Lessons Learned While Implementing a Vendor Neutral Archive (VNA)

Impact Advisors was recently involved in the implementation of an Enterprise Imaging strategy for a large multi-hospital healthcare organization in New Mexico. Listed below are some of the key elements that were instrumental in the success of the implementation of a Vendor Neutral Archive (VNA) Solution.

What is Enterprise Imaging and VNA?

Enterprise Imaging (EI) is defined as “a set of strategies, initiatives, and workflows implemented across a healthcare enterprise to consistently and optimally capture, index, manage, store, distribute, view, exchange, and analyze all clinical imaging and multimedia content to enhance the electronic health record.”

As part of the Enterprise Imaging solution, the VNA consolidates all imaging data from multiple systems, departments, facilities, and vendors into a central clinical data foundation serving as a single source of longitudinal patient imaging information. Typically, VNAs should be able to store and display any file format, images, or multimedia content, DICOM or non-DICOM, as well as retrieve data in its native format. The VNA can also act as a workflow engine by creating a worklist for a modality, route, and prefetch, sending notifications and more.

Lesson #1: Follow a phased approach

Start with forming a governance body that includes representation from all specialties wanting EI along with the information technology (IT) department leadership.

The EI governance committee will then need to develop and approve a strategy with a defined scope for EI. This strategy should incorporate the future EI environment along with the longer-term IT strategies and address security, compliance, system architecture, data storage, data management, data quality, data redundancy, information lifecycle management (ILM), and high availability.

The strategy document should form the basis for moving forward with the development of a multi-year budget to implement a plan for execution and a high-level timeline.

Lesson #2: Complete an infrastructure health check

The VNA is generally implemented by utilizing fault-tolerant, high-availability configurations and should support a dual-sited, mirrored configuration with automated failover and reconciliation to support business continuity.

Evaluate if the existing infrastructure environment can accommodate the implementation of a VNA solution, including data center availability and capacity for implementing new server and storage devices, network bandwidth, and load balancers. Also, evaluate if any of the existing applications would require an update to the latest version to support a complete integration with the VNA.

Incorporating these infrastructure and application system upgrades as a pre-requisite to the EI schedule is critical to the success for its implementation.

Lesson #3: Review existing image storage archive capacity

While the EI governance body is looking forward with the VNA implementation, another important aspect is usually overlooked. As the implementation of a VNA is a time-consuming endeavor, ensure that there is enough capacity to continue storing images in the existing archival repositories for the duration of the VNA implementation. This is especially crucial if the VNA deployment runs into unforeseen delays, and this contingency planning helps avoid detrimental impacts to business and patient care.

Lesson #4: Should the VNA be patient aware?

In a situation where multiple facilities are ingesting patient images into the VNA, one must consider the use of enabling master patient index (MPI). If the organization is already using a third-party tool to manage the MPI, consider integration of the VNA with that tool for data consolidation, thus ensuring data integrity and synchronization. This also enables the clinicians to obtain a unified view of the patient’s available information. Powerful metadata manipulation techniques such as PIX, MPI, and DICOM tag morphing enable this capability, whether searching via medical record number (MRN), accession number, government ID or a patient demographic field (e.g., name, DOB, SSN).

Lesson #5: Synchronize your data

One of the most common complaints and challenges is how to keep the VNA synchronized with the PACS systems, particularly with making sure deletions and modifications made within the PACS environment are also executed within the VNA. Implementing the Imaging Object Change Management (IOCM) profile as defined by Integrating the Health Enterprise (IHE) by both the VNA and PACS systems should largely address the synchronization issue and provide a standards-based solution.

Additionally, HL7 interface deployments between the patient registration systems and the VNA for patient admit, discharge, and transfers (ADT) messages, as well as all other patient updates, patient merge, and unmerge messages, can help keep the patient data in-sync.

While DICOM was created as a data standard for medical images, many current PACS problems are rooted in DICOM itself. DICOM fails to fully specify the metadata tags (fields) used to identify and annotate the data. As a result, the vendors have been able to interpret and use the standard in myriad non-standard ways. Additionally, DICOM permits the addition of private tags, which will not read across vendors. In short, DICOM provides ample opportunities to keep data tethered to a specific application. Through DICOM tag morphing, advanced systems can neutralize non-standard DICOM data, reconcile and manage patient identifiers from multiple sites, and resolve inherent metadata discrepancies. Some VNAs will also allow the altered DICOM header data to retain initial tagging, so that it can still interact meaningfully with the system that created it or for full legal analysis at some future date.

To this effort, evaluate any deviations from the standards by reviewing the DICOM conformance statements from the PACS and VNA vendors. If deviations are found and cannot be rectified by either vendor, then plan for a manual workflow wherein the PACS administrators are making all changes, updates, and deletions twice, once at the main PACS and secondly in the VNA.

Lesson #6: Weigh an enterprise vs. specialty viewer

One primary goal of an EI initiative is to deliver all forms of imaging to the electronic health record. An enterprise image viewer is necessary to achieve this. An enterprise viewer is a thin-client or zero-client application used on any off-the-shelf device to distribute, display, and manipulate multi-specialty images, video, audio, and scanned documents stored in separate centralized archives through, or standalone from, the EHR. Common EHRs launch the enterprise viewer browser at the study level via URL or secure URL in inline frame through an application programming interface (API). This EHR link to the standardized archive can display all the images, imaging-related data and information for each patient.

A specialty viewer, on the other hand, has advanced functionality and diagnostic toolsets associated with dedicated technology typically residing on a single workstation and tied to a departmental solution. Specialty diagnostic tools are image data manipulation features such as obstetric fetal growth calculations, radiology anatomic and perfusion calculations, cardiology stress/rest ECG raw waveform, and metadata.

In general, enterprise and specialty viewers support basic, advanced, specialty diagnostic, and workflow toolsets. No single viewer will meet every provider, technologist or administrative need across all medical specialties. Thus, even with an enterprise viewer, most healthcare organizations should plan on having at least some specialized applications for more technically or clinically challenging diagnostic use cases. Further, the enterprise viewer is expected to cover the broad needs of provider, non-provider staff, and patient image access and viewing.

Lesson #7: Choose between procedural- vs. encounter-based imaging workflows

The non-radiology and cardiology enterprise imaging workflows are also known as “encounter-based imaging workflow” in contrast to the traditional “procedure-based imaging workflow.” The difference is that there is no order being placed prior to the imaging in the encounter-based workflow. This may also be referred to as point-of-care (POC) imaging.

Both these workflows should provide the ability to identify all images associated with the care event, through the assignment of a unique study identifier. For the cases where orders are generated prior to imaging, the middleware interface engine typically can designate the order number, also known as the accession number. This accession number is critical as it is used by the API from an EMR to a PACS and/or VNA to access the images.

For the encounter-based workflows, there are many options available depending on the workflow and it could be quite challenging to decide which option is the best one. Some of these options include generating an order from a patient’s registration HL7 message, using the universal worklist and procedure step (UPS), and use of an API directly into an EMR, HIS, or ADT system. A so-called “encounter manager” that could reside in a PACS, VNA or broker can be used to generate the unique accession number.

Lesson #8: Implement an image and lifecycle management solution

Image lifecycle management (ILM) is often touted as a feature of a VNA application. Storing data in one central location should make it easier to manage the data by reducing the effort associated with keeping track of where the data is.

The VNA should have the capability to apply rule sets to determine when the data can be removed. This would also mean the attached systems like PACS would need to be notified of the deletions and execute them appropriately. Otherwise, if the data is deleted off the central archive but a system using that archive is not aware the data has been removed, there will be incomplete references to the data that no longer exists.

An effective ILM application is dependent on effective rule sets for study deletion and must consider all policies impacting retention. Consider the legal ramifications for legal holds, teaching files and research-related studies in the ILM rule sets. Another consideration is to evaluate whether the deletion impacts just the database pointer, or does it also delete the study details and images.

Make sure the ILM workflow and implications are thought through in detail and how these ILM policies will be managed. This will require coordination between image-generating systems, the VNA and hospital systems such as the EMR. It may take several cycles to achieve and effective solution.

Lesson #9: Finish with data migration

Once a VNA is deployed and archiving commences, there may still be the need to migrate all legacy archived data to the VNA. Depending upon the volume and size of the data that needs to be migrated, this could take several months to accomplish. An enterprise imaging strategic plan authorized by the governance committee should acknowledge this reality and balance the demands of clinical workflow and data consolidation. Regular and clear, concise communications to providers is necessary to ensure awareness and accessibility of key images or studies with greater focus on delivering high-quality care.

As these lessons learned have illustrated, success is often driven by an enterprise imaging plan that reflects the organization’s overall needs. Moving from the current to future state can be challenging. However, with the right leadership, an excellent roadmap, and strong governance stewardship, approaching a VNA implementation incrementally will increase the likelihood for success by resolving workflow challenges in a logical and gradual fashion.