A Merge White Paper Managing Non-DICOM Images within an Enterprise Imaging Solution A Workflow-based Strategy for the Growing Volumes of Patient Image Data
In hospitals and health systems today, providers generate a flood of patient-related data. As healthcare leaders seek ways to achieve clinical and financial economies of scale through industry consolidation, the volume of patient data continues to explode. Multiple sites, all standardized on a different set of equipment, are now working toward centralized enterprise data management strategies. Patient-centric care across multiple sites is the ultimate goal. Beyond the DICOM generated in the radiology department, other service lines throughout the enterprise generate clinical information in many different non-dicom formats, including PDF, MPEG, JPEG, PNG, avi, XML, and others. Creating a comprehensive patient record to present to the physician is, thus, not a simple task. The fundamental challenge is to develop a comprehensive and flexible image management strategy that is useful across multiple departments and multiple enterprises, striving to eliminate departmental silos by implementing standardsbased, highly interoperable solutions. Typically, order-based DICOM information is easily stored in a Vendor Neutral Archive (VNA); however, many specialty departments do not begin their processes with an imaging order, instead tying their images to encounters without generating DICOM exams. Encounterbased workflows in particular add a significant challenge to the traditional method of generating and managing imaging workflow, supported by a traditional VNA. Managing clinical data is fundamentally rooted in workflow. The growth rate of data moving into VNAs is exponential, expected to reach 1.4 billion objects per year in 2017. This growth is partially driven by a PACS-to-VNA migration, but much more predominantly influenced by the increase in non-dicom healthcare images, making up 75% of this data, and the need to archive it securely. A strong enterprise-level image management system should successfully ingest, store, and view a patient s complete image record, including DICOM and non-dicom, within the context of the patient s medical record. Clinical Creating an Inundation of Data Specialty DICOM Digital Clinical Objects MPEG, A/V, WAV JPEG, PDF Other Clinical Most Common Devices Anesthesia In Room C-Arm, X-ray, Anesthetic, Record Keeping Reports Cardiology CVMR, CVCT, Cath, CVUS, CVECG / Holter / Stress / Pace Dermatology Photos, dermatological Reports Emergency Medicine X-ray, CT, ECG, Triage Reports Endocrinology SPECT / CT, PET / CT, Physician Reports, Voice Dictation Files Family Medicine Physician Notes, Reports Gastroenterology Barium X-ray, CT, NM, Endoscopes, US, Reports, Voice Dictation Files Hematology HT Reports, Voice Dictation Files ICU Medicine In Dept C-Arm, X-ray, Patient CIS Flow Chart Reports Nephrology US and MRI Angiography, Scintigraphy (Nuc Med) Reports Voice Neurology Renal Scans, SPECT/CT, iconnect PET/CT, Physician Solution Reports, Renal Grams, Voice Nuclear Medicine Stored in a VNA US, Physician Reports, Voice Dictation Files Obstetrics X-ray, CT, US, Reports, Voice Dictation Files, Fetal Strips, Reports Oncology FDG-PET, CT, X-ray, Single Treatment Database Plans, Densitometry, Biograph Reports Ophthalmology Ophthalmology Laser Images, Physician Reports, Voice Dictation Files Oral Surgery Dental X-rays, Physician Single Reports Storage Pool Pathology Digital & Scanned Pathology, Pathology Reports, Voice Dictation Files Single Server Pediatrics Nuclear VCUG, DMSA Scans, Reports, Voice Dictation Files Pulmonology CT Gamma, SPECT, Single PET, Reports, Admin Voice Dictation Tool Files Radiology MR, CT, XR, US, NM, Radiology Reports, Voice Dictation Files Rehab Medicine Brain Lab Reports, Voice Single Dictation Viewer Files Rheumatology US, MRI, Rheumatology Reports, Voice Dictation Files Single Vendor Surgery In Department X-ray, Endoscopes, Surgery Reports Urology MR, XR, Digital Fluoroscopy Reports, Voice Dictation Files MANAGING NON-DICOM IMAGES WITHIN AN ENTERPRISE IMAGING SOLUTION A MERGE WHITE PAPER 2
Developing a Service Line Workflow This challenge can be approached by examining the requirements of each service line individually. Each department has its own challenges and processes to address, but these requirements can be studied and detailed based on each of their unique workflows. Gartner defines dark data as the information assets organizations collect, process, and store during regular business activities, but generally fail to use for other purposes. This non-dicom healthcare image data is an example of dark data and is generated in many service lines. Much of it is stored on thumb drives, cameras, or isolated modality stations, but it s not available to the broader enterprise. Most critical to patient care, the dark data is not available to the primary care physician or surgeon who is seeking patient data from disparate systems and attempting to piece it all together. The challenge is to bring this dark data to light and make it accessible to physicians. As the EMR is the physician s primary portal to the patient s record, this technology should be utilized and the non-dicom data should be easy to find. All of the patient s image data should be accessible within the context of the EMR, regardless of the department from which it was acquired. The EMR is the source of truth for the patient s identity and the source of all data for the clinicians to access. The best method for designing a process for a specific service line is to first examine the workflow step-by-step. Document the entire workflow, from acquisition to consumption of the data, including the current infrastructure. Think about long-term goals in addition to the immediate needs. Consider all aspects as part of these four phases: acquire the content, normalize the content, store the content, and view the content. Acquiring the The first step of the service line workflow, and one of the most important to understand, is the acquisition of the content. The source and creator of the content are the major drivers of the decisions that will need to be made to address the rest of the workflow. Also, the source of content plays a part in informing the design of the whole solution. Will the data be orders-based or encounters-based? Will it begin as DICOM or XDS? What kinds of cameras or other devices will be used to acquire the images? After understanding how the content is acquired, determine its file format: e.g., JPEG, MPEG, or XTML. Often these non-dicom files created have some level of demographics. Although not enough to build out a full XDS or DICOM object, the patient s name, date of birth, and date of exam can provide a good starting point. The growth rate of data moving into VNAs is exponential expected to reach 1.4 billion objects per year in 2017 Viewing the Equally as important as acquiring the content, consuming the content is the second critical bookend to the workflow. Who will be viewing the content and on what devices? If the consumer is a DICOM viewer, storing the content as DICOM is an obvious choice. A viewer that presents a consolidated view of all of the clinical images so that it becomes a single pane of glass for either DICOM or XDS can be a powerful choice. Whether it s a DICOM CT or an XDS ENT study, it s important to find a way to present all relevant images to the physician. Will the content be viewed in PACS? If so, then it should be stored in a DICOM format that the PACS can consume. Understand where the viewer will be launched from so that anyone who wants to use it can find it easily accessible. Will the content be used for referral or diagnostic purposes? That will inform how it should be stored and viewed. Normalizing the In most cases, the non-dicom content collected is missing key elements like the accession number, study UID number, or different types of metadata. The content will need to be normalized into a typical DICOM or XDS object. MANAGING NON-DICOM IMAGES WITHIN AN ENTERPRISE IMAGING SOLUTION A MERGE WHITE PAPER 3
Creating a standard dataset for a variety of cameras is a challenge because standard workflows don t exist in this area. A process that normalizes the potential types of content to create standard XDS or DICOM objects must be designed. How can the information be converted to a standard content format? Depending on the service line, this effort needed to define this step can be quite extensive. Defining the Use Case from a Clinical Perspective Acquire the Normalize the Store the View the Start with the Bookends Storing the Defining requirements for storing content can help drive decisions for selecting the most appropriate technology. A standards-based approach to storing the non-dicom content can significantly improve success in the portability and accessibility of that data. Should it be stored as XDS or DICOM? Should it be stored in a VNA or XDS repository? Decisions for storing the content actually should be driven by the rest of the workflow, rather than converting data both before and after storing it. If the primary viewer is DICOM, store the content in DICOM. If the primary viewer is XDS or IHE, store the content as XDS. Choices for storage can greatly simplify other aspects of the workflow. The Components of an Enterprise Imaging Solution Merge has tackled the challenge of establishing an enterprise-wide solution with a unified infrastructure featuring a single database, single storage pool, single administrative tool, single viewer, and single set of servers. Departing from the proprietary approach prevalent in the industry, the Merge solution is entirely standards-based. iconnect Enterprise Archive is both a DICOM VNA as well as an XDS-I.b and XDS.b repository. It provides the document repository and archive functionality that supports the storage step of the workflow. This VNA has the many advanced capabilities required to support an enterprisewide strategy. Non-DICOM clinical content can be managed in the VNA as XDS or DICOM. iconnect Enterprise Archive handles Multiple Patient Identity Management gracefully. If a patient is seen in multiple locations that have assigned multiple patient identities, the VNA can present all of this data when queried for that patient. When multiple systems are involved in various functions and operating in many locations, events can be difficult to track. iconnect Enterprise Archive supports audit trails and node authentication (ATNA) to provide a feed of transactions that can be transmitted to a single location for analysis. That central repository can handle security queries to support an efficient audit process. The entire system is built with high availability to support business continuity and disaster recovery requirements. iconnect Access is an enterprise viewer that presents a consolidated view of all of the clinical images. The Merge image viewer acts as the DICOM or XDS consumer, with a single pane of glass viewer to present images, regardless of whether they were stored as XDS or DICOM, or even video. The combination of iconnect Access with iconnect Enterprise Archive provides a single-vendor unified solution. MANAGING NON-DICOM IMAGES WITHIN AN ENTERPRISE IMAGING SOLUTION A MERGE WHITE PAPER 4
The iconnect Access viewer can easily be launched from third-party applications to provide an efficient solution for consumers in any department. It allows users to aggregate and view all DICOM and non-dicom content from the EHR. Merge Document Management can be used to ingest non-dicom images, acquire the necessary metadata, and archive the study to iconnect Enterprise Archive as XDS objects. This XDS importer plays a major role in the overall solution, supporting the normalization step of the workflow. It ingests the non- DICOM content and converts it to XDS so that it can easily be handled within a standardsbased enterprise solution. Merge Document Management also includes viewers to help organize the images. The Merge solution can simplify image management across the enterprise while reducing administrative and storage costs. Data can be shared between departments, PACS systems, and individual physicians, which results in a unified patient record of all clinical content from an integrated solution with a single database. Summary While Merge can store the content in its native format, Merge uniquely stores the native content within a standards-based solution. Many of the competitive solutions store the non-dicom content in a proprietary archive essentially replicating the sins of PACS from the 1990s and 2000s that led to expensive migrations. Merge s solutions are developed in house so that our standards-based solutions can all be supported by a single vendor. Importantly, Merge has the experience necessary to implement a robust solution tailored site-by-site. Figure 3: Merge XDS Solution EA CAN BE A PIX / PDQ MRG. WHEN IN MPI MODE PATIENT IDENTITY SOURCE (EMR, EMPI OR PIX/PDQ MANAGER) PIX/PDQ PATIENT ID FEED REGISTRY QUERY FOR DOCUMENTS iconnect ACCESS CONSUMER icea V11.3 PROVIDE AND REGISTER XDS SOURCE REGISTER DOCUMENT SET DATA SOURCE CONVERSION TO XDS TOOLS MERGE MDM REPOSITORY RETRIEVE DOCUMENTS IMAGE SOURCE RETRIEVE IMAGES RETRIEVE EVIDENCE DOCUMENTS WADO RETRIEVE iconnect ENTERPRISE ARCHIVE ECM-9515 Rev 1.0 Copyright 2015 Merge Healthcare 877.446.3743 x3 merge.com