| Typical light traffic at the exhibition floor |
The May 28 -30 meeting of the Society for Imaging
Informatics in Medicine (SIIM) held at National
Harbor in Baltimore (just south
of DC), was well attended. It seems the decline in attendance has stabilized
and there were, what I estimated to be, between 500 and 700 attendees. This is
the only PACS meeting in the US and it is a good opportunity to network and
find out what is new. I attended all three days, however, I had a difficult
time finding any new developments, technologies and/or products. Much of what
was talked about was either said or published before. Anyway, here are some of
the questions that came up during the meeting:
1.
Is PACS dead? The opening session by Donald
Dennison, one of the SIIM directors, was a rehash of his article in the SIIM
publication Journal of Digital Imaging
called “PACS 2018, an autopsy.” It was actually the journal’s most down-loaded
article last year, which might be more due to the controversial title aimed at scaring
PACS professionals, than any new information it shed on the future of PACS. Yes
there will be VNA’s that provide access to physicians and yes there will be image
enabled EMR’s, but these are just replacing the clumsy non-patient centric
physician viewing capabilities that have been part of PACS for many years. It
does not mean that the advent of the VNA’s and EMR’s that we are ready to
perform an autopsy on a dead PACS. I also thought it interesting that the
keynote speech of a PACS conference talks about the “death of PACS,” I surely
hope that is not the case.
2.
When are people going to understand what a VNA
is all about? VNA’s are still touted as the next greatest thing, especially by vendors.
What is missing is an honest discussion about the issues with early
implementations and experiences. One of the major issues with using a VNA is
that if you have to maintain yet another place where images are being managed
and archived, you better make sure that the information is synchronized. For
example, if you delete an image at the PACS, it should be automatically deleted
at the VNA without manual intervention. There is a standard for that defined as
an IHE profile, called IOCM (Imaging Object Change Management), which has not
been widely implemented (yet). Second, it has become clear that DICOM metadata
is not sufficient to manage the images at an enterprise level, additional
information is needed as defined by the XDS profile, but storing that
information in the VNA image database defeats the purpose of having a VNA to
start with as it is again yet another proprietary database implementation that
requires knowledge of the database tables to get that information out. Lastly,
there is a lot of talk about VNA access by viewers using open standards, but I
have found only one US institution so far that really implements XDS-I image
access to do this. So, it appears that even though VNAs are sold as the
greatest thing since sliced bread, there are still many issues to solve.
3.
What is a MERR? I heard a new term, called the
Multimedia Enhanced Radiology Report or MERR. What I understood is that it is
basically a report with pictures and graphs. I could not really figure out what
the novelty is, as mammography reporting has done this for many years and
measurements such as from ultrasound are already captured through DICOM
Structured Reports and represented accordingly. Sounds like a marketing ploy to
me.
4.
What about non-DICOM data? The fact that most
VNA’s are advertising that they can manage non-DICOM objects seems to make for a
free-for-all for storage of all types of objects, especially from the
non-radiology specialties, which was referred to as the “LTFFT” or “Left To
Fend For Themselves” objects. Yes, these objects are in many cases “orphans,”
as they are often stored and managed locally. And there are many of these still
to be discovered image sources ranging from medical photos, to pathology, to
video’s that are taken to monitor gait for orthopedic patients and many more.
However, I have yet to find an object and/or encoding that cannot be
encapsulated into a DICOM format, including MPEG video’s, PDF documents, and
even waveforms. Therefore, as suggested several times, to store these objects
using new formats such as MPEG7, which is yet another encapsulation of a MPEG4
file, should be strongly discouraged.
5.
What about non-radiology imaging that is DICOM?
There is a wide proliferation of POC (point of care) devices that create
images. At Duke medical center, a survey showed that only 19% of all ultrasound
exams are performed in radiology, meaning 81% are created elsewhere ranging
from OB/GYN’ office, to the OR, the ER, labor and delivery, and specialty clinics,
etc. The challenge is, how to capture all these images in a useful way in the
electronic health record so they can be available to practitioners outside
these departments. It appeared that only 45% of these ultrasound devices support
DICOM and therefore have a way to export the data in a standard manner, of
which only 75% have DICOM worklist capability to allow for patient demographic
and order capture at the device. This is going to be a challenge, requiring
device upgrades and user education to make sure the information is captured.
6.
How do we implement mobile technologies? The
installed base of healthcare information and imaging devices use predominantly
DICOM and HL7 for their communication between the different devices. Neither
one of these standards lend themselves well to access over the web such as used
by mobile devices, therefore we need the new “web-services” version for both
standards. These are called DICOMweb and HL7 FHIR. The good news is that these
web services are relatively easy to implement - there was actually a hackathon
as part of the conference for the true geeks to show how easy an application
can be developed using these tools. The SIIM presentation about these new
services is exactly the type of information that PACS professionals want to
learn about. Too bad that there were so few of these and that the next level of
integration using these services, i.e. by using the appropriate IHE profiles,
was not discussed at all.
7.
What is XDS anyway? XDS is yet another buzz-word,
meaning the IHE profile to provide Cross Enterprise Document Sharing, which was
used in the context of VNA and PACS as well as EMR integration, however, I am
convinced that very few actually understand the details of this and that
stating “XDS support” is as useless as stating that a system supports “DICOM”
or “HL7.” One needs to be very specific about which actor one supports, i.e.
does a device create documents or images (acts as a “source”), is it a
repository, registry, or consumer and what about the patient identity feeds,
where are they generated? To understand the workflow and identify any gaps or
overlap, it is strongly recommended that you create a diagram with all of the
IHE actors in your system. This might be a good exercise for next SIIM meeting,
which was dearly lacking content on IHE anyway.
8.
When will DICOM finally become plug-and play?
After all these years (DICOM was introduced in 1993), it amazes me that there
are still Issues with DICOM connectivity. One speaker said that his institution
cannot pull back images from a PACS at the ultrasound for contrast processing. The
solution is a simple matter of configuring the devices to do a query from the
PACS and the PACS initiating an association back to the modality to store the
images. Sounds simple, and it is, however, apparently it is not, I expect due
to a lack of training and understanding resulting in finger pointing between
the vendors. Amazing but true.
9.
Is it show time for mammography tomosynthesis
yet? This new modality which produces a set of 20-30 image slices of the breast
instead of, or in addition to, the traditional 2-view image is poised to be
introduced in many facilities because of marketing pressure caused by
supposedly better outcomes when using this for routine breast screening. Based
on comments from the audience during the special session about this topic, it
was clear that there are still growing pains. One attendee reported that the reading
takes 20 times (!) longer than when using conventional mammography screening,
another attendee had major problems with the hanging protocols, obviously unaware
of the IHE profile that explicitly addresses these issues. Somewhat scary based
on the number of attendees that were planning to install this modality in the
upcoming year that there are still many technical issues to be resolved,
including required bandwidth and storage capacity.
10.
What to do if the PACS is down? Many
institutions are relying on cloud solutions for a backup. The increasing use of
DICOMWeb making images available on mobile devices in an easy manner from the
cloud now provides a backup solution because practitioners can access images
from their PCs, and increasingly their tablets. Mobile access is evolving as
another good solution complementing a redundancy and backup strategy.
So, yet another PACS meeting, with, as I mentioned, not much
new; in my opinion it was light on technical content, but not poorly attended
so I guess it has its niche audience. The location (National Harbor) was kind
of a bummer, so close to Washington DC and yet too far to easily get to the
city unless you want to take a taxi. Next year is going to be in Portland, OR,
kind of far out in the northwest corner of the US. I’ll probably attend,
hopefully there will be more to learn by that time.
