Medical Images in the Cloud Eliminate Duplicate Tests
In the United States, workers who are exposed to radiation in their jobs are monitored and limited to an effective dose of 100 millisieverts (mSv) every 5 years (an average of 20 mSv per year, with a maximum of 50 mSv in any single year). This concept of effective dose and the mSv measurement estimate the potential future risk of cancer from radiation exposure.
It is estimated that about 4 million Americans each year receive radiation doses higher than 20 mSv from medical imaging alone, but it appears that most patients who are exposed to radiation from diagnostic imaging are not subject to similar monitoring or exposure limits. When was the last time you were asked about previous exposure prior to a diagnostic image being done?
What Some Studies Show
One study examined the medical records of over 900,000 people over multiple years to estimate the number of people who might receive radiation doses from diagnostic imaging at a level that would cause concern in an occupational health setting. In a three-year period during the study, the patient sample underwent more than 3 million imaging procedures delivering radiation exposure. Almost 194 per 1,000 people each year received moderate radiation doses (between 3 and 20 mSv). Almost 19 per 1,000 received high doses (between 20 and 50 mSv), and almost 2 per 1,000 received very high doses (over 50 mSv) each year. Using this data, it can be estimate that about 4 million Americans each year receive radiation doses from medical imaging that are higher than that allowed in industrial settings.
Causes of Overexposure
One of the overwhelming causes of this overexposure to radiation is the ordering of duplicate tests. Often this is because the treating physician doesn’t have access to the previously performed tests and reports. This is where the cloud can provide tremendous benefit. System and enterprise integration with a web-based online radiology system can allow radiologists and physicians to see images and read reports from anywhere, anytime, without having to order duplicate tests.
The Importance of Patient Empowerment
In addition, medical imaging in the cloud enables greater sharing of information with patients. Patients can become empowered to participate in their health care and treatment. In radiology, this empowerment and transparency translates primarily into facilitating patients' access to their imaging reports or the information in those reports. And an online application can aide in this process. Often, this transparency can prevent incidental findings from getting lost in the medical cracks and not being tended to.
Of course, most medical records are legally available to patients through HIPAA, but, unless a hospital has a specific web site for this purpose, the records are rarely accessed by patients in a timely fashion because of the relatively costly and time-consuming process of having them located and copied. Web-based records and personal health records, allow patients to store, manage, and organize their medical information, often collected from multiple locations.
This is particularly important in off-hours, if emergency care is needed. By providing diagnostic quality images and medical records on line, reports can be generated much more quickly, providing better emergency care for patients. This access to medical records and images is one of the major changes in the doctor-patient relationship that has transpired in the 21st century. Patient-centered care, patient partnership in decision making, and patient-doctor transparency are new buzzwords in medicine. These sociologic changes are reflected in the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996, which requires that patients be able to see and obtain copies of their medical records and diagnostic images.
Getting Into the Cloud
Both patients and doctors can make use of companies who provide secure cloud-based storage and access to medical records and diagnostic image-sharing technology on a subscription basis. Usually, these services are very affordable. One such company is Radiology Services Online who provides a Cloud/SaaS solution directly to hospitals and radiology clinics to help transfer test results among doctors, who can view them on a tablet or smartphone if need be. In addition they also offer a MS HealthVault App for pro-active patients who want to take charge of their medical imagery.
Cloud Transmission for Medical Images
Cloud transmission of medical images is an internet-based exchange of medical images between hospitals, physicians and patients. Using the Cloud, rather than traditional media, such as a CD or DVD, helps to speed access to the images and helps to prevent misplacing or losing the images. The primary format for images is DICOM (Digital Imaging and Communications in Medicine). Usually, in addition to the image, reports are included during the sending process. Using the Cloud for image transmission aids in faster diagnosis and empowers patients by giving them control of their imaging histories (reports and images). Today’s web-savvy patients are usually happy to manage these records, much as they already manage their online banking.
Because traditional methods of transmitting medical images from one hospital to another can be time-consuming, cumbersome and expensive, most physicians and hospital managers are in favor of Cloud transmission. Patients, too appreciate the speed of the Cloud, which nearly always prevents the duplication of tests that may be required when imagery sent via mail or courier hasn’t arrived in a timely fashion.
The Cloud, in combination with modern technology and encryption methods helps to speed and simplify the transmission of medical images. Perhaps those who benefit most from these new technologies are small hospitals and rural medical facilities who can use secure medical imaging transmission methods to get immediate help with diagnosis and treatment, rather than needing to send their patients to the nearest big city hospital.
PACS in the Cloud
A Picture Archiving and Communication System in the Cloud can be very easy to use. Since the images are accessed via familiar search engines, such as Firefox, Chrome or Internet Explorer, medical personnel can navigate the system to access and transmit images with minimal training and, therefore, with minimal expense. In addition, images are available without download in a Zero Footprint System, which not only speeds viewing, but also ensures privacy because the image never leaves the hosting server.
In addition to being easy to use, a Cloud system also provides easy security options. Since the system contains multiple encryption tiers, supervisors can assign passwords to personnel that authorize them to access isolated images, groups of images, or the entire digital imaging system, depending on their level of security clearance. The excellent encryption system also enables medical personnel to more easily comply with HIPPA regulations by more effectively limiting access to privileged information.
Added Benefit of Cloud Storage
Not only does the Cloud enhance security but it also makes data storage simpler. Digital medical imagery generates enormous files, which can rapidly fill in-house servers and storage systems. When images are stored in the Cloud, the hospital and health care organizations are not required to maintain large storage servers of digital images on site, thus reducing their IT hardware and personnel requirements. Further, because the digital images are backed-up to multiple redundant servers in multiple locations the medical images and reports are recoverable in case of disaster.
The simplicity of a Cloud system does not end there. Many Cloud systems that are specifically designed for housing medical images also provide easy ways for users to manipulate the quality of images to enhance brightness, contrast, or zoom. One caveat: Make sure that the Cloud you chose delivers diagnostic quality images. This is crucial for enabling patient diagnosis and treatment.
Some Cloud Systems, like Radiology Services Online (RSO) have added benefits including scalability, seamless Integration with non-cloud based DICOM devices like PACS, Modality, and Workstations, as well as platform independence and advanced file compression that offers files that are smaller than other lossless technologies with reference to storage and transmission.
RSO also provides expert FREE X-ray film scanning for all types of X-rays for all of their Cloud customers, digitizing all types of x-rays, up to 14 x 52" film and recognizing down to a 44mm spot size. With over three million x-rays scanned, compressed and sent them to the Cloud as well as to all types of PACS systems, RSO is one of the few companies in the world to have the experience of scanning millions of x-rays and our experience in high-volume x-ray scanning is second to none.
In order to eliminate bottle necks in viewing, RSO directly supports DICOM and offers up to 50-1 image compression. This allows a standard size film to be reduced to less than a one (1) megabyte image and directly relates to quickly sharing lossless images via the Cloud and with other departments.
Lossless data compression allows the exact original data to be reconstructed from the compressed data, and is essential to accurate medical imaging and diagnosis.
The Cloud can eliminate network and traffic problems that may occur within a traditional PACS system.
What You Need to Know About HIPAA and the Cloud
With the medical community looking more and more toward the cloud for hosting and accessing patient records, it’s really important to understand just what is necessary to have a “HIPAA compliant solution.” This means that we have to sort through all of the jargon that’s out there about HIPAA, HITECH, BAA and the Cloud. Let’s start with the acronyms first:
HIPAA stands for the Health Insurance Portability and Accountability Act, which sets standards for protecting individually identifiable information in health records. In the fall of 2013, the HIPAA omnibus final rule, was enacted to strengthen patient privacy protections and provide patients with new rights to their protected health information. Within this law, Title II specifically refers to electronic information.
HITECH is the Health Information Technology for Economic and Clinical Health Act, enacted in 2009, which stipulates financial incentives for healthcare providers that demonstrate meaningful use of electronic health records. Because this meaningful use was required in stages, HITECH continues to impact the medical profession, just as HIPAA does.
BAA revers to a Business Associate Agreement, which is a contract between the “HIPAA covered entity” and a business associate that protects personal health information. In cloud computing, the cloud provider is considered a Business Associate, and therefore, subject to the requirements of HIPAA and HITECH.
What’s It All Mean?
Do a Google search of any combination of the terms “Cloud” and “HIPAA” and you’ll find a wealth of companies who offer “HIPAA-compliant” cloud services of one kind or another. The industry recognizes the need for HIPAA compliance, and you’ll have a choice when you’re looking for a HIPAA-compliant cloud. But beware – you’re still the one that’s responsible, so you better do your due diligence and make sure that the cloud provider really is HIPAA compliant and that they really do provide the services you need for your medical team and patients.
HIPAA Compliance is not a designation or recognition provided by any branch of the U.S. government. Any firm can say that they are HIPAA-compliant. You will need to understand what HIPAA compliance requires of you, and then make sure that the Cloud provider has the necessary controls and processes in place to ensure that these requirements are met. There are no formal audit requirements for HIPAA compliance, but some Cloud providers to submit to voluntary third-party audits. It’s always worthwhile to ask if the Cloud provider you’re considering has an outside audit report. At the very least, the cloud provider must be willing to sign a BAA.
The Health and Human Services website provides information about all aspects of HIPAA and is an excellent reference source to help you ensure that both your medical organization and anyone you partner with is HIPAA compliant. With a Cloud partner, it’s particularly important to ensure that you and the Cloud provider are in compliance with the final HIPAA Omnibus rule, which clarifies that “a data storage company that has access to protected health information (whether digital or hard copy) qualifies as a business associate, even if the entity does not view the information or only does so on a random or infrequent basis.”
Data Security best practices include encryption, however strictly speaking HIPAA does not require the use of encryption. Or, in the round-about language of bureaucracy, encryption is not “mandatory” but “addressable.” While HIPAA declares it to be not mandatory, it is wise to ensure that your data is encrypted. It will help to protect you if your data is somehow breached. Lost or breached data that has been properly encrypted will not be considered a breach of unsecured personal health records. The wise medical facility and the wise Cloud provider will ensure that all personal health information is encrypted, both in storage and in transit.
Of course, beyond the issues of HIPAA compliance, and security are the features and benefits on the individual cloud providers and the solutions the offer. Once you’ve established a level playing field by ensuring HIPAA compliance and security, then you can begin to hone in on exactly what you want to be able to do in the cloud.
Small Hospital Medical Imaging Strategy
Most rural hospitals suffer from two problems – small size and limited budgets. Add to these two problems the obvious “off the beaten path” location, and many rural hospitals find it difficult to keep pace with technological advancement. This often means it’s necessary to transfer patients to specialists at other larger facilities, which means sharing data outside of its network.
This need to transport often means that patients will undergo expensive, duplicate tests in the larger facility, with needless additional cost and exposure to radiology. Additionally, the rural hospital loses the revenue by transporting the patient to another facility. The challenge is to find a way to easily transfer patient data, including large diagnostic imaging files, for second opinions and better treatemtn.
Digital technology aids significantly in the transfer of patient data, it being easer to transfer a CD than it is to transfer paper files and film. But, while departmental PACS and a hospital-wide RIS are huge improvements over paper and film, small and rural hospitals who take advantage of today’s advances in cloud technology may find that they can optimize workflow and improve patient outcomes to an even greater extent, regardless of their geographic location.
Because medical imaging is so ubiquitous in clinical practice today, the Radiology Department is one place where attention to technical improvements can return big dividends in patient outcomes as well as in cost savings. Small, rural hospitals who venture into the cloud with their RIS may enable big hospital benefits.
What is a RIS?
Wikipedia defines RIS as “a computerized database used by radiology departments to store, manipulate, and distribute patient radiological data and imagery. The system generally consists of patient tracking and scheduling, result reporting and image tracking capabilities. RIS complements HIS (Hospital Information Systems), and is critical to efficient workflow to radiology practices.”
Add to this the concept of Cloud computing, and the rural hospital can have the benefit of consultations with physicians at major medical centers in larger cities without the need to move the patient and subject them to additional tests.
These are basic RIS features:
· Patient management, scheduling and tracking
· Results reporting and delivery
· Image tracking and delivery
· Integration with PACs or WebPACS
· Radiology Department workflow management
· Modality management
The strategic goal in RIS is to bring order to the workflows in radiology, to manage medical images in a filmless environment, and to improve the referral base. Small and rural hospitals who implement RIS for the first time are wise to prioritize the optimization of clinician workflow and productivity in order to be able to handle additional referrals and increase the initial ROI of the investment.
The workflow and accessibility that a Cloud RIS offers enables the small, rural hospital to offer more imaging services, with the advantage of remote reads and diagnosis provided by the experts at the larger city hospitals. The small hospital benefits by the increased patient base; the patients benefit by being able to have diagnosis and treatment performed locally, rather than traveling to a larger hospital.
The Cloud allows radiologists to store, share and connect more easily than ever before. Since radiologists work with large images such as CT scans and X-Rays, the ability to store and share images on a cloud-based system can maximize efficiencies. Newer medical devices often generate complex imagery with very large file sizes. The Cloud provides a platform that is capable of supporting very large files.
Radiology Services Online is one HIPAA approved Cloud application that enables radiologists, hospitals, clinics, imaging centers and specialists to administer and distribute images and reports. By providing consulting physicians will have better access to images and reports rural hospitals are able to make a faster diagnosis, potentially providing better patient care.
Some patients may still need to be transferred to a large hospital for care, if the rural hospital is not equipped to handle the diagnosed condition. But Cloud RIS consultations can cut down on needless patient transfers when the diagnosed condition can be handled locally.
DICOM – View for Free? Or Diagnose?
DICOM, the acronym for Digital Imaging and Communications in Medicine DICOM is a standard which specifies a nonproprietary data interchange protocol, digital image format, and file structure for biomedical images and image-related information. The goals of DICOM are “to achieve compatibility and to improve workflow efficiency between imaging systems and other information systems in healthcare environments worldwide.”1
The DICOM standard is maintained the DICOM Committee, which exists “to create and maintain international standards for communication of bio-medical diagnostic and therapeutic information in disciplines that use digital images and associated data.”2 It is an independent, international standards development organization administered by NEMA’s Medical Imaging and Technology Alliance. NEMA is the National Electrical Manufacturer’s Association, which is an association of Electrical Equipment and Medical Imaging Manufacturers.
How Do DICOM Images Differ from Other Files?
Image files that conform to DICOM standards are commonly called DICOM-format images. The basic difference between a DICOM-format image and other image formats, like JPEG, TIFF, and GIF is that the DICOM image contains a ‘header’ with information (such as patient demographics, machine, scan parameters, and a host of other non-image data) in addition to the image data. This header makes it possible to identify the origin of the image, the patient, the data acquisition parameters of the study and other similar data, even if a single image is analyzed in isolation. The adoption of DICOM standards by medical imaging equipment vendors has helped in effective cross-machine communications and made possible integration of imaging equipment from different manufacturers
While DICOM is the accepted standard for the storage and networking of medical images, unlike other accepted image files (JPEG, TIFF, and GIF) the DICOM format cannot readily be viewed on an average personal computer, tablet or smartphone. This often means that viewing these images outside the radiology network requires printing of the images on hardcopy films or CDs, or using a specialized DIOM viewer.
Types of DICOM Viewers
There are a number of different DICOM viewers available on the market today…ranging in price from free to costly. These DICOM viewers, or browsers, as they may be called, can be broadly separated into four different types:
Free DICOM Viewers
These readily available, downloadable viewers are simple and intuitive. Their purpose is to enable viewing of DICOM images that are not part of a radiology network. Most equipment manufacturers offer the option of archiving imaging data on compact discs (CDs) which can be transported, stored, and reviewed easily. Though a proprietary DICOM viewer is written into the CD along with the image data, it is often limited in its functionality. Using a DICOM browser of one's own choice permits the use of a set of tools suited to one's needs, irrespective of the source of the imaging data.
It must be remembered that most freely downloadable software is intended for educational purposes and is not custom built for medical diagnosis or commercial purposes. Most of the freely downloadable viewers are easy to use and intended for use by the non-professional. Free DICOM viewers are useful for radiology students, and may allow some medical image viewer aimed at no-professional users and radiology students. These simplified viewers, often used for teaching, usually convert the DICOM format to some other image format, such as JPEG, GIF, or TIFF prior to creation of the file. These formats are more compact than the original image and are recognized by most non-medical image management software that can be used to create teaching files and albums.
These free viewers usually have the ability to adjust image quality, size, and resolution, much as you can adjust the photos you take and store on your computer. Often these viewers are simplified versions of commercial software. But, what if you need professional, diagnostic viewing away from the radiology center? Then free DICOM viewers will not do!
DICOM Viewers for Professional Use
A DICOM viewer that is intended for professional use must be able to serve up a diagnostic quality image on any PC, tablet or smartphone. It should provide the ability to access, store and retrieve, transmit, display, and process images that were generated by DICOM-compatible equipment.
Viewers in this category range from simple solutions called mini-PACS or Web-PACS to extremely complex systems that interact with the hospital information system/radiology information system (HIS/RIS), electronic medical record systems, and web servers. In fact, they are far more than just DICOM viewers.
Essential features of such solutions include the ability for hospitals, clinics, imaging centers and specialists to administer, distribute and view images anywhere, anytime, as long as they have an internet connection. The images must be true DICOM images, from which a legal diagnosis can be made. The viewing system must be zero-footprint, meaning that the image is never downloaded. This protects patient privacy, and speeds the viewing process, since it is available for on-the-fly viewing. Images must be stored securely and redundantly and available to be sent to any fully functioning PACS system. Finally, it must be able to interface seamlessly with any workflow or electronic health record system.
If you’re a non-professional or a student, a free downloadable DICOM viewer will serve you well.
But if you’re a professional, using the right DICOM viewing solution can enable better access to images and reports, allow faster diagnosis, no matter where you are, as long as you have an internet connection, and patients can obtain faster and more effective care. Footnotes: 1. & 2. DICOM Committee
Is it Time to Upgrade Your EMR?
When your healthcare practice first switched to Electronic Medical Records (and once everyone had learned the new system), it seemed like your office had taken a technological leap forward. No more paper files to maintain…faster access to patient files and easier updates; no more Dictaphones and transcription services, because every Doc had his or her own laptop or tablet for updating records on the go.
But now, several years later, and more technologically savvy, you’re beginning to notice a few things that could be better, faster, and easier; or, you’re wishfully thinking that you need some additional bells and whistles to make the system more responsive to your needs. For instance, maybe you realize that having access to medical images right within your EMR would make diagnosis faster and easier. Is it time for an upgrade?
Upgrade vs. Update
Don't confuse an upgrade with an update to your EMR. In general, updates are changes to drug lists, ICD-9 codes, and fixes of minor bugs — updates don't change the day-to-day operation. EMR updates can be compared to the regular updates that you get to your Windows operating system or the Adobe reader on your home computer. Upgrades, on the other hand, are bigger changes that address features of the product (much like changing from a Windows 7 to a Windows 8 operating system).
Advantages of upgrading
Being eligible for support. In general, software manufacturers support only the most recent versions of the software. Even when everything is working just fine, it’s best to upgrade to the current version of the software. Staying with the old version will often leave you with no support and can also mean that you will be forced into an upgrade under duress rather than as a planned move forward.
Keeping up with new technology. Whether you upgrade or not, technology advances. For instance, mobile technologies like smart phones and Ipads have inspired new features in EMR software that enable healthcare workers to stay updated on patients from anywhere, anytime.
Evolving with the product. As any product is put to use, manufacturers get feedback from the field, and that feedback is used to make the product better. Whether is addressing product deficiencies, adding product features, or meeting government regulations, the EMR will evolve and change over time, and your practice should evolve and change with it.
Upgrades mean a certain amount of change in the status quo. And change, no matter how beneficial, is always disruptive. Practice workflow may need to be changed to take advantage of new features or to meet government requirements. The simple learning process of using a new system will slow things down for a few days or a few weeks. This is one reason for avoiding being forced into an upgrade under the duress of necessity because of system failure. Upgrades need to be planned and systematically carried out, just like the initial implementation was. You can’t avoid the disruption, but you can minimize it.
Prior Planning Prevents Poor Performance
Working with your software vendor well ahead of the upgrade will ensure that the process goes as smoothly as possible. This is the time to find out just what’s going to be different in the upgrade, and also a time to voice what additional features you may require. For instance, many EMR packages still do not incorporate medical image viewing into the software itself, but there are very mature “plug-in” applications that serve very well to make diagnostic images available on a pull-down menu within the EMR software. Implementing additional feature such as this at the same time as the upgrade can save time and money overall.
Get your staff involved in the upgrade as well. They will need a preview of how things will change for them as a result of the upgrade. How big will the disruption be to the daily practice? Which staff members will be affected? Will overtime be required? But don’t just focus on the negatives -- make sure that the staff understands the benefits that will come from the upgrade. Motivate the staff who stands to gain the most from the upgrade as your in-house champions for change.
Once you’ve assessed the internal impact and have the staff working with you, you will also need to plan for any hardware upgrades that will be required. Make sure that you know if the system will need to be down during the upgrade, and how long that will be. Enlist the staff to help with contingency plans.
Focus on advance training. Well before the actual upgrade, give your staff an opportunity for some hands-on training on the new system. Most vendors are more than happy to work with to ensure that this happens. Remember, it’s in the vendor’s best interest to make sure the upgrade goes smoothly and that the system users are happy with it and understand how to use it.
Finally, consider a lighter scheduling load during the upgrade. Everything will probably take a bit longer during the transition time, so having fewer patients to care for during this time will help to keep your practice running smoothly.
Radiology Cloud Standards
Over the past several years, cloud computing has made a positive impact on radiology. By expanding the means of storing, retrieving, archiving and accessing radiologic imagery, the Cloud has enabled better record keeping, faster diagnosis and treatment, easier second opinions, more widely available images throughout departments and facilities.
When chief information officers begin to consider using a radiologic cloud or expanding their existing cloud to include medical imagery, they should be aware of existing and developing standards that may impact their cloud launch. In point of fact, what they really need to consider are two sets of standards: (1) radiology standards; and, (2) cloud standards. More importantly they need to consider how these two sets of standards will be merged into a system that incorporates all requirements while being easy to use, cost effective and readily usable by the facility staff. Let’s look at both sets of standards.
Due to the critical use of medical imagery in diagnosis and treatment, the radiology industry has stringent performance standards that must be part of any care model. Any provider of a cloud used for radiology must be 100% committed to these standards. Diagnostic accuracy is vital, so any medical image accessed via the cloud must be able to be viewed and manipulated with the same degree of ease and visual acuity that a non-cloud system would provide, if not better. Importantly, there must be system-wide accountability to these standards.
Often radiologists and radiology providers are measured by their practice criteria and the standards to which they adhere on a daily basis. Maintaining required standards can elevate the cloud-driven radiology practice to a new level of value for referring physicians, hospitals at large, and the entire health system. Adding the speed and efficiency of the cloud to precise radiologic standards can ensure that radiologists are providing the best service to referring physicians and hospitals and, by extension, best service to patients.
The standards that are applied to the practice of radiology include the following:
- Accurate and consistent final reports, with standardized templates and diagnostic check lists that make it easy for physicians and hospitals to interpret the results.
- Communication of critical findings within 60 minutes of the tests being performed, with consultation as required.
- Provision of complete subspecialty coverage which ensures that all complex and high-risk imaging is read by the appropriate subspecialist
- Diagnostic accuracy requires the maintenance of less than two percent error rate with programs providing peer review of all studies and concurrence review of high risk studies
- Analyze how physicians use the data, with site of care and modality, maintaining greater than ten percent follow-up imaging rate
The Radiology Quality Institute has proposed these standards in order to hold the practice of radiology accountable for the quality of its services.
For cloud standards, we turn to the National Institute of Standards and Technology (NIST), which has been designated by the Federal Chief Information Officer (CIO) to accelerate the federal government’s secure adoption of cloud computing by leading efforts to identify existing standards and guidelines. Because NIST works closely with U.S. industry, standards developers, other government agencies, as well as leaders in the global standards community we believe that it can be looked to for standards that will support secure cloud computing across all applications, including radiology.
The NIST Cloud Computing Standards Roadmap Working Group has reviewed and recommended standards for interoperability, performance, portability, security, and accessibility relevant to cloud computing. By using this readily available information, cloud providers can ensure that their systems adhere to current standards and standardization priorities
The NIST Definition of Cloud Computing, Special Publication 800-145, “is a good starting place for understanding cloud computing, while the document identified as NIST_SP-500-291_Version 2_2013_June18_FINAL focuses on interoperability, performance, portability, security, and accessibility.
Both are informative documents that should be read, understood and adhered to by any cloud services provider.
NIST has also developed a Cloud Computing Reference Architecture and Taxonomy Working Group that provides a set of views and descriptions that are the basis for discussing the characteristics, uses, and standards for cloud computing.
- Cloud computing use cases describe the consumer requirements when using cloud computing service offerings. Through its working groups, the NIST Cloud Computing program has studied a range of U.S. federal government and general-purpose use cases to extract features that are amenable to standardization.
- Other standards have been developed or are now being developed to support specific cloud computing functions and requirements, such as virtualization, infrastructure management, service level agreements (SLAs), audits and cloud- specific data handling.
- Finally, the NIST Cloud Computing Standards Roadmap Working Group has compiled an Inventory of Standards Relevant to Cloud Computing. This inventory is being maintained and updated as necessary.
Any radiology cloud should actively embrace and coordinate both cloud computing standards and radiology standards in order to ensure the highest possible level of performance, security and diagnosis.
DICOM on the Web
What is DICOM?
DICOM (Digital and Communications in Medicine) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. A DICOM image consists of a list of data elements (so-called attributes) which contain a multitude of image related information:
- patient information (name, sex, identification number),
- modality and imaging procedure information (device parameters, calibration, radiation dose, contrast media), and
- image information (resolution, windowing).
For each modality, DICOM precisely defines the data elements that are required, optional (i. e. may be omitted) or required under certain circumstances (i. e. only if contrast media was used). This powerful flexibility is at the same time, however, one crucial weakness of the DICOM standard because practical experience shows that image objects are frequently incomplete. In such objects, required fields are missing or contain incorrect values. These problems can lead to subsequent problems when exchanging data.
DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state which DICOM classes they support. DICOM has been widely adopted by hospitals as well as in smaller applications like dentists' and doctors' offices.
Viewing and Exchanging DICOM Images
Traditionally, DICOM Images were viewed and exchanged via an in-house network – the PACS. However, the combination of modern internet technology and zero-footprint viewing via the web has simplified and broadened the ability to view and exchange DICOM data. This enables a wider reach for members of the medical field, with benefits to patients via speedy diagnosis and easier second opinions. Gone are the days when small-town and mobile medical facilities remained economically and technologically incapable of handling the exchange of medical images. With the introduction of the new DICOM viewing and exchange technology via the web, rural and mobile medical facilities can easily access high-quality medical imaging.
Sometime called Web PACS, or Web Picture Archiving and Communication Systems, are very easy to use. Since the Web PACS database may be accessed via a familiar browser interface, medical personnel can navigate the system with minimal training and, therefore, with minimal expense. In addition, images are not downloaded, but viewed with a zero-footprint viewer, so are accessible via nearly any mobile device, from anywhere. There is no need for installing costly software on multiple workstations. These features all make the viewing of DICOM images via the web quick, convenient and easy.
One such DICOM viewing and exchange system is Radiology Services Online. In addition to being easy to use, this Web PACS system provides easy security options. Since the system contains multiple encryption tiers, supervisors can assign passwords to personnel that authorize them to access isolated images, groups of images, or the entire digital imaging system, depending on their level of security clearance. The excellent encryption system also enables medical personnel to more easily comply with HIPPA regulations by more effectively limiting access to privileged information.
Not only does Radiology Services Online enhance security with its easy-to-use system, but it also makes data storage much simpler. For instance, unlike old PACS systems with multiple storage silos, usually segregated by departments, Web PACS maintains digital images in the “Cloud” minimizing the need for computer storage space. Any authorized user can view any image he or she is authorized to view, no matter which department “owns” the image. This makes it easier for multiple doctors treating a single patient to confer.
The digital images also back-up to multiple locations so that medical records remain recoverable in case of disaster. Because increased use of medical diagnostic imaging has created a greater demand for digital images, the need for sufficient storage remains at the forefront of Radiology Services Online technology. Once images have been uploaded to Radiology Services Online, users may not only view the images, but they may also manipulate the quality of images to enhance brightness, contrast, or zoom, aiding in patient diagnosis and treatment.
Medical Image Storage – How Do You Store Billions of Images?
While I wasn’t able to find any current, reliable statistics on the total number of medical imaging diagnostic tests performed in the U.S. each year, there is ample proof that for quite some time diagnostic imaging has been increasing, and the numbers of medical images being stored continues to expand.
Here are some statistics from the past decade:
- In 2003, Booz Allen Hamilton reported that the use of diagnostic imaging was projected to grow by 26% by 2008, when almost half a billion procedures would be done each year
- A report by John Iglehart in The New England Journal of Medicine (2009) indicated that, between 2000 and 2007, use of imaging studies grew faster than that of any other medical service in the Medicare population.
- A 2012 study published in The Journal of the American Medical Association by lead author Dr. Smith-Bindman, a radiologist and epidemiologist, looked at data on one million to two million patients a year from 1996 to 2010 in six health maintenance organizations across the United States, only some of whom had imaging. The number of CT scans tripled over the study period, to 149 per 1,000 patients in 2010, while the number of MRI’s quadrupled, to 65 per 1,000 patients in 2010.
- A 2013 Wall Street Journal article quote as many as 600 million imaging studies performed per year.
While there may be speculation concerning the many reasons for these increases, including advancing technology, patient requests for scans, “defensive medicine, and financial incentives, the focus of this article is not on the “why,” but rather on the “how, “ as in: How do we store, account for, and access all of these images?
So, the fact is that if you go to the doctor for any undiagnosed pain or problem it is likely that part of the diagnostic procedure will include some type of medical imaging – X-ray, MRI, CAT scan. Health care providers are generating high-resolution imaging data from tests such as these at an unprecedented rate. One of the reasons is that imaging modalities go a long way toward improving patient care through early, accurate diagnosis. However, the storage of medical imaging files can be a significant and costly challenge, with the need to manage, cool and expand data centers and hire additional IT personnel. Because of this, many health care organizations are turning to the Cloud for medical image storage.
Another reason for turning to the cloud for medical imaging is the Health Information Technology for Economic and Clinical Health (HITECH) Act within the American Recovery and Reinvestment Act. This Act set aside billions of dollars in federal funding for health IT, particularly Electronic Health Records (EHR) technology. This push toward EHR has been driving the availability of more cloud-based health IT options over the past five years.
Increasingly, health-care providers are embracing cloud services, the model of shared computing in which data is stored on remote servers that hospitals can access via desktop, tablet or smartphone. Instead of big capital investments in their own storage, they are paying a relatively modest upfront charge and monthly usage fees for cloud services.
Some statistics show that about cloud-based storage for images is growing rapidly with as many as half of the country's health systems using or planning to use cloud storage for medical imaging.
What Does All of this Mean?
One benefit for patients is the availability of personal health records (PHR) that can be accessed from their own mobile devices. Personal health records (PHR) can contain complete information regarding an individual’s medical history -- such things as vaccination history, laboratory test results, allergies, medications, surgeries, family history and medical images.
In the past, this information was normally kept as paper documents and film records on file at the doctor’s office. If you were traveling or had a medical emergency, the record might be inaccessible. With the advent of PHR services, however, these files are available electronically, for both doctors and patients themselves.
Benefits for healthcare organizations include savings on the capital investments of hardware and software upgrades, as well as helping doctors make diagnoses faster, reducing the need for duplicate images and protecting patients from the extra radiation exposure of having another CT scan because an original can't be found. Cloud-based storage systems also can let doctors call up historical images for comparison quickly and easily.
More Data – Bigger Files
Cloud medical image storage can address the rapidly growing need for a cost-effective way to maintain and access medical image archives. With hundreds of millions of new imaging procedures performed each year, and the legal requirements to keep the images for at least seven years, the availability of cost effective efficient medical image storage is a must! Additionally, as images become more complex, they take up more and more space. All this means that image archives are increasing by as much as 40% annually.
Cloud medical storage services help control medical costs while allowing health-care providers to store, view and share patient medical images expeditiously over a secure network. They can help doctors make diagnoses faster, reduce the need for duplicate images and protect patients from the extra radiation exposure of having another CT scan because an original can't be found. Cloud-based storage systems also can let doctors call up historical images for comparison quickly and easily.
Why You Must Add Diagnostic Images to Your HealthVault PHR
If you’re one of the many health-conscious consumers who is ensuring your ability to access your own health information anytime you need it, then you’ll be interested in knowing an easy way to add and maintain your own diagnostic medical images in your HealthVault PHR.
Why should you maintain your own X-ray images, CT Scans and other diagnostic images?
One key reason is simply the fact that imaging tests are far more frequently used in diagnosing illness today than ever before, and that sheer frequency implies that the images are important enough to be part of your personal healthcare records. As an example of the frequency of diagnostic imaging tests, it is reported that in one large health plan 377,048 patients underwent 4.9 million diagnostic tests from 1997 through 2006, and in the years since 2006, estimates indicate that diagnostic imaging tests continue to grow exponentially.
Because the use of imaging has skyrocketed in the past decade, you will want to maintain a record of all your medical images, both to ensure access to them when they are needed, and to prevent needless exposure to additional radiation through duplicate tests because the required images aren’t available.
Proactive patients make sure their complete medical records, with images, are available at their fingertips when needed.
Another key reason for maintaining your own health care records and medical images is the mitigation of errors. Some surveys show that as many 30% of respondents report that either they or a family member or friend have experienced a medical error and as many as 73% of respondents are concerned about medical errors, while 45% are “very concerned. What better for individuals to watch out for potential errors or mistakes in their medical information than by maintaining their own records and ensuring that all their medical images are available when needed?
Unfortunately, one of the main problems with many personal medical apps is their inability to serve up diagnositic quality images. Most make due with thumbnails, which cannot be used by your doctor for diagnosis. However, one company, Radiology Services Online (RSO), located in Celina, Texas has solved that problem. With their MediCle App for Microsoft HealthVault, they provide savvy consumers with an easy to use, HIPAA compliant service that enables any individual to store, access and share diagnostic-quality medical images, including X-ray, CT Scans, Ultrasounds, Mammograms and other diagnostic medical images as an add-on to their Microsoft HealthVault medical records. The MediCle app is a great reason to sign up for HealthVault.
Sean Nolan a Microsoft Distinguished Engineer had this to say about MediCle: “I am incredibly excited about the work that the team at Radiology Services Online has done with MediCle. “Not only have they delivered a great web-based image viewing experience, but their film-scanning service makes it even easier for individuals and families to create a comprehensive record of their care. We’re thrilled that ROS has made their work a
vailable for HealthVault users and (are pleased) to see real people taking full advantage of it.”
How Does MediCle Work with HealthVault?
RSO stores and hosts all MediCle app images within the same secure professional cloud system that is used and recommended by hospitals, mobile xray providers and physcisians. RSO provides backups and restores information; meets all HIPPA-required compliances; and, guarantees users’ privacy and security via the RSO/MediCle proprietary image-hosting Cloud.
HealthVault users are assured that no bulky images are saved in or running through their HealthVaullt account, their computer or mobile device. Everything is located in a secure remote cloud. The low cost MediCle app provides access to your personal X-rays, MRIs and other diagnostic images from any internet-enabled device, without slowing down your system or using up your storage with large files. These are full PACs diagnostic quality images for you and your physician to use.
Provisions for X-Ray Film
For HealthVault users who have x-ray film, rather than digital x-ray files, Radiology Services Online provides localized x-ray film scanning services through a network of regional scanning centers. This service, too sets this app apart from other medical imaging apps.