In today’s I-need-it-yesterday world, healthcare facilities are faced with an already monumental task that seems to be growing exponentially. The storage and archiving of medical images can be daunting and confusing and seem like a checkbook-breaking endeavor for any size facility.
However, when navigating the vast world of archiving options, there are ways to cost-effectively approach this crucial aspect of medical imaging.
Experts from some of the industry’s storage equipment and archiving providers agree that when considering image storage, the most important issues to keep in mind are accessibility, reliability and scaleability. Although the initial outlay may seem hefty, a facility’s ability to quickly and reliably retrieve images is virtually priceless.
Where to begin
When a facility assesses storage requirements, decisions should be based, in part, on existing infrastructure. An existing PACS, DICOM capability and media all play a role in determining the route and cost of an image storage system. Other essential elements include how much information facilities want to keep readily available in online, near-line and off-line or shelf-managed storage.
If that isn’t enough balls to keep in the air, other crucial aspects include how many imaging modalities are used and images produced in order to create a system to meet storage demands for as long as possible.
FileLink (Bloomington, Minn.) generally recommends a gradual strategy to expand a facility’s storage capabilities over approximately three years.
“[Hospitals] have CT and MRI that are generating a lot of digital data per year. They may start out at the lower end and begin with CT and MRI, then gradually start adding other modalities,” says John Paumen, FileLink’s vice president and general manager of healthcare solutions. “They could install a one terabyte solution and then grow that into the three-year solution with pretty nominal incremental costs.”
FileLink CEO Rick Berglund estimates the cost of a 1.1-terabyte solution between $85,000 and $120,000, depending in part on existing infrastructure.
Berglund profiled a 500-bed hospital with a full complement of imaging modalities. “Based on image size and average number of images per study, this 500-bed hospital generates something on the order of about 20 terabytes a year,” he adds, assuming every stored image is digital.
Most of those terabytes would be consumed by data-intensive cardiac cath lab images. When those images are excluded, Paumen estimates that a 500-bed hospital would need six to eight terabytes per year.
“In a medium-sized facility,” he adds, “3.5 terabytes per year would be adequate, and for the smaller institution, somewhere again three quarters to one terabyte per year” would be enough.
Hardware and software costs for a low-end solution would be approximately $60,000, Paumen estimates, $100,000 to $115,000 for the medium solution, and closer to $200,000 for the high-end solution.
PAC-ing it on
For facilities that have taken the leap to PACS or are considering a PACS, several companies are working to make that introduction more palatable. DeJarnette Research Systems Inc. (Towson, Md.) is preparing its first full PACS offering, which includes a long-term archive capability.
DeJarnette is developing an architecture that President Wayne DeJarnette describes as physically distributed, but logically centralized. The modification is designed to provide advantages, such as scaleability.
“This Radiance system buys you the ability to have storage at multiple locations, with one central agent or central set of agents, or even a distributed set of agents that appear to be central that then manage all of this,” DeJarnette says.
There are three components to DeJarnette’s archiving system. NetShare IQ is a highly distributed RAID (redundant array of inexpensive disks) short-term or online storage component. MediShare IQ acts as the PACS database and the gateway or interface to a HIS (hospital information system) and a RIS (radiology information system). The third component is ImagePortIQ.
“We don’t put any application intelligence on the archive itself,” DeJarnette says. “We’ve taken all the application smarts and sit that on a separate box we call the ImagePort IQ, which is basically a gateway to the archive between the imaging application and this neutral object storing long-term archive.”
Before a facility can calculate costs, there are questions to answer. One query is what the facility wants to do in terms of database redundancy. Does the facility require a system that is highly redundant and will switch over automatically, if one of the MediShare IQs goes down for some reason, and continue to operate a department without missing a beat?
“Depending on the answer, the image management portion would cost from $80,000 to something north of $200,000 for a 500-bed facility,” estimates DeJarnette. The larger figure would be for a highly redundant system.
For a system with a reliable instrumentation, but no redundant database, a facility could pay approximately $80,000 to $85,000. Those figures represent the image management piece, excluding storage.
The next step is to determine how much online storage is required. Days, weeks, months — what needs to be stored so that users can get to it quickly, keeping in mind the number of modalities or modality clusters, which allows for the determination of how many NetShare IQs, or online storage components, a facility would need.
“On that type of a system, you are probably talking about $300,000 worth of online storage to get those images quickly,” DeJarnette says. As for the third piece? ImagePort gateway is relatively inexpensive at approximately $20,000. Before installation, a facility must decide how much online storage it needs, and how long the images will be stored.
“You can spend anywhere from $100,000 up, depending on the answer, whether you want to use optical media, or whether you want to use tape,” DeJarnette adds.
Reducing Costs
In addition to simplifying the transmission of medical images, PACS have made image storage easier to manage, and for some facilities, decreased the overall cost of image storage. Sometimes, those savings come at an unexpected point in the process.
Ken Waldbillig, PACS operation manager for Data General Corp. (Westborough, Mass.), says some facilities approach PACS with the attitude that they are going to be able to stop making film and reduce the cost of film, jackets, storage and chemistry.
Those costs only add up to about $8 per procedure, according to Waldbillig.
Data General specializes in computing for the healthcare environment, which guarantees a facility 99.9 percent uptime. This also means having scaleability in the storage for a 500-bed hospital to generate 150,000 to 200,000 radiographic procedures annually.
The first element — image acquisition — is a function of how many CT scanners, MR scanners and ultrasound systems a facility has. Waldbillig estimates that in a 500-bed hospital one would expect to have approximately 20 modalities. Configuration also depends on the age of the modalities and if they are DICOM-compliant. If they are DICOM compliant, a facility would not need equipment to convert information to DICOM.
“In that category you could easily expect to spend in a non-DICOM environment $250,000 for image acquisition, if you had 20 modalities and none were DICOM,” Waldbillig says. “If half of them were DICOM, it would be about $150,000.”
The second component, image management and distribution, is likely the most expensive. Waldbillig pegs the tab at $500,000 to $700,000 for a 500-bed hospital.
Facilities can capture images and store them on a hard-drive or RAID, then spin them off to an optical technology. The third tier of storage is digital linear tape, or a large jukebox. With this approach, the middle tier could be refilled by rewriting it, and the permanent archive would be tape. The challenge becomes one of pre-fetching and getting information off the tape as needed.
While Waldbillig has seen a trend to RAID systems where everything is online all the time, there are still some cases where facilities want to have a second off-site option, in case the storage system breaks.
A newcomer on the medical image storage market is Data Management Services (Houston), a department of Western Geophysical (Houston). The company has managed and stored petrophysical data, including film copies, for seismic and digital data storage for the oil and gas industries for more than 25 years and now is moving into healthcare.
The company manages five million tapes, and at its main facility there are 32 STK Powderhorn storage silos, produced by StorageTek (Louisville, Colo.), a provider of network computing storage. The silos are on-site mechanical, automated data libraries that hold approximately 6,000 tapes each.
“As for cost-effectiveness, Data Management Services is projecting up to a 30 to 40 percent cost savings for the hospital or institution on their storage management,” says Richard Johnston, director of data management services for Western Geophysical Worldwide. “The company can manage the off-site data storage, and the facility no longer has the capital cost of purchasing equipment, the hardware and upgrade costs that are associated with that equipment, or the service and maintenance costs.
Data Management Services has found the most cost-effective media to be RAID disk for online and immediate access. For long-term storage, the company utilizes a high-end commercial magnetic tape, such as the IBM 3590.
On-site storage
For hospitals that choose to manage images on-site, there is hope. A variety of companies are equipped to walk a facility through the winding path of storage management, while keeping track of the multitude of elements that ultimately shape a solution.
At IMCO (Pewaukee, Wis.), formerly Rogan Medical Systems, the company works with the facility to estimate current and future storage needs to create a cost-effective system. “We typically encourage customers to put in two years, because the media and the jukeboxes tend get faster, cheaper and better,” says IMCO President Mark Schwartz.
As these improved technologies hit the street, facilities may work more of the less expensive storage pieces, such as RAID, into their system. “We see customers looking at longer and longer time on their RAID,” Schwartz says. “We have even quoted some going all the way up to 12 months of data on the RAID.”
From RAID, Schwartz says clients typically want to put images into a jukebox storage system for from one to seven years. “Ideally, everyone would like to keep their data forever in the jukebox, but, at some point, you are using the data so infrequently it may make more sense to keep the media on the shelf and if the patient comes back into the hospital just put the media back into the jukebox,” Schwartz says.
In Schwartz’s opinion, cost-effective media depends on what a specific facility’s requirements are. Although the tape systems are less expensive, it may take much longer to retrieve the images. And the optical systems, which are faster in retrieving images, are more expensive.
“We think that DVD is probably the best happy medium in the sense that you are getting a lot of storage for a reasonable price, but also fast access,” Schwartz says. “If a customer is very budget-sensitive, that will tend to push them more toward the tape alternative and if they are performance-sensitive than that would tend to push them to large RAID.”
Weighty Decisions
Investing in a reliable storage solution is most definitely a weighty endeavor that involves a considerable amount of input, calculation and speculation, not to mention the modalities, the number of exams per year and the number of images acquired per exam.
“You also have to take into account all of that detail when sizing an archive and a hidden factor that is how may legacy exams are going to be retrieved for purposes of comparison with new exams,” says Dean Kauffman, director of marketing for Impax Solutions Group of Agfa Medical Imaging, Agfa-Gevaert (Mortsel, Belgium).
The pre-fetching does not have much of an effect on the archive itself, but on the RAID, or near term storage. Since a facility will be pulling images off of the archive rapidly and frequently, Kauffman says users need to make sure the images are on RAID.
When facilities are considering PACS, Kauffman says he encourages them to look at the infrastructure and items such as clinical displays. Although archiving is considered separate from some of the other infrastructure components, overall the infrastructure of PACS can be the greatest percentage of the cost especially for a small to medium size institution.
“Archiving can be the biggest chunk of those infrastructure costs, depending on a number of factors, one being the performance and the associated server’s capacity that is needed,” Kauffman says. “No. 2 is based on the amount of data that they are going to need to store long term each year that is going to define the jukebox capacity. The third factor is how many days of online storage they are going to need and that’s going to define the RAID capacity. There are a number of factors that have to be considered. If you want to simplify it, it’s not unusual that the archive take up a big chunk of change.”
Doug Tucker, Impax’s director of product development and technology, estimates that between 15 and 30 percent of the overall cost of a PACS program would be dedicated to storage.
“That may be storage that is distributed on local disks to workstations, or the storage associated with a centralized archive, but 15 to 30 percent tends to be a fairly big chunk of change when you are looking at the purchase of a multi-million dollar PACS,” Tucker says.
Agfa’s Impax AS 3000 archive station reflects the major issues involved in image storage — price, reliability, and scaleability. Kauffman says the server’s reason for being is to make sure that when staff requests an image from RAID storage or an archive jukebox, images can be found quickly and sent to the requestor. The scaleability issue is to ensure that a given level of performance is maintained as the amount of information stored increases and as the information coming into the system to be stored increases.
Yet another factor can be the number of requests for information coming out increasing. “You’ve got these three demands being placed on the system that are almost in conflict, of information coming in and out and being managed very quickly,” Kauffman says. “So, the system has to be very high-powered, it has to scale, especially when you get into imaging environments where you doing more than 150,000 exams a year. Many of our customers are performing 200,000 to 300,000 exams a year.”
When adding up image storage costs, facilities need to be aware of what it will cost to store and manage the data over time, an important cost factor that is sometimes ignored. “You may shell out any number of dollars up front for hardware and software, but when you get into digital image management as well as analog film management, you’ve got carrying costs,” Kauffman adds.
Because PACS invariably grow as hospital volumes increase, when a facility purchases a PACS and an archive, they do not just buy it once and walk away from it, the way they might with a modality archive. “A PACS archive always needs to be expanded, always needs to be upgraded and kept current from a technology standpoint,” Kauffman says.
Although every facility desires a system that is operational 100 percent of the time, Tucker warns that the more technology evolves and the closer companies get to achieving that end, the associated costs will continue to increase.
“The reality is that you can never keep any system up 100 percent of the time and the closer you get to being 100 percent available, the cost to achieve that escalates something beyond linear, approximating exponential cost,” he adds. “You can go to extreme ends to achieve 100 percent reliability or attempt to achieve that. The issue is the cost to deliver that level of performance will soon outstrip your ability to provide it to the customer. There is always this trade-off between how much reliability, how much redundancy at what cost that you are willing to deliver to the marketplace.”
There are myriad elements to keep in mind when a facility is considering how to address their image storage needs, and it can seem overwhelming. With today’s technological choices and spectrum of companies that provide everything from consultation and installation, to maintenance and upgrades, healthcare institutions are now better equipped than ever to cost-effectively manage and store their data.
Decisions regarding image storage must take a number of variables into account including not just the bottom line, but how quickly and reliably a physician will be able to access a patient’s records. 
