How the VA Midwest Healthcare Network deconstructed their PACS and gained agility and flexibility for its radiologists.
By Aine Cryts
Mike Ryan at the Veterans Affairs (VA) Midwest Healthcare Network—also known as VISN23—is proud of his team’s work on deploying a “deconstructed PACS” across the network’s 11 facilities. Still, Ryan, who is informatics coordinator of the imaging service line, would rather talk about the honor of working with his fellow VA employees to “serve those who have served.”
Eagan, Minn.-based VISN23’s patients include a substantial geriatric population, though the network sees a large influx of younger veterans and more women veterans than ever before, according to Ryan. And this makes sense, since the United States is largely winding down its presence in both Iraq and Afghanistan, after two hard-fought wars in those countries.
Ryan’s team decided on a deconstructed PACS strategy in 2013 because the network was coming to the end of its contract with its previous PACS vendor. He defines VISN23’s deconstructed PACS as a solution that includes three components:
- First is the imaging viewer from San Diego, Calif.-based Visage Imaging;
- Second is the storage component, a vendor-neutral archive (VNA) solution from Lexington, Ky.-based Lexmark
- Third is the worklist component furnished by San Francisco-based Medicalis.
According to a press release issued by Visage Imaging, VISN23’s enterprise-wide viewing solution will provide access to nearly 500,000 annual diagnostic imaging studies for the hospital network that serves 400,000 enrolled US veterans. The network will be able to provide access to imaging throughout Iowa, Minnesota, Nebraska, North Dakota, South Dakota, and parts of Illinois, Kansas, Missouri, Wisconsin, and Wyoming.
Agility and Flexibility for Radiologists
There was no precipitating event that caused the move to a deconstructed PACS, according to Ryan. It really came down to the fact that the network wanted more “agility and flexibility” for radiologists. “As [enterprises] look ahead to the next five to eight years, as they consider their [PACS] replacement cycle…they need to do an evaluation to determine if that solution is fully meeting their expectations. The industry hasn’t changed, but maybe it makes sense if there’s a new leader in one of the key components that’s provided by a PACS,” said Ryan.
He highlights the solution’s worklist capability to enable radiologists to interpret studies. “We’re networked and we have distinct facilities. Prior to now, we were more siloed in our facilities. With our worklist solution, we’re able to bridge facility barriers with an integrated solution,” said Ryan. That means radiologists can do peer review more readily and more fully leverage radiologists across facilities, especially for subspecialty readings.
Ryan also points to the value of a worklist that’s customizable to each radiologist. For example, radiologists can now choose the color appearance of the worklist, and they can also arrange the worklist as they decide; that means, for example, that CTs will appear at the top and general radiology studies will appear at the bottom of the worklist. The effect is more control for radiologists, which can help make them more efficient. He notes that it’s also valuable that radiologists and other clinicians will all have a very similar user interface; still, VISN23 is mindful about which clinical team members have the ability to annotate images and those who have read-only access.
“A strategy of deconstructed PACS is reflective of state-of-the-art technologies working in synchrony: workflow, vendor-neutral archiving, and viewing,” according to a spokesperson for the three vendors providing the deconstructed PACS solution. “With Visage Imaging, Lexmark, and Medicalis providing an enterprise-wide approach for VISN23, imaging is no longer restricted by the location of the patient, the radiologist, or legacy system limitations.
“All images are now rapidly available and care is delivered with high quality as all clinical information is at the fingertips of radiologists and physicians, ensuring the right study is read by the right radiologist at the right time,” according to the vendor spokesperson. “Cross-site diagnostic reading, ready access to prior exams, and regional clinical viewing of images is the reality. Enterprise imaging has enabled VISN23 to create a VISN-wide imaging service line, providing a platform for innovative, veteran-focused services.”
Image Migration, Timeline, and Lessons Learned
The storage component has performed to Ryan’s expectations and he’s also pleased with the ability of Lexmark to help his facility migrate studies for the project. Lexmark has helped Ryan and his team by setting up a path to store images to the network’s long-term archive.
The deconstructed PACS deployment should be complete by August. As of the writing of this article, five of the 11 sites were up and running with the deconstructed PACS. VISN23 will continue to work with Lexmark on a full migration of legacy images, according to Ryan. The migration is “proceeding as well as can be expected and…our processes allow us to comfortably proceed with a go-live as we migrate in the background.”
Ryan advises organizations looking into a deconstructed PACS solution to be strategic, realistic about current resources, and to get buy in from across their organization.
His advice includes:
- Have a solid understanding of your organization’s needs and goals. “It’s important to note that [a deconstructed PACS] may not be the best for everyone,” said Ryan. “We’ve found it to be working well for us—but I’m not saying it’s the best solution for everyone.”
- Keep your eyes open. Essentially, you need to make sure you have a firm understanding of what your organization needs and the resources you have to do the job. You also have to make sure you’re aware of what’s available from vendors.
- Realize that this can represent a large strategic change for your organization, so buy-in is essential. “It’s imperative that you have buy-in from your radiologists, your finance people, your radiology administrators, and your directors of radiology. You don’t want anyone to be surprised by your approach,” he said.
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Aine Cryts is a contributing writer for AXIS.
Visage Imaging is a proud Deconstructed PACS partner of VISN23. Mike Ryan’s passion and VISN23’s tireless efforts have transformed imaging informatics across the region. We’re humbled and honored to work with the great men and women of VISN23, serving our nation’s Veterans.
Brad,
Thanks for those kind words.
Mike Ryan.
Brad,
Thanks for the kind words
Mike.
Who /how is modality worklist managed? Is that still provided by the PACS vendor or who?
What about technologists? How do they work in this environment?
BTW, I am a system PACS Manager with > 40 sites delivering images into our PACS systems.
That is a very good question! For the purposes of this article, we discussed what might be call the “big three” of a deconstructed PACS. Obviously, as you have pointed out, that’s not all that is required to make a truly de-constructed PACS.
To you question, we use PACS Connect from Lexmark (formerly Pacsgear) as our MWL solution. We started the MWL cutover well ahead of our de-constructed PACS implementation.
http://www.lexmark.com/en_us/solutions/healthcare/enterprise-imaging/enterprise-image-connectivity/worklist-solutions.html
Another key component allowing us to proceed with implementing a de-constructed PACS is a HL7 integration engine. There are, of course, several offerings on the market. We chose Corepoint Health of Frisco, TX as our HL7 vendor partner. Anyone familiar with the VA’s VistA system understands that it can sometimes be a challenge to enable new HL7 feeds from VistA. With a HL7 integration engine living within the Biomedical Engineering and Imaging service line’s sphere, we were able to work with VA’s OI&T to enable one to several HL7 feeds from each of our facility based VistA instances. This allows us to amalgamate all radiology HL7 messages as well as many lab messages into a single system. Now we (Biomed and Imaging) can work with vendors as they come aboard to customize HL7 message as needed. We have also use Corepoint’s HL7 engine for a variety of non-imaging needs such as a Tele-ICU wherein we receive and proffer imaging reports and lab values for VA hospitals as far ranging as Portland, OR.
http://corepointhealth.com/products/corepoint-integration-engine
-Mike Ryan
Sorry for the double posts. For some reason, posts didn’t show up for several days.
Regarding the MWL comment, that is a very good question! For the purposes of this article, we discussed what might be call the “big three” of a deconstructed PACS. Obviously, as has been pointed out, that’s not all that is required to make a truly successful de-constructed PACS.
To your question, we use PACS Connect from Lexmark (formerly Pacsgear) as our MWL solution. We started the MWL cutover well ahead of our de-constructed PACS implementation.
http://www.lexmark.com/en_us/solutions/healthcare/enterprise-imaging/enterprise-image-connectivity/worklist-solutions.html
Another key component allowing us to proceed with implementing a de-constructed PACS is a HL7 integration engine. There are, of course, several offerings on the market. We chose Corepoint Health of Frisco, TX as our HL7 vendor partner. Anyone familiar with the VA’s VistA system understands that it can sometimes be a challenge to enable new HL7 feeds from VistA. With a HL7 integration engine living within the Biomedical Engineering and Imaging service line’s sphere, we were able to work with VA’s OI&T to enable one to several HL7 feeds from each of our facility based VistA instances. This allows us to amalgamate all radiology HL7 messages as well as many lab messages into a single system. Now we (Biomed and Imaging) can work with vendors as they come aboard to customize HL7 message as needed. We have also use Corepoint’s HL7 engine for a variety of non-imaging needs such as a Tele-ICU wherein we receive and proffer imaging reports and lab values for VA hospitals as far ranging as Portland, OR.
http://corepointhealth.com/products/corepoint-integration-engine
Another key component and excellent vendor partner in our implementation has been Laurel Bridge’s Compass DICOM image and HL7 router. We’ve used the Compass router within our daily operations for more than five years. In fact, it has been our successful use and implementation of “niche” vendors like Laurel Bridge that has given us the experience and knowledge to feel confident in taking on a de-constructed PACS project. The Compass router has remarkably easy to use tag-writing capabilities, which allows us to “clean” data. For instance, we use Compass to ensure we have proper DICOM body part and laterality information added to migrated data making hanging protocols, etc. much easier to manage in a new PACS viewing solution. We’ve also used Laurel Bridge’s Navigator product to assist in an ad hoc migration. It quite literally rescued our implementation in Iowa City (the first “go-live” site) by allowing us to schedule image study retrieval of our next day’s scheduled patients (CT, MRI, NM, etc). By bringing those study jackets aboard overnight, it freed up resources on our legacy PACS for providing real time pre-fetch without crippling our legacy PACS. While we worked out our enterprise desktop viewing integration, we had to maintain both our new and legacy PACS systems and, yes, that’s as nightmarish as it sounds! Navigator might well have prevented me from being tarred and feathered by radiologists and technologists.
As a government employee, I’m not in a business of endorsing one vendor over another. The vendors I’ve mentioned above, after careful consideration and due diligence by a multi-disciplinary selection committee, were found to best meet our needs in both price and performance. Our hope is that we will truly see the value of a de-constructed PACS solution in 5-7 years when we may well be in the market for upgrade or replacement of PACS components. All of us working in this field have witnessed the dramatic improvements achieved by ALL vendors across the Imaging Informatics spectrum. The king in today’s market might be a pawn in 5 years. Time will tell!
-Mike Ryan
Mike
Thanks for the feedback! This helps a lot that “I’m not making things up”.
Your additional information provides me the support for this type of change.