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For years the radiology industry has been nibbling around the edges of the commerce-driven World Wide Web. By attaching Web servers to a traditional picture archiving and communications system (PACS), a radiology facility can send or receive images via the Internet using conventional personal computers and Web browsers. But transmitting these huge electronic files often isn’t practical or even possible.

However, as the Web becomes more sophisticated and reliable, cyber-oriented PACS companies are popping up at Internet speed with information management and distribution solutions that they say will change the way radiology does business.

Web-enabling applications
Traditional PACS components are connected by a local area network (LAN) with dedicated lines that maximize transmission rates and minimize concerns about reliability and security. A LAN works well within a facility or to several off-site locations, but that option becomes prohibitively expensive for facilities with numerous remote locations or that want to provide electronic images to referring physicians or on-call radiologists. The ubiquitous Internet potentially can overcome that obstacle and nearly all PACS sold today can connect to the Internet to transmit or receive images. But to date, the practicality of that function, both technically and economically, has been limited.

“The biggest issue we have is bandwidth,” says Michael Cannavo, president of Image Management Consultants (Winter Springs, Fla.). The large file sizes make transmission times prohibitively slow. “You’re talking 800 to 1,000 slices with the new ultra high-speed CT scanners. How are you going to deliver that?”

Cannavo points out that while about two-thirds of the nation’s metropolitan areas have access to the relatively large bandwidths of DSL or cable modems, less than one-half percent of rural areas — where nearly 70 percent of the nation’s hospitals reside — have such access.

What that means, says Stentor Inc. (South San Francisco) CEO and President Oran Muduroglu, is that 95 percent of the facilities that tried to switch to an all-digital radiology system still are shuffling films around. Stentor and other companies have opened shop selling “Web-enabling” software that they say fulfills the distribution and information management promises made by Web-enabled PACS.

For the distribution piece, that software often involves compressing the image to a size that can be transmitted faster. Although the methods for achieving compression may differ and some software carry additional features, each company offers a method of delivering images at a faster, seemingly acceptable rate to end users.

For example, Stentor’s iSyntax server — which is located on-site — fills in the end user’s requested image progressively rather than waiting to open the image all at once. As the user zooms in or pans around the image, only the information required to fulfill the user’s needs is sent from the server. Other methods for distributing images include software that determines the resolution of the end user’s monitor and then sends only the amount of data that is needed or pre-fetching software that delivers images before they are needed, such as prior to a patient’s appointment.

Anyone using the Internet can plug in and get the browser to view iSyntax images. It also can be used in concert with an existing PACS. Other companies offer similar benefits, among them are LizardTech Inc. (Seattle), RealTimeImage Inc. (Dallas), and Xippix Inc. (Larkspur, Calif.).

The Internet also can streamline information management, and PACS companies quickly are adding productivity enhancements to their products. Amicas Inc. (Newton, Mass.) recently engaged IBM Corp. (Armonk, N.Y.) to create a transaction portal. Whenever a client produces, transmits or stores an image, that information is recorded in an off-site databank. Referring physicians can go to a Web site and retrieve information about their patients’ images — no matter where they were created or stored.

Fuji Medical Systems U.S.A. Inc. (Stamford, Conn.) has made interconnectivity a major feature of its Synapse PACS software. Clay Larsen, vice president of marketing and network development, says that instead of appending a Web server to a previously existing system, Fuji built Synapse with thin-client Web technology at its core.

In addition to easy navigation and increased productivity, Larsen says Synapse is designed to install on an off-the-shelf NT client server and maintenance is minimized, because software upgrades can be downloaded automatically from a network server. The interconnectivity features also give clients the opportunity to link with other information systems.

Larsen says Fuji’s system can be used within a LAN or over the Internet, but adds that image distribution via the Web is not a requirement or even practical for primary diagnoses.

When it comes to Web-enabled PACS, security and reliability are concerns for many. Philip Drew, president of Concord Consulting Group (Concord, Mass.), says he finds that some people are deeply concerned about these issues and won’t use the Internet because of them. Others aren’t concerned at all, but, he says, “the very fact that somebody from far away can get at an electronic image means there’s going to have to be a higher standard of security than there would be otherwise.”

The Health Insurance Portability and Accountability Act likely will impose security regulations on the industry when finalized this summer, but industry observers say they feel comfortable that they’ve addressed the Internet’s security and reliability issues. Some technology being used includes biometric authentication, such as thumbprint and eye scan authorization; information encryption; firewalls; intrusion detection systems; and virtual private network, or VPN, which creates a secured transmission tunnel inside a public network.

Off-site storage
The increasing options provided by Web-enabling software have given rise to another Internet service: off-site image storage. “Healthcare is about networking information,” says Cedric Tuck-Sherman,

vice president of imaging services at Radiology.com (Chantilly, Va.). “Part of the challenges or the limitations of healthcare today is that information is strewn all over the place and most of it is on paper.”

Radiology.com officials say the solution is to transmit images over the Internet for storage in a central data center managed by the vendor. Once captured digitally, images can be read on a personal computer, then sent to Radiology.com for archiving. No images are stored on-site at the facility. Anyone with authorization has access to the images over the Internet.

“The benefits of networking will be that all of those images will be able to be accessed over a common network,” says Tuck-Sherman. “It provides universal access and aggregates the information over different health plans and imaging centers.”

Tuck-Sherman adds that PACS — even when Web-enabled — create “digital islands” that don’t serve the community. One benefit of universal access is patient control, he says. If a patient moves away or switches health plans, her images are still available, potentially saving the cost of new images or unnecessary procedures down the road. If a patient wants a discrete second opinion, he or she can allow another physician online access. Tuck-Sherman says security measures prevent unauthorized access and patients themselves would not have access to the images and reports.

Tuck-Sherman says he understands the medical community may resist such open access, but he says they won’t have a choice much longer. “I think that in order for radiologists to remain competitive, they’re going to have to step up to the plate and offer that kind of value. I think that with increasing consumerization of healthcare and patient empowerment, patients are going to demand that.”

Others question whether the Internet’s limitations can make full off-site archiving a reality any time soon. Milan diPierro, business unit manager for radiology PACS at Philips Medical Systems North America (Shelton, Conn.) says: “Part of the challenge that PACS puts forward is image quality and image manipulation, both of which are of paramount importance to the end user. I haven’t seen any Web-based PAC systems that handle those two areas well.”

Of particular concern is the quality of compressed images. Although teleradiology through telephone lines — and now the Internet — has used compressed images for years, some say

radiologists are not ready to use such images for everyday diagnostic purposes. Providing compressed images to referring physicians is one thing, they say, but diagnosing radiologists and surgeons need better quality. “It’s got to be a tough sell to stare a radiologist in the face and say, ‘The image doesn’t have to be that good,’” says diPierro.

Fred Goeringer, chief technology officer at Radiology.com, says that data compression is becoming an accepted technique. “There have been several extensive studies in the last 10 years in medical imaging to document the fact that image compression is very useful and you really don’t lose the diagnostic fidelity of the image,” he says.

Amicas President and CEO Hamid Tabatabaie says compression, when done correctly, can enhance an image by eliminating some of the “noise.”

Amicas provides software that allows for distributing and storing both compressed and non-compressed images. Although it does not offer off-site storage yet, the company plans to introduce the service by the end of this year.

Tabatabaie does not expect off-site storage to become the only method for archiving images. “We think the market isn’t quite ready for seeing its own images stored somewhere else for a primary storage environment,” he adds.

Milton Silva-Craig, general manager of clinical eServices at GE Medical Systems (GEMS of Waukesha, Wis.), asserts storing all data off-site is not realistic. GEMS’ approach is to offer a hybrid system in which recent non-compressed images and reports are stored on-site for quick retrieval, but the system can then send information off-site for long-term archiving. When those images are needed, they can be obtained more economically and in less time than long-term archiving of films requires today, despite long Internet transmission times.

John Strauss, vice president of marketing at eMed Technologies Corp. (Lexington, Mass.), says that instead of bringing the images to one central location, eMed decided to develop and host customized Web sites for radiologists where referring physicians can go to access the images from the radiologists’ on-site archives. Although the Web site can be used for on-call radiologists, Strauss says the intent is not to provide primary diagnostic readings over the Web.

“Does offsite archiving make sense economically? Absolutely,” Strauss adds, but “physicians are not going to wait for images to be delivered from a remote archive over a wide area network. I don’t care how fat a pipe you have.”

Economic advantages of the Internet are providing the greatest benefit and incentive, companies say. Again borrowing from industries outside of healthcare, many companies offer hardware, software and off-site storage on an application service provider (ASP) model.

But don’t be confused by all of the hype, says consultant Cannavo. Traditionally, ASP is a method of financing in which the provider owns the hardware and software off-site, allowing clients to use them on a pay-per-use financing system. Because clients are sharing, the cost for everyone is lower. In addition, clients do not have to maintain or upgrade expensive hardware and software on-site.

Many companies refer to the method of financing hardware and software they place on-site as ASP as well, bending the term to fit the radiology industry. Others say that’s the same leasing arrangements traditional vendors have offered for years. The important issue, say ASP companies, is that they are making PACS and image distribution and management more affordable for everyone.

“PACS fall into the category of types of technology that are most cost-effectively done on a pay-per-use or on an ASP basis,” says Radiology.com’s Tuck-Sherman. “It’s the ASP provider’s responsibility to maintain the security, reliability, and to keep the whole infrastructure up-to-date.”

With ASP financing, clients do not need to hire information technology staff or worry about obsolescence. In addition, ASPs say they deliver image management at a greatly reduced cost, typically citing $4 to $24 for electronic images vs. $35 to $45 per film study.

The financing arrangements and hardware vary by company. Some vendors include PACS hardware with on-site storage and off-site archiving services. Others provide only on-site servers or only off-site servers with or without additional PACS hardware. Systems can be purchased outright, as an ASP or a combination of both.

Stentor’s iSyntax server, while placed on-site, is owned and maintained by Stentor and the facility pays on a per-use basis. eMed Technologies sells PACS equipment upfront, but the Web sites and applications are hosted centrally and financed as an ASP. Companies, such as Inphact The Radiology Solutions Co. (Nashville), are providing full radiology services, including installing and maintaining the hardware, off-site storage and diagnostic readings, all paid on a per-study basis.

Traditional PACS vendors also are jumping into the ASP business. While some new ASP companies question whether traditional PACS vendors can overcome their legacy systems and provide swift service in the fast-moving information technology market, GEMS’ Silva-Craig says legacy systems are not the Achilles heel one might think. Developing partnerships with information technology companies, PACS vendors can offer ASP services and enter markets that previously could not afford their systems, he says. GEMS recently partnered with Emageon Solutions Inc. (Birmingham, Ala.), an image archive provider, to manage the storage of diagnostic images for GEMS’ new ASP business.

diPierro says Philips also is developing a partnership to offer ASP off-site archiving. “I think customers that traditionally buy PACS would be more comfortable talking to a PACS vendor about ASP than to an ASP provider about PACS,” he adds.

It’s “ASPandemonium” out there, says consultant Cannavo. With new and traditional PACS companies now vying for the medium to small-sized facilities, it’s important to look past the rhetoric, he says.

Each institution must weigh the advantages and disadvantages of ASP financing and the profusion of products relative to their own situation and needs.

“There are definitely applications for ASPs,” Cannavo says, “but it’s not the panacea it’s made out to be.”end.gif (810 bytes)