platforms. It will run on high-end technology, like enterprise-class Unix servers, and also on low-end hardware, like Windows NT.

Scalability and performance will continue to be of utmost importance, York says, and for several reasons: images are getting larger; the use of months-old images, or “priors,” is increasing; and hospitals are moving all modalities into the digital age, thus requiring enterprise-class image storage across an entire operation, not just for a radiology department. “A number of institutions have hit the wall with the previous generation of technology,” he remarks. “We engineer to meet these increasing sizes, increasing utilization and increasing pressure on the network. We can keep adding DICOM associations or users into the network with any performance degradation.”

Emageon CEO Chuck Jett says he grasped the promise of Emageon’s enterprise archiving technology before he came on board in January of this year. Jett attended the 1999 annual meeting of the Radiological Society of North America (RSNA) as a venture capitalist and saw an industry traditionally served by a departmental orientation — in this case, radiology. Because of that slant, archiving products and services have been clinically, rather than technically oriented.

Nowadays, he notes, the trend is to streamline information and images, making everything available at the point of care and integrating it with other information technology services in order to serve the hospital as a whole, from a centralized enterprise archive, on or off site.

More “solutions”
Created with an eye on the entertainment and graphic arts industries, and weaned on large graphic files that needed to be moved and stored digitally, Wam!Net (Eagan, Minn.) recently entered the healthcare market with an outlook that mirrors that of Inphact and Emageon: image archiving is more of a service solution than a product.

The company’s primary offering, then, is an ASP model with transport infrastructure and off-site storage, targeted to radiology departments. “What that means,” explains Mark Hunter, Wam!Net marketing director, “is we work closely with the PACS companies that provide workflow with the bricks and mortar, and we extend their long-term archive to add both long-term and redundancy, which means that [PACS vendors] do not have to worry about capital acquisition and maintenance and neither does the customer when we get into archives that go into three, five, seven and 10 years.”

Wam!Net stores images in two geographically separate locations. Primary storage is at company headquarters in Minnesota; backup storage is at a Wam!Net facility in Las Vegas. An additional storage facility is located in Brussels with another planned for the company’s potential foray into the Asian marketplace.

For the past year, the University of Maryland Medical School (College Park, Md.) has served as a Wam!Net pilot site, using the company’s transport and storage systems in conjunction with its Agfa PACS. Wam!Net also works with the U.S. Department of Immigration and Naturalization Services in moving chest X-rays from border communities to Veterans Administration hospitals for diagnostic readings, reporting and storage.

Wam!Net’s direct service, which is its most complete and managed service, including storage, takes shapes with the installation of its network access device, which Hunter regards as a “pretty significant piece of technology that we bring inside the bricks and mortar to provide a secure gateway for customer data.” Installation prices vary, depending upon the scope of the service, but range from $1,500 to $10,000, he says, “and after that, everything pretty well turns into a transactional model. No direct charge for the hardware, that’s part of our infrastructure. Use fee depends upon volume.” Customers sign with Wam!Net for a minimum of 12 months.

For some companies, however, the image archiving market is all about product.

They may be “clever,” but …
Nick Donofrio, program manager at Merge Technologies Inc. (Milwaukee, Wis.), acknowledges as “clever” the movement in the marketplace to sell storage, archiving and management capabilities to hospitals on a per-click basis. “I see some companies trying to sell that approach,” he comments. “I would hesitate to say whether that is being widely accepted by hospitals, but it is another interesting way to skin the cat.”

Merge, meanwhile, has been shipping its MergeARK for about two years and recently introduced a second-generation version of the program’s hardware and software platform. A DICOM-based information and image server, the newest MergeARK has a new hardware platform based on Dell servers with the Red Hat Linux operating system. Nick indicates that MergeARK is capable of storing virtually all approved DICOM objects, such as radiology images, but also “structured reporting,” or various text information.

The MergeARK knows its audience: the small- to medium-sized, 200- to 500-bed hospital. A bargain-basement, basic MergeARK is available for $50,000 to $100,000. A more expensive version, for more than $100,000, comes with a high-powered Dell Computer server hardware platform and additional storage RAID for online cache.

One feature that Donofrio says sets the MergeARK apart from other archives is its “stored print” function — a feature designed to help hospitals transition from film to soft copy.

Donofrio explains stored print as a digital representation of the sheet of film. As film goes through the MergeARK DICOM print network and is printed, the print server creates a stored print object and sends that object to the MergeARK.

“We found it is not uncommon for radiology departments to loan films out that never come back,” he says. “Sometimes, films are misplaced, they are lost, they are damaged, so having the stored print object on your archive is a digital backup of the film that you produced, so you can always call it back for reprinting in case somebody wants a duplicate.”

Behind every OEM …
Rorke Data Inc. (Eden Prairie, Minn.) is another company for whom product is the mainstay of its image archiving business, although in the past 10 years, Rorke has evolved from a hardware-only company into one providing a full-solution — server, archive libraries in tape, optical or DVD configurations, network products, service and digital media — to original equipment manufacturers (OEMs) and resellers.

f01b.jpg (7528 bytes)Rorke Data’s 600-slot, 30 terabyte native AIT* library is nearly double the capacity of the current 360-slot AIT.

Aaron Blotsky, Rorke regional sales manager, indicates the company will showcase its two newest products at RSNA 2000 in November.

The first is a 600-slot, 30 terabyte native AIT* library, which is nearly double the capacity of the current 360-slot AIT. The second unit is a 14X, 9.1-gig drive magneto optical library, double the size of current 5.2-gig drives.

“The technology just keeps advancing and there is such a high demand for more storage per square foot,” Blotsky adds. “Real estate is very valuable in hospitals and imaging centers, so they are trying to get more storage out of the space they have, so they keep trying to double the capacity of the drives.”

The 600-slot AIT will list for approximately $127,000, but other prices have yet to be determined. Shipping for all new products is planned to coincide with RSNA.

As the manufacturer of optical disk drives since the mid-1980s and a longtime supplier to healthcare vendors, Maxoptix (Freemont, Calif.) continues to roll out product for image storage. To GEMS and its counterpart companies in Japan and Israel, Maxoptix supplies 5 1/4-inch magneto optical storage. The company also counts Philips Medical Systems International B.V. (Best, The Netherlands) among its customers.

In August, the company introduced its newest offering — a DVD RAM jukebox that handles the DVD media in a standard cartridge.

Dave Kalstrom, vice president of sales and marketing for Maxoptix, describes the new product as containing the same120mm disk, same size as a CD, but housed in a protective cartridge to guard against the disk’s worst enemy: fingerprints. The robotic jukebox handles the media in a standard cartridge, which Kalstrom considers a plus when the disk needs to be removed or replaced.

“Our box may be slightly larger for the same amount of capacity,” he adds, “but it has the cartridge protection. We do it that way because that is the background we came from — our company also makes the 5 1/4-inch MO which has a cartridge to protect it — whereas many of the other jukebox manufacturers come from the CD side of it.”

Kalstrom points out that average access time for the DVD RAM is about 200 milliseconds as compared to 25 milliseconds with the 5 1/4-inch MO, a difference that he claims is critical in data applications but not in jukebox imaging applications. Cost for the new product is approximately $25, a third of the $74 retail price of a 5.2 megabyte MO, he adds, but MO drive costs hover around $2,000, whereas a DVD RAM drive is “officially” priced at $800 and may be had for less.

“We’re not eating our own children,” he says with a chuckle. “We have spoken to people in the medical imaging community, and they are looking at DVD RAM. It is more economical for them.”end.gif (810 bytes)