Feature | November 09, 2006 | Nadim Daher

Disconnect between front-end and back-end infrastructure creates room for middleware to manage enterprise data.

Nadim Daher is a medical imaging market analyst for Frost & Sullivan.

With the adoption of PACS within multiple departments across the enterprise and its increasing operation across distributed environments, PACS is rapidly evolving into the model for enterprise-wide image management. It is no wonder the imaging community feels it is time for PACS to have a ‘name-lift’, one that would take away the connotation carried over by the word ‘PACS’, that is, that of a departmental system for radiology or cardiology alone.
Changing Paradigms
While the front-end clinical applications, already fairly uniform across PACS vendors, continue to evolve slowly to incorporate more features and integrate information from more systems, the back-end infrastructure of PACS is increasingly being shared across the enterprise. This growing ‘disconnect’ between the front-end clinical application and the back-end infrastructure creates room for an improved layer of middleware to manage enterprise data, including but not limited to PACS. As end-users’ expectations from their information systems continue to evolve, the purchasing cycle of PACS customers is growing more complex. While largely departmental based in the past, the internal decision-making process within the enterprise is moving steadily to the C’x’O level, actively involving the IT department as seen in the figure below.
It is no longer a secret to anyone: Consolidating storage in the healthcare enterprise yields lower total costs of ownership (TCO). Direct operational savings can be achieved through centralizing and optimizing the management of enterprise storage in the IT department. What the market is only starting to realize, however, is the importance of the mid- and long-term benefits of implementing an enterprise-wide archive strategy. Sharing a common storage infrastructure can improve interdepartmental communication and generate more synergy in the enterprise. Aggregating, or better yet integrating, data on a patient-centric basis can constitute a sure first step toward developing a comprehensive EMR. Such benefits ultimately improve the efficiency and quality of patient care.
In light of these developments, the enterprise archive management middleware arena constitutes an interesting, almost explosive, competitive structure where the different vendor groups in the PACS industry converge. PACS vendors, storage hardware vendors and specialized medical archive software vendors are demonstrating different approaches and bringing different backgrounds and technologies to fill in this new-found gap in the structure of the modern day information system. These companies are competing in a nascent, highly promising niche market.
PACS Vendors’ Turf?
Present day PACS vendors are facing a critical stage in the lifecycle of PACS technology. Up until now, the ‘turnkey’ model for selling PACS has secured PACS vendors with complete control over the entire deal, including software, hardware, professional services and service contracts. On the one hand, this provides their customers with a “single throat to choke” when something goes wrong, which is crucial in mission-critical environments. The downside of this monolithic approach, however, has been the proliferation in healthcare facilities of departmental storage silos that work against the vision of an enterprise-wide storage strategy. Worse, in the majority of these silos, data reside in proprietary formats, creating an unpleasant feeling in the market that PACS vendors have been holding their customers captive. Early PACS adopters who underwent a data migration project have tasted the bitter inconvenience of losing any information that was not archived in the DICOM format. Only recently did additional PACS data such as presentation states, user-defined hanging protocols or annotations start to be ‘DICOMized’.
The trend toward a broader-encompassing archiving solution started with cardiology PACS. Fundamentally distinctive from the radiologist’s workflow, cardiologists require a holistic view of a patient’s record to properly assess his or her situation. This fact has driven the design of cardiovascular information systems (CVIS) that combine DICOM image data with several types of nonDICOM objects such as waveforms from electrocardiography and electrophysiology or cine files such as echocardiograms and angiograms. The recent industry consolidation activity between radiology PACS and cardiology PACS companies is touted to accelerate the application of this concept at the enterprise level, where the diversity of the clinical data is even larger.
At this time, the concept of a general purpose archive is far from being universally supported by PACS vendors’ solutions. Expanding the lower software layers of the PACS application, whose function is traditionally limited to Hierarchical Storage Management (HSM) of tiered DICOM storage, only certain PACS vendors today offer archive management solutions that go beyond managing radiology PACS image data.
Enterprise PACS Archive Vendors: a Fresh Start
As PACS vendors update - or re-architect – the archive management component of their PACS, some software vendors have given it a fresh start, taken further steps towards realizing true enterprise archive management (see box). These companies have designed innovative solutions that can manage PACS storage along with all the imaging-related clinical data. These solutions rely on open standards and provide an enterprise data repository that manages DICOM as well as non-DICOM objects such as video files, wave files from transcription systems, HL7 CDA documents generated as part of IHE requirements, digitized pathology slides and other secondary capture images, etc. Advanced algorithms utilize the metadata from DICOM or XML objects to design healthcare-specific policies and information lifecycle management (ILM) capabilities.
A major benefit is the fact that the repository can feed from multiple sources and maintain true vendor independence. Indeed, these vendors enjoy a comfortable position when it comes to ‘connecting’ multiple vendors’ PACS systems to a single archive. In light of the dynamic consolidation among healthcare facilities, this scenario is increasingly common, especially in multisite organizations. PACS vendors are not usually keen on working with other vendors’ systems. As a matter of fact, let’s face it: The reality is that deep inside, PACS vendors are all but excited about the prospects of interoperating of their systems in multivendor environments, such as predicated by the IHE. Rather, they appear to be drawn into it by a more mature market that is evolving more uniformly and toward
better defined goals.
These software companies are among the first in the industry to embrace the new XDS (Cross-enterprise Document Sharing) standard. A joint effort between the RSNA, HIMSS and IHE, the implementation of XDS is touted as the means by which the different systems in the healthcare ecosystem, or at least those in the HL7 and DICOM domains, will communicate among themselves, paving the way to a true EMR.
What about Storage Vendors?
Storage hardware vendors have traditionally been subcontracted by PACS vendors to supply the storage “box” that would complete a turnkey PACS solution. With limited experience with the specificities of medical imaging, storage hardware vendors have, until recently, played a background role in the PACS market.
Content-addressed storage (CAS) solutions such as EMC’s Centera platform and the similar solutions developed subsequently by the remaining storage vendors were the first storage solutions that could be perceived as being tailored to medical imaging applications. Clinical images are indeed fixed-content data. Also, CAS solutions manage the data as objects, which provides a good basis for use by clinical applications and offer truly seamless scalability to address the increasingly unpredictable storage volume growths.
Today, storage vendors are also developing powerful middleware (or software, if looked at from a hardware vendor’s perspective), applying in the healthcare realm the capabilities they have developed in other areas such as for ILM. They are establishing strong partnerships with other software vendors to add value and functionality to their offerings. This occurs as Moore’s law continues to hold true year after year, and the price of hardware, the raw material out of which the solution is built, continues to fall, shifting profit margins towards added-value middleware and services.
This trend is slowly securing a more active role for storage vendors in PACS deployments. Indeed, these vendors are ideally positioned to communicate directly with PACS customers in order to realize their aspirations for an enterprise-wide storage strategy. Storage vendors continue to foster their partnerships with PACS vendors, and over three quarters of their revenues are still led by ISVs (Independent Storage Vendors). However, with improved middleware solutions and enhanced experience in healthcare today, storage vendors are developing a more direct foothold on the market and increasingly offering their services directly to their customers in projects that may revolve around, without being limited to, PACS.
As the healthcare community awaits hardware vendors’ propositions for RHIOs and how to go about implementing a national healthcare information network (NHIN), storage considerations cannot remain bounded to PACS and leave PACS living in a vacuum — that is, if the plan is to image-enable the healthcare information exchange (HIE) that will eventually be established.

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