The vendor neutral archive market heats up as technology advances

Streaming images to the clinician

Cincinnati Children's system is structured around a universal, or enterprise, viewer from Merge that uses server-side rendering to stream even the most complex medical images to clinicians' mobile devices or zero-footprint desktops. Zero footprint refers to a terminal without software actually loaded on it.

Similar cloud-based image sharing is also benefiting patients, as well as providers who already make medical images, such as MRIs, available on laptops, tablets or smartphones with no viewer or processing required by the user.

Joe Marion

The advent of streaming in the vendor neutral archive market is a significant development that has occurred over the last few years, according to Joe Marion, a medical imaging expert and principal at Healthcare Integration Strategies LLC.

That popular and relatively simply approach and its growing adoption is part of the steady march of VNAs as they supplant PACS more and more when providers are looking to upgrade or replace imaging systems, Marion said.

"They're becoming more accepted.  There are more places that are starting to look at them," Marion said of VNAs.

Another driver for VNAs, Marion said, has been the anticipated image-sharing requirements of meaningful use stage 3, which is now being replaced by new federal emphasis on value-based healthcare and Medicare reimbursement.

Storage options with VNAs

Beyond image sharing, storage of the rapidly expanding universe of digitized medical images is yet another force propelling the movement to VNAs.

Marion said one client of his recently turned to VNAs, reasoning, "We're running out of storage capacity on our PACS, and we need more space to store images."

"A lot of [providers] are saying 'Let's just turn to a VNA and do it that way, '" Marion said.

As for VNA image storage, providers generally are pursuing three approaches currently:

• remaining solely with on-premises data center storage and backup under the thinking that it provides  greater security, control over images and lower latency than cloud storage;
• relying on a hybrid storage setup that keeps the most urgent images on premises but stores backups in leased cloud space; and
• moving to all cloud-based storage, an option now offered by some VNA vendors, including Merge, which runs a multi-tenant private cloud for some of its clients.

Image formats at the heart of VNAs

Yet another relatively recent trend in VNAs is the move toward the newer XDS (Cross-Enterprise Document Sharing) imaging format as an option for storing patient imaging content, said John Hansen, vice president for interoperability at Merge.

John Hansen

In fact, the latest iterations of Merge's iConnect VNA support XDS because Merge considers the XDS image interoperability framework considerably more "lightweight" than DICOM (Digital Imaging and Communications in Medicine) systems, Hansen said. It is also compatible with the Merge iConnect Access universal viewer that streams images from the VNA server.

DICOM, a mature medical image exchange standard born of radiology more than two decades ago, is an essential component of many VNAs and PACs.

The new Merge XDS-based viewer "is optimized efficiently so there's no image degradation or image skipping," Hansen said. "The primary use case for it is distribution of images across an enterprise and image sharing, but we do have customers using it for primary diagnosis."

Physicians can make diagnoses because the system has clearance from the Food and Drug Administration for applications involving primary diagnosis of medical images. However, this approach is not allowed on mobile devices.

VNAs assisting with clinical conditions and billing

Towbin, of Cincinnati Children's, said the hospital system is also starting to use the VNA with a small department in the hospital that focuses on patients with "sunken chest" syndrome. The VNA helps the team produce and share CT scans, ultrasounds and other images to guide surgeons and help them avoid cardiology complications.

Alex Towbin

Towbin said another value of the VNA, which has been in place at Cincinnati Children's since early 2015, is that increasingly ubiquitous imaging procedures, such as point-of-care ultrasounds, can be accurately documented and billed for. That capability will aid in the transition to value-based care and bundled payments.

Meanwhile, Towbin described a typical real world healthcare scenario and how VNA technology improves the imaging component of care.

"I have a child with congenital heart disease who gets radiology and cardiology for imaging and would have chest X-rays, cardiac [MRI], cardiac echocardiogram," Towbin said.

"In the past, for us, it's been in separate systems -- not always the easiest to access," he continued. "Now, the images will be there side by side and accessible anywhere, so anyone -- radiologists and cardiologists -- will be able to see [them]."