At the landmark 10th Oct 2008 Meeting of our Group, it has become very clear the global direction of travel for Image and Report Sharing. Nicola Strickland (Radiologist from Hammersmith) set the stage by defining the clinical requirements 1. It is not adequate for just having image sharing, reports were a vital component of an imaging study. (it was a waste of national resource of radiologists time if reports are not shared). 2. Automated process was required for image and report sharing (manual processes via Dicom Push were unreliable, and were a waste of national resources from staff time required to do this). Manual Processes like Dicom Push also produce huge amounts of duplication in local Archives and in the long-term comes at a huge cost to the public in a public funded health service as in the UK. 3. The information about the entire imaging history needs to be available at the front end used by radiologists and doctors via their PACS workstation/clinical review station to improve NHS patient care (having a separate web-browser for reviewing images/reports done elsewhere was a waste of national clinical time from a strategic perspective).
The Speaker from Wales defined the strategic direction from Wales. Wales has a strong requirement for a image and report sharing solution to work in a multi-vendor environment. They looked at XDS as a standard to deliver this (similar to the Canadian Infoway project).
Dave Harvey (an International Expert of IHE and Dicom) clearly defined, that XDS was the only international standard available to deliver the clinical requirements defined by Nicola. However, support was needed from the PACS suppliers to make their main stream products XDS compliant, and deliver the XDS functionality at their front end for radiologists and clinical users.
Alex Heck from GE Healthcare IT elegantly rose to the challenge from Dave, and also defined XDS as the standard for image and report sharing between health-care organizations. XDS is an open standard from IHE (it was vendor neutral--hence work in a multi-vendor environment). GE also showed screen shots of their clinical front-end (radiologist workstation/clinical review station) called the "cock-pit" by GE. So GE was already developing their clinical front-end and back-end PACS product to support XDS. They seem to be emerging as the world PACS leaders on this front.
It was also becoming clear that Central Data Store requirements are becoming things of the past. In public funded health services like in UK, most patients like to use their local hospitals. There is only 2-3% of our DGH patients who are likely to be treated in other Trusts where their images will need to be available. XDS uses the architecture to support “Distributed Information Sharing” as it uses the registry-repository model (like Google)---sharing of information is possible although the information lies in the local archives. This will produce huge saving on nationals costs of maintaining huge datacenters, and also the requirement to pull and push images from data centres with the network bandwidth cost and investment.
Both BT (Chris Whitton) and Agfa (Adrian Watts) recognised that XDS was the strategic direction for image and report sharing, and expressed their support to it. However, they also identified their interim solutions (PACS exchange for BT and Services Platform for Agfa).
PACS Exchange was a centrally hosted Sectra PACS which received Dicom Send and Dicom QR links with all London Cluster PACS. It also allowed web-access to users in the cluster. However, it required manual processes, and was not suitable as a strategic solution--which was recognised by BT.
The Services Platform from Agfa was an automated image and report sharing solution, but was based an Agfa Proprietary interfaces (hence would work with difficulty in a multi-vendor PACS environment--as Agfa Proprietary interfaces would need to be developed with every vendor). It also resulted in duplication in multiple archives as it was based on Dicom QR and store. Although it seemed to have some of the attributes of the registry type of function as in XDS (in its hub), it was not a truly an open standards based solution.
Cost Effective Interim Solutions for Image and Report Sharing was described by Rhidian Bramley using the Point to point Dicom Push and PACS portal as developed and used in the North West Cluster. This is recognised as a good interim cost-effective solution for NHS. However, there remains a need for meeting the national clinical requirements as defined by Nicola.
Scotland had implemented a national image and report sharing solution. However, it was recognised that they had a single PACS vendor (which made it easier) for them. Andrew Downie from Scotland identified their innovative way of dealing with the NHS number issue. Through the presentations it was becoming increasingly obvious the importance of the unique identifier. Scotland uses the NHS number (CHI-number as called in Scotland) as their primary identifier. It is recognised that all patients will not have a NHS number at time of x-ray (newborns, not registered with GP, foreigners etc). When the NHS number is not available, the RIS/ PACS solution automatically puts in the Accessions number into that box (as accession numbers are NACS prefixed they are unique—and hence there is no room for false merges in the central store. I am not sure why CFH and LSPs and not adopted a similar approach to this, rather than trying to reinvent the wheel, in England.
Mary Barber (from CFH) defined the commitment of CFH for improving NHS no. use in NHS trusts and GP surgeries. Also recognised that it was not possible to have 100% NHS number at the point of patient care. Hence, it is a clear message to PACS vendors to develop their products in the similar approach to Scotland’s approach to this same problem (and stop trying to pin the blame on NHS for lack of 100% NHS number availability).
So to summarize the position, in order to deliver the optimal national clinical requirements for reports and image sharing to benefit NHS patients (as described by Nicola), and provide a cost effective solution for the public: 1. NHS number adoption in the NHS –as this is the pivot for image and report sharing(this is already gaining momentum through CFH NHS Number Team. A recognition that NHS number will never be 100%. PACS vendors to develop the name functionality as Carestream PACS in Scotland to deal with less than 100% NHS Number. There should be no more excuses 2. Adoption of XDS as the open standards based method of image and report Sharing to benefit patient care (to meet patient care requirements as described by Nicola). This needs adoption by PACS Vendors (interim use of XDS brokers who will convert non-XDS data to XDS, as described by GE until such time that there is a global adoption of XDS as a standard by the PACS/RIS suppliers) 3. Revisit the need for Central Data stores which are to be a huge drain on the public purse for little patient-care benefit. GE seem to be emerging as the world leaders on the PACS supplier front, moving towards a clinical/patient requirement based information sharing using open standards on a multi-vendor platform. Both Agfa and BT recognize the need, and render their support towards this initiative.
Mary Barber also explained CfH's commitment to the Care Record Guarantee. This is fundamental to a nationally-procured data sharing (I suggest the main pivot). Together with NHS number these are why she said such sharing is "some way off."
Care Record guartantee in common terms is about data security and patient confidentiality. This must be protected at all stages, and must not be "some way off". Even today all Trusts have to commit to protecting patient confidentiality.
Protecting patient confidentiality in my view is about 1. Ensuring access to clinical records is ONLY provided to those who need it to provide clinical care 2. Minimum of a Password or Smart-card requirement for access 3. Regular audit of data access: Easy to understand audit trails for data access. Suppliers need to develop real-time view log of who has accessed the patients episode is a way forward. Some health-care suppliers are already building this into their sofware. Others need to develop this functionality.
These fundamentals need to be present in interim data sharing solutions (that we use today) and also the strategic solution for our patients in the future.
The strategic solution needs to be considered now-- and not be "some way off", otherwise there will be a huge wastage of public funds on large datacentres and duplication in local archives. This wasteful expenditure could be better used in better care for our patients.
There is another factor that as a patient I think is FAR more important to me - namely that the doctor who sees me has access to the images taken in other hospitals so that they can make the correct decisions about my care. In radiotherapy this is potentially a life and death issue whereas confidentiality is not - in fact personally I have no objections to anyone at all seeing my images. I am hearing more and more cases where lack of access to images is compromising the quality of care. While patients have a right to expect that their data will be confidential, they also have a right to expect that their doctors will be able to see the images that have been taken of them when they need to. Although images within the hospital are now more available it seems that in many cases images from other centres are less avaialable than when film packets were being transported. It is a pity that we seem unable to reach a common simple solution to this.
Thanks Phillip. You make a very valid point. "While patients have a right to expect that their data will be confidential, they also have a right to expect that their doctors will be able to see the images that have been taken of them when they need to." This very statement emphasises the need for a robust national image and report sharing solution!
I enclose a word document of the Summary of the 10th Oct 2008 Meeting --focussing on Image and Report Sharing.
Strategic Direction for Image and Report Sharing is gaining Momentum. Some of us have been to the Accenture Offices to review the Mawell Infobroker solution. Accenture are happy for me to open the discussion of this on our forum.
We discussed with Accenture about reviewing the requirements and a open standards based solution to meet the requirements.
A. IMAGE/REPORT Sharing for SIMPLE REVIEW OF IMAGES and REPORTS: Images and reports being available for review. When radiologists are reporting an exam/clincians are managing their patients, availability of the entire patients imaging history (irrespective of where they have been performed) on the system they use for reporting/review (PACS software), will improve patient care and reduce unnecessary repeats of examination. IHE has a standard to support this process of data sharing for review. 1. Accenture could provide a XDS Registry (like Google) which would store the metadata of where images/reports lie, and put folders together based on the NHS numbers. 2. Local Trust PACS would be required to publish image and report information to the XDS Regisrty. 3. Trusts would need to ask their PACS vendor to make their product XDS compliant, and thus be able to publish images and report information to XDS Registry (PACS brokers store copies of reports, and hence for simplicity I have used this model--and not involved RIS at all) 4. If PACS Vendors are not able to provide XDS functionality, then an XDS Broker could be offered by the Accenture, which would sit in each Trust and link with PACS to publish XDS data for reports and images to XDS registry. 5. For reviewing XDS meta-data, PACS vendors would need to make their PACS front end XDS compliant (similar to the Centricity Cockpit display of XDS registry) as shown by GE at the 10th Oct GRoup Meeting. 6. If PACS Vendors cannot make their front end XDS compliant, then Accenture could provide a web-browser like Mawell Infobroker to display XDS registry information via automatic display desk-top integration with PACS. 7. This adopts a vendor neutral methodology for Image and Report Sharing. 8. This methodology does NOT require 100% NHS number. 9. This method does NOT require for storage of images and reports in the Central Data Stores, but uses a distributed storage architecture. 10. This allows for Non-LSP Trusts to participate in Image and Report Sharing without have to join the CDS or having to replace their PACS with expensive LSP PACS. 11. This uses a open standards based approach for Image and Report Sharing in a multi-vendor environment. 12. It provides financial incentives for PACS vendors to develop XDS Inter-operability within their products. It also provides a fallback for those Trusts to take on an XDS-Broker/XDS browser from Accenture, should their PACS vendors be unwilling to adopt a XDS standards based approach.
B. IMAGE/REPORT Sharing for REPORTING/ SECOND OPINIONS: Radiology exams may be performed in one Trust but there maybe a requirement to get reports done by another Trusts or Independent Sector/A second opinion may be requested/provided by another Trust. Currently as there is a lack of report sharing (due to lack of standards to support this), there are a lot of second opinions requested by clinicians of their local radiologists. There should be a reduction on number of second opinions should report sharing as described above becomes available to the NHS. However, XDS currently does not support the workflow for this type of Data Sharing. Mawell Infobroker with propriety interfaces with the PACS and RIS in each Trust will be able to provide this functionality (until such time that a standard appears for this). This functionality was well displyed by Mawell.
My view is that there should be step-wise approach to National Image and Report Sharing. The demand for IMAGE/REPORT REVIEW currently is much greater than the need for reporting/second opinions (this was demonstrated by the Statistics produced by Rhidian on use of the PACS Portal in the North West). There is also an open standards based approach for this. The next step should be the provision of IMAGE/REPORT Sharing for REPORTING/ SECOND OPINIONS using proprietary interface with Mawell Infobroker (if a standards based approach has not arrived by then.
I am pleased with the interest from Accenture to develop an Vendor Neutral, Standards based approach for Image and Report Sharing within the NHS.
Mawell looks good and seems a better bet than the CfH "vision" of CDS.
I'd like to see 3 things:
Accenture get it scaled up and ready to deploy as soon as poss.
CfH support this and not create needless barriers to adoption by trusts. An image sharing solution will only work if everyone buys into it. This looks as though it could be used by R1, R2 and other sites.
This should be free to LSP sites as we are already paying for an image sharing solution which hasn't been delivered.
There is a pressing need to develop networks facilitated by solutions such as Mawell to support for example the Stroke strategy and Cardiology networks. Central MDTs would greatly benefit from some of the demonstrated Mawell functionality such as the addition of addendums to reports which are then updated in the local RIS. I understand that there are other solutions which support data sharing not only of Radiology bases images but other ologies too.? Forcare and Mach7Technologies.Does any body have any info on these? Laurence
Image and Report Sharing is not in the LSP contracts to deliver. CDS was not designed to support Data Sharing (but a simple offsite Dicom archive).
If NHS has a requirement for a Image and Report Sharing Solution, then there needs to be further public investment (let us not get into the debate of who is paying Trusts/SHA/CFH--because at the end of the day it us, the public who are paying for it, for what is a requirement for us as patients.)
Phillip makes a very valid point: "While patients have a right to expect that their data will be confidential, they also have a right to expect that their doctors will be able to see the images that have been taken of them when they need to." This emphasises the need for a strategic National Image and Report Sharing solution. National Initiatives like Choose and Book, Centralization of Cancer/Stroke/cardiac services NEED Information sharing and it is the duty of CFH/SHA/other NHS bodies to enable this.
What we emphasised to Accenture on Friday (who to be fair were listening to us), is that there needs to be a open standards based approach to Data Sharing (to ensure that we deliver a VFM solution for the NHS). Proprietary interfaces are expensive to develop and maintain, and in the long-term will be extremely expensive to the NHS. The only global standard for this type of Data Sharing is XDS and XDS-I. Accenture needs to adopt the open standards based architecture (whether they sub-contract with Mawell or other companies to deliver this type of Image and Report sharing)
At the time that we wrote business cases for PACS we were told that image sharing would be a reality. A chunk of the benefits in the CFH approved business case were around image sharing. I seem to remember being criticised for not "sexing up" that part.
We were promised this and we are paying for it. Accenture are overdue delivering this, and if they can't with the barmy architecture devised /designed with CfH, maybe they ought to offer Mawell as a free alternative.
I, too, am puzzled by your statement: “Image and Report Sharing is not in the LSP contracts to deliver”.
The contracts were based on the (608-page) Output Based Specification (OBS): “Integrated Care Records Service Part II - LSP SERVICES”.
The Section (115) of the OBS primarily concerned with PACS begins on page 253: 115 - DIGITAL IMAGING INCLUDING SPECIFICATION FOR A PICTURE ARCHIVING AND COMMUNICATIONS SYSTEM (PACS) SOLUTION
Within “SCOPE”, it states: “Supports transfer of individual images/reports (or the images/reports for an individual)” BETWEEN HEALTH COMMUNITIES.
Also in the first two pages of Section 115, the following “Benefits and Outcomes Scenarios” are described.
SCENARIOS (b) James’ Heart Attack • James is reviewed and referred for a coronary heart bypass graft assessment. The heart SURGEON IS ABLE TO REVIEW ALL OF THE IMAGES (ECHOCARDIOGRAM, CHEST X-RAY, AND ECG TRACING) FROM THE GENERAL HOSPITAL AND COMPARE THEM WITH MORE RECENT TESTS ARRANGED AT THE SPECIALIST HOSPITAL.
(c) Mohamed Breaks His Leg • An x-ray taken for Mohamed as a child shows an abnormality. If his previous films had not been available (because they were taken before PACS and in a different part of the country), then an apparent abnormality which is in fact a past Episode might have been misinterpreted as a new condition resulting in unnecessary intervention.
(d) Infant Penny has a rare life threatening genetic disorder • Six year old Penny has MPS (Mucopolysacrodosis), a rare aggressive and degenerative genetic disorder. This is FIRST DIAGNOSED AT HOSPITAL (A) from the OPHTHALMIC REPORTS AT THE EYE HOSPITAL (B). As a consequence she is ADMITTED TO CHILDREN’S HOSPITAL (C) to be operated for a VP shunt to equalise her CSF pressure (due to communicating hydrocephalus). As a consequence of the initial diagnosis and in order to plan treatment, she has to have a LUMBAR SPINE MRI SCAN AT Hospital (D) and an ECHOCARDIOGRAPHIC SCAN AT THE HEART HOSPITAL (E).
Through the use of the multi-site digital imaging system integrated with the single patient care record, her RETINAL IMAGES; HER SKULL X-RAY AND CT IMAGES; HER LUMBAR SPINE MR IMAGES, HER CARDIAC SCANS AND HER COMPLETE CARE RECORDS CAN ALL BE SEEN TOGETHER AT HOSPITAL (A), thus empowering her primary paediatric clinician to give her a planned path to timely and lifesaving, care and treatment.
END OF QUOTE
Clearly, anyone reading (even the first 2 pages of) the relevant OBS Section could be expected to have the understanding that the LSP’s have already contracted to provide Image and Report Sharing.
I agree with what both John and Richard are saying, about what we were all led to believe. However, I am also hearing that actually Image and Report Sharing wasn't in the negotiated contract with LSPs.
Rather then trying to dwell on the past, I am trying my level best to help shape the future in the right direction, using a open standards based approach towards Image and Report Sharing. Maybe once again, these will fall on deaf ears by those who will actually negotiate/be responsible for the deals with suppliers/contractor---i.e. SHA/CFH/new body. Anyway, nobody can blame us for lack of effort. Let us all watch the space.
posted on Wednesday, October 22, 2008 - 09:43 am
I am doing my best to develop selective amnesia wrt CfH, but it isn't quite ready for deployment.
My point is that if Mawell comes at a cost this will be a barrier to implementation. Which would be a shame as there is a need, and it looks like a potentially good solution.
posted on Wednesday, October 22, 2008 - 02:16 pm
Richard, When you have successfully developed and deployed your selective amnesia product, will you please make it available to the rest of us (hope the price will be less than the LSP catalogue price).
Now jokes aside. 1. I entirely agree with the promises that were made, but seem not to be in the contract for LSPs to deliver. I agree this does need to be questioned. But I do not know who should be questioning this. Should it be the SHAs? I do not know the answer to this. 2. Over the last year a standards based Image and Report Sharing via XDS has been developing. This is based on a distributed storage architecture and a multi-vendor economy (rather than expensive Central Data Stores and single supplier monopoly). I do think this is the national direction we need to take. Major Global PACS vendors are already developing this in their products. We need good Clinical IT leadership to steer our country in this direction 3. Lessons need to be learned, but we need to move on.
posted on Thursday, November 06, 2008 - 01:27 pm
Just to make you all aware that the current Mawell Infobroker offering from Accenture is based on proprietary interfaces (not on XDS). Accenture do realise that an open XDS type standards based approach is required in NHS.
The Royal College of Radiologists has issued this document "National Strategy for Radiology Image and Report Sharing". This paper supports need for use of open standards for inter-operabilty. This document is being sent to DOH, CFH etc. I would be grateful if readers within the NHS community could distribute this far and wide within your Trust, SHAs or anyone you think may benefit from this. This helps Trusts to insist on vendor-neutral inter-operabilty standards for future PACS replacements which are already on the horizon.
I am really pleased that The Royal College of Radiologists has come up with a vendor neutral inter-operabilty standards based strategy to Clinical IT for NHS . As many of you are aware vendors are already developing this in their products. On 10th Oct 2008 meeting Alex Heck from GE showed their new Centricity product which has on its front end ability to pull XDS information (which could pull all the patient's imaging history--anywhere in the NHS and from any PACS vendor--if NHS adopted an XDS methodolgy for image and document sharing.)
This type of approach is vital if we are to see real patient benefits from public expenditure in NHS IT. This will indeed bring about VFM for public funds. Let us hope lessons have been learnt.