Digital breast tomosynthesis (DBT) is one of the most exciting new technologies in breast imaging. DBT poses a challenge to existing departmental, enterprise, and cross-enterprise image storage, distribution and viewing infrastructures.

DBT is a relatively new modality that is finally coming to market after many years of development and evaluation. Early evidence suggests that it has superior performance to full-field digital mammography (FFDM). Accordingly, it is likely to become popular, and there are already hundreds of installations according to one of the currently approved vendors, despite there being no additional reimbursement for the use of DBT yet.

View this special forum and hear the discussion between early adopters, clinicians, and vendors on how to address the challenges posed by DBT images for acquisition, storage, distribution, compression, display, CAD and long-term archival.

Learn how to avoid repeating the same interoperability mistakes with DBT as the “first” time around with FFDM. In addition, examine how to make use of the DICOM Standard Breast Tomosynthesis object, rather than proprietary formats.

There were many great presentations that came from SiiM.  Here are a few of them.  They will all link from the Siim.org web site.

• Digital Breast Tomosynthesis & the Informatics Infra-Structure – Standards & Interoperability
• Imaging Innovations – Tying the Pieces Together
• Digital Breast Tomosynthesis – PACS/Workstation Vendor Perspective
•  Infrastructure Issues Regarding Digital Breast Tomo Implementation
• Tomosynthesis: Lessons Learned and Challenges
• Digital Breast Tomosynthesis & the Informatics Infra-Structure – How Digital Breast Tomosynthesis
• Tomosynthesis Display and Storage Dilemmas

The original information source is here.

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The solution will encompass everything from digital X-rays, patient notes and scanned letters.

Originally VNAs were an advancement the was initiated  due to issues with proprietary solutions related to PACS or Picture Archive Communications Systems.  The main issues were integration restrictions and with data migration when an organization wanted to change vendors or move to a different solution.

Currently VNAs aren’t just for PACS anymore.  They are equipped to handle data from many departments within the healthcare enterprise using industry protocols such as DiCOM, HL7 and XDS. Using standard protocols is what allows the VNA to be ‘neutral’.

You can read the Inquirer article by clicking here.

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Years ago when I was working for an imaging vendor, they bought a technology company and leveraged to develop a PACS Vendor Neutral Archive.  The term was still in its infancy, however the functionality seemed obvious given the name ‘VNA’.

The integration process between our PACS and the new VNA went very well.  We were able to send various DICOM images from our PACS and the VNA was receiving everything without a glitch.  We were also able to query the VNA from our PACS Viewer and retrieve images.  Things were good…until…

It didn’t take long to see through the normal course of PACS Administration duties that corrections that were made in PACS did not forward to the VNA.  Image Pre-fetching was another function we had taken for granted that wasn’t a feature.  Two critical features that just ‘happened’ using a PACS system, were now not available.

One of the major benefits we had was owning PACS and our VNA was we were able to implement changes internally without involving any other vendors.

In this scenario the VNA and PACS both used Oracle databases.  Eventually we had the two Oracle databases linked to one another and updates and changes were being updated.

Before we got the synchronization issues worked out, coming in during the implementation and seeing the PACS Admins do reconciliations twice, once in PACS and once in the VNA, was not a good feeling.

One of the biggest challenges VNA companies are having now is synchronization with PACS.  The vendor I worked for accomplished with through database communication, however not every company has the luxury of controling both sides of an issue.

Vendors are able to take advantage of an an IHE profile called IOCM – Imaging Object Change Management in order to accomplish this task.

Imaging Object Change Management (IOCM) specifies how one actor communicates local changes applied on existing imaging objects to other actors that manage copies of the modified imaging objects in their own local systems. The supported changes include (1) object rejection due to quality or patient safety reasons, (2) correction of incorrect modality worklist entry selection, and (3) expiration of objects due to data retention requirements. It defines how changes are captured and how to communicate these changes.

Here is a great article from OTech Imaging the expands on the PACS/VNA synchronization issue.  Click >>>HERE<<< to read the article.  You’ll be directed to OTech Web site.

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Herman Oosterwijk, President, OTech Inc published a >>> white paper <<<  that described and defined what a Vendor Neutral Archive (VNA) is.  He also discussed some essential features and aspects of VNAs.

Although the White Paper was sponsored by TerraMedica, there weren’t any mentions of vendors or any other proprietary information.

If you are unfamiliar with VNAs or simply want to enhance and expand your knowledge in this subject area, the white paper will provide you with that information.

The first thing that may surprise readers is that a vendor neutral archive is not a standard of any kind.  In fact, I imagine the term was invented by some company’s marketing team.

VNAs do not fit or conform to any sort of IHE standard, therefore much care must be given when doing vendor selection.  Although VNAs are not a standard, they however use existing profiles and standard protocols such as DICOM, HL7 and XDS.

The term Vendor Neutral Archive gives the reader the impression that the archive will be able to fit in to any environment and work easily with minimal issues or integration challenges.  This couldn’t be further from the truth. Integration is a critical factor in any implementation.

Some go smoother than others, however that is more to do with the flexibility and features of the software as well as the skill of the integration engineers.  Also some healthcare organizations having varying requirements with different degrees of complexity.

One of the initial catalysts for a Vendor Neutral Archive was due to migration challenges organizations faced when moving from one PACS vendor to another.  Although DICOM is a standard, it was clear with all of the image migration challenges that vendors had different interpretations of that standard.  As a result PACS image migrations were long in duration, complex and expensive.

As the PACS market evolved,  healthcare centers looked for ways to leverage their existing PACS infrastructure and share data.  Other departments in the hospital also wanted to store and share data as well. What was needed was a configurable multi-function PACS server that could accommodate the various requirements from various healthcare departments.

With more departments and in some cases institutions wanting to store and share data, the level of complexity also increased.  Traditionally each department was like a silo containing individual patient IDs and visit identifiers.  In order to have a continuity of care and keep all of the data reconciled to the correct patient, more than a PACS server would be required. Patient IDs would need to be reconciled.

The paper mentions 5 distinct architectures, which deal with the challenges listed above, however I believe the last three architectures combined would be a closer vision of what most people feel a VNA is or should be.

There is a checklist at the end of the White Paper that readers can use when doing vendor selection or formulating a RFP

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Compared to traditional mammography, 3D mammography—known as digital breast tomosynthesis—found 22 percent more breast cancers and led to fewer call backs in a large screening study at the Hospital of the University of Pennsylvania (HUP), researchers reported today at the annual meeting of the Radiological Society of North America (RSNA).

Conventional digital mammography is the most widely-used screening modality for breast cancer, but may yield suspicious findings that turn out not to be cancer, known as false-positives. Such findings are associated with a higher recall rate, or the rate at which women are called back for additional imaging or biopsy that may be deemed unnecessary.


Tomosynthesis, however, allows for 3-D reconstruction of the breast tissue, giving radiologists a clearer view of the overlapping slices of breast tissue. And though a relatively new technology, it has shown promise at reducing recall rates in all groups of patients, including younger women and those with dense breast tissue.

This study, presented by Emily F. Conant, MD, chief of Breast Imaging the department of Radiology at the Perelman School of Medicine at the University of Pennsylvania, is one of the largest prospective trials in tomosynthesis to date.

For the study, the research team compared imaging results from 15,633 women who underwent tomosynthesis at HUP beginning in 2011 to those of 10,753 patients imaged with digital mammography the prior year. Six radiologists trained in tomosynthesis interpretation reviewed the images.

Researchers found that, compared to conventional mammography, the average recall rate using tomosynthesis decreased from 10.40 percent to 8.78 percent, and the cancer detection rate increased from 4.28 to 5.24 per 1,000 patients, a 22 percent increase.

“Our study showed that we reduced our callback rate and increased our cancer detection rate,” said Dr. Conant, the study’s lead author. “The degree to which these rates were affected varied by radiologist. But importantly, the ratio of callback to cancer detection rate improved significantly for our radiologists.”

The overall positive predictive value—the proportion of positive screening mammograms from which cancer was diagnosed—increased from 4.1 percent to 6.0 percent with tomosynthnesis, a 46% increase.

Since October 2011, all screening mammograms at Penn Medicine now include tomosynthesis, according to Dr. Conant.

“It’s the most exciting improvement to mammography that I have seen in my career, even more important than the conversion from film-screen mammography to digital mammography,” she said. “The coming years will be very exciting, as we see further improvements in this innovative technology.”

Click here to read the original article.

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The Connectathon is an annual event that demonstrates the benefits of interoperability, where health information systems (HIS) work together to share information across organizational boundaries.

The testing showcased the abilities of BridgeHead’s Vendor Neutral Archive (VNA) DICOMStore(TM) to successfully integrate with other leading healthcare information systems, and the solution now qualifies as a full XDS-I.b Imaging Document Source.

Here are some great HL7 and XDS resources that I found on Amazon…great tools!

  


The 14th annual IHE NA Connectathon drew hundreds of the industry’s top engineers with 8 IHE domains tested on over 160 systems. New features included testing of HL7’s Consolidated Clinical Document Architecture(R) (C-CDA) and a new qualification in standards and certification criteria for Meaningful Use Stage 2 in the U.S.

“Healthcare IT integration companies such as BridgeHead Software help make the Connectathon a success,” said Joyce Sensmeier, president of IHE USA. “This year, 500 systems engineers from 101 companies engaged in testing at the event. Collectively, we are driving the industry forward and improving quality care with interoperable systems.”

Read the rest of the news release about Connectathon 2013 and IHE XDS

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The architecture allows a healthcare system to save both time and money by creating a global patient work list and efficient radiology workflow among all its locations.

Cristine Kao, marketing manager for Carestream, says that the company offers a vendor-neutral archiving at the back end, a cardiology tool, and a workflow integration tool. Kao said that last year the company also launched an embedded, or native, voice-recognition solution.


Vue PACS has a charge model that includes a pay-per-use cloud service that includes an uptime guarantee, technology upgrades, data security, and duplicate data storage that addresses business continuity/disaster recovery.

Related Articles:

• Top 9 PACS Systems

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At one of my first PACS installations, we used a StorageTek 9710 Tape Library for long term archiving and had a 1 terabyte RAID for ‘on-line’ storage.

At that time it seemed like a huge amount of space.  Although after all of the system ‘overhead’, there was only about 6oo gigabytes out of the 1 terabyte left.

There wasn’t a lot of resources out there either. A quick search on Amazon and I found lots of great resources as you can see below.  You can even buy medical grade monitors on Amazon.

Nowadays tape libraries have been replaced by different tiers of spinning disk online storage. The terabytes of storage we used to discuss have changed to petabytes in some cases.

Especially when dealing with region systems.

In my service region we started implementing PACS at a research facility as a pilot project with a goal of having a regional PACS system spanning the entire province. Leveraging the success of that first implementation would lead to installing at additional hospitals.

As that first installation progressed, eventually the PACS data center was receiving ‘remote’ images from rural health centers. At the time it was an amazing accomplishment.

In Canada geography is a huge challenge and obstacle.  There are many patients who live in rural areas or distant cites that lack the required health care providers in their immediate area. Many rural patients are hundreds of miles away from health centers with the required health care providers.

It’s also challenging for physicians and radiologists to travel in a timely manner as well to service those patents. In the year 2000 to have the ability for radiologists to view images for a patient that was hundreds of miles away only minutes after acquiring CTs, X-rays or Ultrasounds was a life saver.

Fast forward to 2012 and the landscape has changed considerably.  There are many more vendors involved in PACS, the architecture has changed considerably including cloud computing, integration with dictation systems, huge increases in storage requirements and now PACS service extends beyond the radiology department.

Although technology prices have dropped considerably, PACS still requires a significant capital expense.  In order for organizations to leverage the costs and infrastructure of PACS the ‘enterprise’ as a whole needs to be considered. This includes added integration capabilities for documents, images and electronic health records.

When dealing with images in healthcare the DICOM protocol is the universal standard for image transfer, so  that’s obviously a requirement for the PACS environment.  In addition to DICOM,  there are a few additional requirements expected when dealing with enterprise healthcare.

• Hardware agnostic
• HL7 compatible
• Having an API (Application Programming Interface)
• XDS capable (cross enterprise document sharing)
• Migration capabilities

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Enterprise Storage For Healthcare – VNA

A report from KLAS found that most healthcare providers were devising strategies for enterprise access of medical images. The study from KLAS called  Enterprise Imaging 2012: Provider’s Strategies and Insights revealed the the two top emerging trends are PACS enterprise storage and VNAs (vendor neutral archives).

Two prominent names in the study were GE and Philips who were mentioned as strategic partners related to PACS enterprise storage.

For VNA related strategies Merge and Agfa were the vendors mentioned both.  Agfa’s VNA product is called IDC or Impax Data Center, while Merge’s VNA product is called iConnect.  The study also indicated that although Merge has the required ‘pieces’ they were still waiting for integration. This is a crucial aspect as without integration capabilities, there is no going forward.

Acuo and TeraMedica were also mentioned as VNA providers, although they do not have a PACS solution. Some of Acuo’s clients said some of the strength’s of their system is in image distribution and data migration. The study mentioned that Acuo is increasing in number of vendor partnerships.

Of the providers interviewed, 27% indicated that a VNA would be central to their enterprise imaging.

I wonder if those providers considered the integration challenges ahead with a Vendor ‘Neutral’ Solution.  Being vendor neutral doesn’t imply an archive works with ‘any’ PACS solution, on the contrary.  Being vendor neutral means that a VNA provider doesn’t work well with any PACS system. By choosing a VNA provider there isn’t any standard ‘out of the box’ integration you might otherwise have going with a single PACS provider.

Sure…the VNA will store any DICOM images you send.  This is no different that any other PACS or VNA provider.  I don’t see that as a competitive advantage as all providers dealing in PACS or VNA can provide this service. The competitive advantage is in the integration. Will your PACS system be able to pre-fetch from the VNA? When my existing PACS workstations queries the VNA for images, will I be able to send those images to the workstation I’m working on?

Strategically it’s a good move for Acuo to build up partnerships with PACS providers as the integration between a PACS and VNA is critical. Sure it’s easy getting images in to a VNA, but now try to get them out.  What about metadata updates in the PACS?  DICOM doesn’t send messages containing information on merges/updates/deletes etc to the VNA…unless there is some level of integration not at the DICOM level. If that integration isn’t there, someone is going to have to update two systems.

DICOM and metadata update integration requires a lot of cooperation between the PACS and VNA vendor.  If I’m the PACS vendor, I’m not sure how I would feel about a VNA coming in and taking market share and business from me.

Original article posted here

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