f04a.JPG (11058 bytes)When Diane Keenan became office manager of a doctors’ group in suburban Washington, DC, in 1995, the idea of electronic medical image storage was so foreign to the partners that, she says, “the Boston Red Sox finally winning a World Series seemed more likely.”

“If you think about where we were in technology then—and where we are now—and see how far behind the medical industry is on data archiving and electronic access, it’s really unbelieveable,” Keenan reasons. “We have near-perfect satellite images of Saturn and Jupiter, we are sending photos across our cell phones, and you can sit in a park and read the Internet on your laptop without a [land-line] connection.

“But when it comes to saving people’s lives with instant access to their medical information, we might as well be the Wright Brothers at Kitty Hawk. It seems like the storage and access technology is that far behind for doctors.”

Keenan is right. A very pressing and topical issue within the medical field is electronic storage and access to a patient’s files. But just before Thanksgiving, the very influential Institute of Medicine made a plea for hospitals and physicians to adopt electronic record-keeping, a measure that could spare tens of thousands of deaths each year.

An estimated 44,000 Americans die each year due to medical errors. So the endorsement by the Institute of Medicine is no small feat for medical archiving. Only 10% of physicians and about 8% of hospitals use electronic record-keeping. But with emerging technologies coinciding with lower storage/server space costs, the prospect looms for more hospitals and doctors’ groups to leap into the 21st century.

“Health care is the most information-intense enterprise in the country. It is 20, 30, 40 years behind less information-intense industries like banking. We need a Manhattan Project for health care information, and we need people at very high levels to understand that,” says Kenneth Kizer, head of the National Quality Forum (Washington, DC), which helps hospital and medical systems measure and monitor the quality of care.

Those people at high levels are in the federal government, and thanks to a confluence of recent events, the protocols and standards for such record-keeping would be established by the Fed. In turn, hospitals, clinics, and physicians will be able to choose their own hardware and software. And over time, electronic record-keeping and participation in a national medical information network would become almost mandatory, because the system would create a seamless surveillance for disease control.

“I think we’re laying the interstate highway system for electronic health information,” Paul C. Tang, a physician and informatics scientist at the Palo Alto Medical Foundation, told the Washington Post.

Given today’s technologies and advances through high-speed Internet, it’s almost impossible to believe the medical industry is so far behind. But then, access and archiving is not as easy as it sounds. For one, the storage is expensive. And for another, there are legal issues. Medical records are akin to legal documents and need bullet-proof security. And yet another is the lack of a standard network or distribution system. Remember the days of VHS and Beta videocassette formats? That’s what medical archiving is experiencing.

“Imagine spending all the time and money digitalizing your records and then the system becomes obsolete,” says Rob Callery, public relations manager of network storage operations at EMC Corp (Hopkinton, Mass).

The recommendation by the Institute of Medicine likely means a quicker leap into electronic record-keeping, thus creating a ripple effect within the core medical technology sector. Not that many companies weren’t already moving forward. EMC’s Centera Compliance Edition software is designed to deal with industry regulations around security. Last fall, Fujitsu (Tokyo) introduced a lightweight, portable optical drive and software that allows health care professionals to transport and view medical images and data on a laptop computer. Called the DynaMO Pocket, this solution is the first of its kind for reviewing medical records away from the office.

f04b.JPG (14814 bytes)Additionally, Cedara Software Corp (Toronto) has developed a new medical image viewer that allows hospitals and clinics to acquire, distribute, and archive medical images and diagnostic reports across the Internet.

“Cedara’s new Web viewer advances the current capabilities of our PACS system,” says Michael Plitnikas, PACS engineer at Mt Sinai Hospital in Miami Beach, Fla. “We now can distribute patient information and digital images over the Internet in a way that is clinically relevant. Technologists can send images to the emergency department, hospital in-patient units, and to physician offices via the Internet while doctors working remotely can pull the images needed to expedite the care and treatment of patients.”

Physicians’ office manager Keenan, says that switching to electronic archiving is far more complex and expensive than most can imagine. That’s why the government will likely become involved.

“For decades, a doctor has taken a patient’s chart from a file, jotted down his notes, and handed the file back to an office worker to be filed,” she says. “But to re-input all the old data into new electronic systems is an enormous expense of manpower and equipment. That’s why so few physicians have made the leap.”

Dr. Andy Tucker is an orthopedist for the Baltimore Ravens NFL team. “Most folks still have hardcopy files,” he says, “and if we wanted to get access to something from another city, more times than not, they would print out another copy and mail it to us. Now, some institutions are having the cap-ability to store digitally. But often, we’re still dealing with handling records by hand. The technology is there. It’s a matter of insti-tutions and medical groups paying for it.”

Tucker believes cost is the biggest challenge for bringing electronic record-keeping and digital image storage to the forefront of the medical industry. He’s right. And the government might have to foot the bill for bringing the medical industry up to speed. Ten years ago, server storage was $10-$12 per megabyte. Today, it’s pennies. But to store one patient’s series of MRIs will still cost double digits. “Storing one X-ray would have cost a fortune,” says EMC’s Callery.

f04b.JPG (14814 bytes)Many large institutions, such as the University of Maryland Medical System, are already ahead of the curve. MRIs, X-rays, and CT scans are taken and stored digitally, giving quick acess from offices within the system. Digital technology with images has been around since the early 1990s, but each has been purchasing operating and storage systems that best suits their budgets and needs, not for a national network.

Because of funding, hospitals are in better financial shape to adopt electronic record-keeping. The government’s role is expected to hasten a connected national health care system without actually creating a new one. The key is standardization. Under the Institute of Medicine proposal, many federal agencies—such as the Agency for Healthcare Research and Quality as well as the National Library of Medicine—would take on new responsibilities at standardizing information flow among themselves in a single network.

Perhaps the greatest obstacle is a universal blueprint for systems and software. Some facilities are jumping head-first into the entire project while others are simply wading into the waters. Consequently, vendors are forced to get to know the individual needs (and budgets) of the clients. Apparently, one size does not fit all. The health care industry is hoping that the government allows individual hospitals and practictioners to choose their own software as long as it’s compliant with the needs of the network. The Institute of Medicine backs this idea.

The making of digital images is one subject; the best way to store them is entirely another. Storage providers started archiving to tape or DVD for reasons of storage capacity, but magneto-optical disc (MOD) technology has become the future. Unlike tapes and hard drives, MODs are resistant to magnetic fields, which is why they initially became involved with radiology systems.

MOD combines laser and magnetic technologies, meaning the discs are written thermo-magnetically and read optically. The discs have twice the capacity of DVDs with advertised archival life ranging from 40–100 years … or more. The lifespan is needed because most states require records to be kept for at least 2 decades.

But what many health organizations did in the early days of personal computing was store to tape. What they are discovering now is the lifespan of that data is about 20–25 years. (Paper data is good for 200 years, microfilm for 500 years). But because the tapes can hold so much data at such an inexspensive cost, it’s been hard for practitioners to step away.

That might be easier now that storage drives and devices are now hitting the 1TB range. The problem is with devices that can access that enormous block of data and provide the information quickly. Storage capacities are doubling about every 18 months.

“If a player goes down for a routine MRI, say of his knee, they can pull up old digital images and compare them to the new,” Tucker says. “That’s with the touch of a button. But even if the images are archived, it can take the system many, many minutes to pull up.”

Some experts say it could be 30 years before a standard software and hardware system links all hospitals and physicians. As disk drive storage capacity requirements increase, the hardware technology could become obsolete in less than a couple of years.

One area that cannot wait 3 decades for a solution is security of the records. By the most primitive measures, a patient’s medical records are safer in a file cabinet than they are stored at an online server. Now, medical images are available to physicians like Microsoft Power Point presentations. Sending these files over the Internet increases the potential of an image being altered. The larger hospitals perform around 100,000 exams a year and face a plethora of federal regulations on privacy, including the Health Insurance Portability and Accountability Act (HIPAA).

“These images are considered legal documents and a hospital is liable,” says EMC’s Callery. “The patients’ privacy is at hand; you have to make sure their records don’t get into the wrong people’s hands.”

EMC’s Centera Compliance Edition is first online archival storage medium capable of guaranteeing content authenticity and scaling to hundreds of terabytes without requiring additional management overhead.
Robert Williams is president of Cohasset Associates (Chicago), one of the nation’s top records management consulting firms. “Electronic records management poses the next great challenge for financial, legal, and IT departments across all industries,” he says. “The widespread digitization of records has prompted a wave of new laws and regulations surrounding how these records are retained. Most organizations today, however, are unable to access electronic records that they created and stored just a few years ago, much less demonstrate in a legal proceeding that those records are still accurate, reliable, and trustworthy.”

Added Steve Duplessie, founder of Enterprise Storage Group (Milford, Mass), “Compliance with records retention reg-ulations is becoming the hottest issue in IT. Although regulated industries are the first to be impacted, it is only a matter of time before data permanence is mandated in every IT department. As a result, there will be a huge demand for cost-efficient disk-based systems capable of storing objects permanently, in an unalterable state.”

Centera basically provides a digital fingerprint on the data and recognizes any changes. It’s also designed to adapt to hard-ware changes and technology advances in archiving. It’s a good thing.

Based on the accessibility that Washington wants on sharing health care data and the enormous job and cost facing practitioners to make their records electric, the digital, storage, and compatiability issues have a lot of work to do.

Dennis Tuttle is a contributing writer for Medical Imaging.