From top to bottom: External MOD drive from Fujitsu; Plasmon Server; Sony’s StorStation LIB-162 is an AIT archive for small clinics and private practices.
There was a time when electronic image archiving seemed mysterious. It required an engineering degree to understand and a fancy network to use. People talked about it reverently, in big words, or didn’t talk about it at all because they couldn’t grasp it. Everyone got accustomed to thinking of picture archiving and communications systems (PACS) as multi-layered, enterprise-sized productions that only big hospitals might need or be able to afford.
That’s all history now. As storage and network prices dive and high-speed Internet availability spreads, smaller organizations are getting in on the act, too. User-friendly interfaces and open-standards platforms rule. Increased media capacity, cheaper hard drives, redundant arrays of independent disks (RAID), and conveniences such as outsourced storage have effectively rewritten the rules about what archiving really means and, perhaps more important, who can take advantage of it. Archiving is for everyone, and it’s coming to a neighborhood practice near you.
If it walks like a PACS ?
Originally, the traditional PACS model consisted of three tiers: quick-access storage of current studies, nearline storage for studies six months to a year old, and long-term deep archives. Recent advances, however, have blurred the old definition. Even teleradiology systems, once the e-mail of rural medical outposts, resemble PACS more and more each day. Now PACS-like telerad systems are a trend, thanks to the desire of hospitals both rural and metro to be networked to each other, as well as to outpatient clinics, remote radiologists and referring physicians.
One example is Washington County Hospital in Nashville, Ill. As part of a recent expansion of its emergency department, the hospital traded its old telerad system – which, in the classic tradition, stored nothing – for something considerably more sophisticated.
Washington County is a rural, 58-bed critical-access hospital that relies heavily on two radiologists whom it shares with another hospital 20 miles away. Its old telerad system was installed primarily for their use. Last December the hospital replaced it with an iPACS server from RealTimeImage (RTI of San Bruno, Calif.). RTI’s streaming technology for Internet transmission is significantly faster than the technology it replaced, and the radiologists were pleased about the speed. But then they and the hospital staff got excited about the conveniences of on-site soft copy availability.
Kim Larkin (left), head of radiology at Washington County Hospital, says the new system is so popular that “the ER physicians requested their own workstations so they can view studies the same way the radiologists can. Our ob/gyn physician and internal medicine physician have jumped on it, too. Soon we’ll get the referring physicians to start looking at studies online.
“Annually we do about 1,300 CT scans, 1,700 ultrasounds and 400 MRIs,” says Larkin. “We’re saving all of our studies to the new server on a very large hard drive. It’s intended to hold images temporarily so that the radiologists can retrieve them remotely and call a report in to the ER physician. Any time they’re at home or the other hospital, they can just get on the Internet and look at my studies. Prior to having this, they had to drive back up here to look at films, or a tech would have to drive films to them. It was actually faster to drive films 20 miles than to transmit them with our old system. You can’t wait 90 minutes to get a study interpreted on a trauma patient. Now the radiologists can provide an immediate emergency report wherever they are, and do a full read when they get here later.”
A sonographer images a patient at Washington County Hospital in Nashville, Ill. The center does about 1,700 ultrasound scans annually and archives its images on an iPACS server from RealTimeImage.
Because the price of hard drives is falling, they are finding their way into systems like Washington County’s iPACS, which doubles as a telerad system and a nearline archive. All the hospital’s modalities are digital and connected to its LAN, says Larkin, with film and tape back-up; PACS is on the drawing board, and the existing server can scale up the need arises. Her long-term plan: “We figured out what our volume was, averaged the file size, and multiplied it by two years to come up with enough hard drive storage on this server so that we can save all of our CT, ultrasound and MRI studies for two years. On down the road, when we go to a PAC system, I’ll have two years’ worth of database studies with which to populate my PACS.”
Meanwhile, the current configuration is giving everyone at the hospital a taste of what a future with PACS will be like. Larkin says, “If a patient comes in as an outpatient and has a routine CT scan this week, we’re saving it on the server. Then if he comes back in the ER next month with a stroke and we do another CT scan, my radiologist can see the CT scan done in the ER alongside the one from the prior month.” As for the holdouts “who still want that piece of film in their hands,” she says the new system is helping to ween them off hard copy.
The HIPAA Police: More like a grand concept than a big army
HIPAA, the Health Insurance Portability and Accountability Act of 1996, has been called everything from tyrannical to unenforceable by those subject to it. The nicer names include inconvenience and budget drain. The reality, at least as far as archiving is concerned, actually lies somewhere in the middle.
Washington County’s Larkin says the old telerad system she replaced last year guaranteed at least one HIPAA conflict. “When the radiologists retrieved exams at home, the telerad system software would automatically store the exams on their home PCs that their kids were using. So we had privacy and security issues with that.”
Then there’s the April 14 compliance deadline that has everyone quaking. Really, it’s not panic time yet, says David Ginsberg, president of PrivaPlan Associates, Inc. (Santa Fe, N.M.). He designed and markets a do-it-yourself HIPAA compliance resource kit called PrivaPlan. “Many systems have yet to fully incorporate the final security rule under HIPAA,” says Ginsberg. “But that rule was only just published in February, and there’s a two-year compliance window.”
A far more worrisome situation, Ginsberg says, is system vendors who leverage HIPAA jitters to expedite sales. “We are finding that some vendors are saying to their customers, ‘Upgrade now for the technical security requirements of HIPAA.’ Obviously, vendors want to drive purchases of more software and hardware, so nobody can blame them. However, it’s not like practitioners have to jump up today and do hardware or software modifications. They’ve got time to wrap that into a new system purchase.”
Some good news: HIPAA’s encryption requirement was eliminated in the final ruling. Unauthorized access is less problematical these days, partly due to common safeguards such as password protection and VPNs. The bad news: A much bigger security problem is internal privacy management, which Ginsberg says is exacerbated by a lack of file-flagging capability.
“Let’s assume a patient tells an imaging clinic he never wants his records released to any third party other than another treating provider, and the imaging facility agrees to that. Does the system that manages images have a method to flag that particular record?” If not, what happens in six months when an attorney litigating an injury case submits a request for records? “Does the practice know they agreed never to release such a record without the patient’s specific authorization?” Many, Ginsberg says, do not.
Now that everyone’s in a certified tizzy over HIPAA and whether they can pass scrutiny, it’s a good time to wonder: Who’s minding the store? Ginsberg says, “The policing is handled by two Department of Health and Human Services agencies. The privacy rule is done by the Office of Civil Rights (OCR). The technical security rule and the Electronic Data Interchange [EDI] standards are being handled by CMS [Centers for Medicare and Medicaid Services]. OCR has stated that investigation will be complaint-driven; therefore, they’re not going to conduct random audits to be sure that imaging facilities are getting patients to sign the appropriate acknowledgments.”
What may in fact have more profound repercussions, says Ginsberg, is civil litigation. “For the first time, there is a standard of privacy created by the federal government. Litigators now have something to call upon on behalf of patients who believe they’ve been harmed.
“However, the idea of HIPAA police and physicians or administrators going to jail is far too trumped up. That won’t happen unless there’s been truly willful misconduct.” If someone sells celebrity mammograms to the National Enquirer, says Ginsberg, “I suspect they’re in big trouble.”
Easing into PACS
For various reasons – rapid technology changes, tight budgets, changing storage needs – some adopters conclude the best way to archive is to lease. Using an application service provider (ASP) for storage is sort of like leasing a car: You get the latest equipment and software for less than you’d pay to own them, and you drive all you want. When that new-car smell starts to fade, you just trade up to the latest model. What ASPs usually lease is some combination of on-site and off-site equipment for as long as a customer needs it, with upgrades as part of the deal.
The Yavapai Regional Medical Center in Prescott, Ariz., chose an ASP solution last year as part of a system overhaul. The 128-bed hospital has an outpatient center 11 miles as well as a second, 250-bed hospital under construction there. The group needed flexibility and scalability in a system that wouldn’t bankrupt them, and chose to use InSite One, Inc. (Wallingford, Conn.) as their storage provider.
Mary Sterling, director of imaging services at Yavapai, says, “We replaced a traditional telerad system with an archive system and a Web server. The primary purpose was to provide remote reading for our radiologists when they were on call. Now we are at the final stages of implementing a radiology information system [RIS]. That’s the key piece to the long-term storage. We have on-site RAID, as well as redundant storage in InSite One’s two data warehouses [in Arizona and Connecticut]; everything will be stored simultaneously. We transmit internally to the RAID through our hospital network, and via the Internet to the off-site warehouses.”
Hewlett-Packard’s ProLiant DL 380 server is being used as a local archive by the Yavapai Regional Medical Center in Prescott, Ariz. as part of its ASP archive solution form InSite One.
Yavapai was able to step up to multi-tiered storage because the cost of hard drives is falling, making them more accessible to facilities that might not have considered them before. The local archive at Yavapai is an expandable Hewlett-Packard (Palo Alto, Calif.) ProLiant server. It can hold a year’s worth of images. The image management software is InSite One’s InDex, a DICOM-based application that ensures fast and easy file migration among different environments.
“We can add drives if we need them,” says Sterling. “Retrieval is very quick. We’re estimating we’ll be storing 75,000 procedures per year from all modalities: CT, MRI, nuclear medicine, ultrasound, and diagnostic. The only thing we’re not storing digitally is mammography.”
Sterling points out that while the current arrangement is not a full-blown PACS, Yavapai does have most of the components in place plus its RIS, and looks forward to the additional conveniences PACS will provide when implemented. “The radiologists now use VPN [virtual private network] access through cable modem. When the PACS is deployed, they’ll have access to the long-term storage and will be able to pull up historicals. We’re looking to go filmless in the third quarter of next year.”
Cheaper, bigger, faster
While there may be some angst involved in a stepping-stone type of transition to fully tiered archiving, there are advantages, too. At the top of the list: The longer you wait to buy technology, the less it costs and the better it gets. Hard drives and speed streaming are merely two examples of that. Tape, optical discs, and their respective drives continue to improve, too.
Consider Super AIT, a.k.a. SAIT, a new tape from Sony Electronics Inc. (Park Ridge, N.J.). It’s a half-inch version of its 8 mm AIT – the foundation of many an existing archive library. SAIT-1 can hold up to 500 MB of native data or 1.3 TB of compressed data on one single-spool cassette. Compare that with 100 GB native/260 GB compressed on AIT-3, and you can see why SAIT’s target market is users of multi-slice CT and large hospitals with massive deep archives, though any facility should find it serviceable. The product will start shipping later this year.
Sony is pursuing the scaled-down customer with StorStation, an economical AIT-based solution for physicans and clinics. The FSV-1 model is geared for the small office/home office with a capacity of 80 GB. Clinics are served by the BSV-M1, with storage capacity of 2.08 TB.
StorageTek’s 9940 tape drive and 9940 cassette medium
Magnetic media still tend to be the first choices of archivists. They hold formidable amounts of data and are reasonably reliable, having been around the longest and benefited from extensive field testing. Half-inch tape outsold all other archive media last year. The 9840 two-reel and 9940 single-reel cartridges from StorageTek (Louisville, Co.) topped the list, with single-reel DLT coming in second. But optical media development has not been stagnant. Those formats, too, have gotten better and more affordable.
DVD, as an example, already has devoted fans and finds more as capacities increase and drives become more versatile. The notorious cross-compatibility issues that plagued early versions are quickly being addressed by manufacturers. For instance, last September Sony introduced Dual RW, the first drive to support both DVD+RW and DVD-RW. It also supports 24X CD-R, 10X CD-RW, and the new 4X DVD-R.
Plasmon, Inc. (Englewood, Colo.) is a player, too, with its new Enterprise D series DVD jukebox that scales up to 20 TB of storage. Dave Berg, Plasmon’s strategic account sales manager, says, “The base unit is 875 slots, and with the addition of expansion wing modules you can grow the capacity up to 2,175 slots. We use something called a multi drive in these jukeboxes, so they have the ability to read and write multiple formats: DVD-R, DVD-RAM, DVD-RW, and also CD. Siemens Medical Systems [Malvern, Pa.] is reselling this product and GE Medical Systems [Waukesha, Wis.] is looking into it.”
Plasmon will soon introduce a new technology called ultra density optical, or UDO. The 5.25-inch disks are intended to replace 5.25-inch MOD. (UDO is only readable and writable on UDO drives, and isn’t backward compatible with MOD or any other media.) The format is based on blue laser technology (MO uses red laser). UDO write-once/read-many (WORM) disks are unalterable and have a 50-year media life, making them prime candidates for long-term archiving.
“People always thought magneto optical was a great technology for permanent archiving,” says Berg, “but the cost was a little bit prohibitive, and at 9.1 GB per disk of data, it’s not really suitable for mass storage. So the UDO is starting out at 30 GB, over three times the capacity, and it’ll be a fifth the cost of MO.”
Eventually, the third generation of UDO disks will hold 120 GB. UDO-1 will be available later this year commercially, and next year will appear in Hewlett-Packard’s StorageWorks jukeboxes.
Now the question is this: Will magneto-optical media be relegated to museum displays alongside Beta video and DAT? Not quite yet. Plasmon claims it will continue to support MOD. In fact, UDO drives can be installed within G Series jukeboxes alongside MO drives, and data can be migrated from one to the other. G Series drives support Sony’s latest 9.1 GB 5.25-inch MODs in rewritable and WORM formats, and manage up to 5.8 TB of data.
Internal MOD drive from Fujitsu
Even the smaller MODs are running hard to keep pace. “Our 3.5-inch disk capacities have really improved greatly,” says Dan Dalton, director of optical products for Fujitsu Computer Products of America (San Jose, Calif.). “We just launched our 2.3 GB products last year, and we’re looking for DICOM approval by summer.” Dalton says they have a data life of 50 years. “Most of our customers who use our drives are using them for nearline storage.” They are a mainstay in most ultrasound systems, too, which offers reassurance of their continued popularity.
Just when you think something’s been around so long it’s rote, that’s when you should watch it most closely. Right now, one of those things is image archiving.