While cloud computing has been around for more than a decade, health care is finally embracing it today. A recent market study1
reported that the global cloud computing market in the health care
industry was valued at US$1.82 billion in 2011 and is expected to reach
US$6.79 billion by 2018, growing at a compound annual growth rate of
21.3% from 2012 to 2018.1
The rapid adoption of cloud
computing in health care presents opportunities and challenges.
Cloud-based PACS along with mobile apps promise to simplify image and
data sharing and cut costs, yet one challenge is secure storage. Medical
images are projected to require 30% of the world’s storage and could
soon represent 10% of all of U.S. healthcare costs or about 1.5% of US
GDP.1 From an IT perspective, the average 100-bed hospital,
performing 40,000-50,000 radiology exams annually, is adding 5 terabytes
of data to image storage.1
There are several
approaches to building a cloud-based PACS or image exchange, which offer
feasible solutions to managing enormous volumes of readily accessible
Why choose the cloud?
How do cloud-based
solutions affect radiologists? It is becoming more practical from an
efficiency and cost perspective for radiology to share images and
reports across a secure cloud network.
As more health care
providers and hospitals invest in electronic health records (EHR), they
are integrating image viewers into EHRs—essentially building a bridge
between referring physicians and radiologists. These infrastructures are
increasingly using cloud-based networks as the backbone.
a major factor driving the rapid adoption of cloud-based
infrastructures in health care. According to the Government
Accountability Office, 75% of all imaging procedures are performed
outside of the hospital setting where picture archiving and
communication systems (PACS) are practically nonexistent.2 Currently, the National Healthcare Information Network (NHIN) requires a PACS to share medical images,2
which means 75% of medical images will not be available to providers
without PACS. A cost-effective solution to the problem is
Software-as-a-Service (SaaS) or on-demand software. Since applications
are delivered as a service over the Internet, users can pay on a
With on-demand applications, such as radiology
information systems (RIS), PACS, remote image review software
(teleradiology), advanced 3-dimensional (3D) apps, and billing software,
facilities avoid paying huge upfront costs.3 Multiple
hospitals can share standard software, infrastructure, storage, and
processing power. Cloud computing can help imaging [networks] rapidly
scale and descale operations and avoid huge spending on maintenance of
costly applications and storage.3
flexibility of anywhere, anytime access to medical data allows
radiologists to report remotely from outside the hospital.
These factors—low upfront costs, cost-effective scalability, and flexibility—are driving the migration to cloud-based PACS.
Cloud-based models simplify image sharing
of the true marks of genius is making something technically complex
seem simple. This was the approach Steve Jobs took when introducing the
concept of the personal computer.
In health care, what seems
simple is actually quite complex. This is the case with image and data
sharing. A recent survey found that outside images were handled in
emergency departments where approximately 20% of images were hand
carried or emailed directly to physicians; about 90% of images were
entered into the hospital PACS, while about 10% were managed through the
departments treating the patient. Several of the physicians and IT
staff in the survey noted that images were frequently lost and exams had
to be redone.4
Using zero-footprint software, applications that do not require end users to install any software,5
is very cost-effective since it only requires a browser and runs on any
platform. Some PACS claim to be zero footprint, yet if they require
plugins, only run on specific browsers, and do not support tablet or
mobile device capabilities, then the true advantage of a zero footprint,
such as decreasing cost of ownership and deploying data with minimal IT
support, is diminished. On the other hand, many zero-footprint
implementations in the market are very basic and do not support full
diagnostic viewing needed in a PACS.
A notable zero-footprint
viewer is Nil solution by Claron Technology, which is just as powerful
as a standalone workstation with support for multi-monitor, rule-based
hanging protocols for exam viewing according to physician preference. As
a pure zero-footprint viewer, there is nothing to install and there are
no restrictions on browser use.
Improving referral services
a solid referral base is the life-blood of radiology and poses a
particular challenge for private practices. It is no longer enough to
provide accurate radiological reads with quick turn-around times;
referring physicians want radiologists to play a more collaborative role
by reviewing a case at a moment’s notice and must be notified of
Growing private practices like Sand Lake
Imaging, Orlando, FL, a high-volume freestanding imaging center with 350
patients a day, need to communicate with local referring physicians as
well as with those located nationally and internationally. By converting
their RIS to MedInformatix and CoActiv’s cloud-based PACS, the imaging
center increased its productivity by 30%, improving its service to
“The CoActiv PACS has resolved our
challenges to expand our practice capabilities to interface with
physicians across the continuum of care. It’s a cloud-based system that
is easy to set up, to get all of the doctors set up onto the system in a
manner that is HIPAA compliant and nonintrusive to their own
practices,” said Stephen M. Bravo, MD, Medical Director, Sand Lake
With the new system, subspecialists can now view 3D
reconstructed images and cine images of the heart and PET/CT
examinations. “That has significantly helped us service these
subspecialists in ways we weren’t able to in the past,” said Dr. Bravo.
The program also provides a feature for subspecialists to view the
records of those patients whose primary care doctors initially sent them
to Sand Lake Imaging.
Another challenge is effectively
communicating urgent results to referring physicians. It can take 10 to
15 minutes and several administrators to connect the radiologist with
the referring doctor for a 2-minute conversation, says Sid Prakash, MD,
DABR, a diagnostic radiologist at Total Radiology at Bainbridge MRI, in
Bronx, NY, where they recently installed RoentgeonWorks by BRIT Systems.
The RoentgenWorks DICOM Cloud is a browser platform for
uploading medical imaging studies and reports. Users can upload, view,
and share studies and reports 24/7 from any https connection. Users can
also send out email invites to colleagues and patients, allowing them to
view images via Brit’s WebWorks browser-based viewer or the DoctorWorks
“Today you need to report critical results to
the referring doctors. I was looking for a PACS vendor focused on
communication, not just on the PACS user interface,” said Dr. Prakash.
“The fact that it tells you there’s an urgent finding is great. If you
dictate an urgent study on acute fracture, for example, it picks up
those words and knows if it’s urgent and gives you options to call and
leave an automated voice message on the doctor’s phone and also send
information on the urgent finding.”
Dr. Prakash was also looking
for a PACS that supported mobile apps to share images with physicians.
“It’s huge to be able to have reports on iPads, in particular because
more doctors want to see reports on their mobile devices. When I provide
a doctor access to reports on a mobile device he will remember that my
practice was able to do that while others were not. In the private
practice space, it makes a huge difference—it’s a competitive advantage.
Whatever you can do to make it easier for them is important,” said Dr.
Cloud supports the VNA model
One of the
advantages of the cloud-network is scalability. A network can add on
services and capabilities through the cloud. One way to create an
enterprise imaging strategy is to use a vendor-neutral archive (VNA). A
VNA is a comprehensive cloud-based image storage and management
solution. Images are archived on a short- and/or long-term basis and the
archive can grow as capacity requirements increase. VNAs help health
care providers consolidate imaging data from multiple PACS.
fact, Colorado Telehealth Network (CTN) built the CTN Colorado Imaging
Exchange on a cloud-based VNA network. The concept was to store all of
the images in a central cloud repository to facilitate sharing imaging
studies. As part of the service, Acuo Technologies and Client Outlook
provide vendor-neutral archiving services and diagnostic-quality medical
image viewing, and GNAX Health hosts and manages the cloud. The network
enables hospitals, imaging centers, clinics, and other health care
providers in Colorado to safely store and share medical images through a
“We want CTN’s Colorado Imaging Exchange to be
interoperable. The solution demonstrates the power of an alliance,” said
Ed Bostick, Executive Director, CTN. The platform is a private
point-to-point network with built-in encryption for securing data.
of the benefits of the VNA is that radiologists often like the workflow
of a specific PACS, but their IT doesn’t like the way the
infrastructure is deployed and managed,” said Toria Thompson, Consultant
to CTN. “Because our solutions take care of the archive piece of the
PACS, it takes that heavy lifting off of the PACS. Now, the PACS can go
back to being primarily a radiology workflow management tool, and all of
the archiving is in a standard system.”
One of the pain points
for radiology reading groups is getting priors, noted Thompson. “With
CTN’s Colorado Imaging Exchange, you can grant access to radiology
groups to the priors that they need or push priors to the radiology
group so that they have them waiting. So in many ways, it’s an easier
workflow for getting priors,” she said.
Reducing the total amount
of storage required is another advantage of a VNA. By having studies in a
central place, it eliminates storage redundancy. Users can view images
directly from the unified cloud-based viewer. Because the data is not
sent by Internet to different locations but viewed from one location,
there is no change to the data, which contributes to data integrity.
universal viewer has a collaborative benefit as users can manipulate
studies and view them in real-time. “One of the things that we were
missing with PACS was the collaboration in radiology. The unified viewer
gives you that collaborative effect,” said Thompson.
viewer includes an iPad capable app and Android download that is 510(k)
cleared. “Many radiologists choose to look at images first in the viewer
because of the speed with which you can get to studies with a Universal
workflow app,” said Thompson.
Another leading VNA provider
working with large hospital networks is Siemens Healthcare. Siemens is
deploying its VNA to Intermountain Healthcare, a 22-hospital network
based in Salt Lake City, UT. Siemens Image Sharing & Archiving (ISA) VNA
will handle Intermountain Healthcare’s enterprise imaging needs by
storing images in the Siemens Healthcare Computing Center (HCC), which
is redundantly hosted in a Dell data center. The archive is managed with
Dell’s clinical data management software, federating images to the Dell
Cloud Clinical Archive (DCCA).
“Our costs for managing images
would scale with our utilization – but not in a traditional way,” said
Marc Probst, Vice President and Chief Information Officer, Intermountain
Healthcare. “If our volume expands, we would expect our costs per study
to go down, [and] if our imaging volume actually goes down, we have an
opportunity to reduce our overall costs. This type of budget certainty
is a key factor in making this solution our long-term answer to
enterprise image management.”
ROI on the cloud
saying goes, if you can’t measure it, you can’t manage it. This begs
the question—what are the true savings on a cloud-based PACS?
a Philips Pilot Program, medical facilities can identify their
return-on-investment based on workflow efficiency and savings. After
installing IntelliSpace PACS by Philips Healthcare, The University of
Pittsburgh Medical Center reported realizing a 43% decrease in study
management costs across its 18-hospital network, which translates to an
estimated savings of $14 million annually.
interfaces with the hospital or imaging center’s existing HIS and RIS,
and can image-enable EHRs. Specific to radiologists’ needs, it generates
work-to-do lists and an order/protocol; schedules exams for modalities;
provides referring physicians a full view of their patients; and
supports patient ward-specific worklists for critical care units. MD
Anderson Cancer Center, another participating hospital in the Philips
Pilot Program, expects to save $30 million over 8 years.
Managing cloud security
ongoing threat to cloud-based networks are data hackers and viruses.
Although cloud storage has been around for a long time, in a recent
survey of health care professionals, 47% of respondents indicated
significant security concerns with cloud-based image
One reason Patrick Ward, CIO, Central
Illinois Radiological Associates (CIRA), chose Visage 7 was that it did
not require moving patient imaging data from the hospital data center
“What Visage does is differential streaming of the images,” said Ward. “The actual DICOM data allows
us to keep the data file on the hospital’s network – it does not leave
the boundary of their security that they manage and administer. Visage
does graphical processing to stream the data to the physician. The file
is never actually transferred just the visual data—it’s very fast and
The platform at CIRA, a large radiology group
with dozens of hospitals, IDNs and centers across Illinois, combines
Visage 7 as its viewer, Nuance PS360 for workflow/reporting, and Acuo
for managing the data. This integrated environment now provides
network-wide access to images, regardless of where their radiologists
reside, with a single enterprise worklist.
In a recent study,3 researchers identified several steps radiology departments can take to secure data:
- Store data remotely in virtual compartments in the storage media;
- Encrypt data during storage and transfer;
- Connect with the server using a secure URL, such as URLs beginning with https (s stands for secure);
- Use biometric checks to protect access to data;
- Employ mirror servers to avoid service disruption; and
- Develop a long-term archival strategy to protect the security and integrity of data.
Impact of mobile apps
It used to be that radiologists
went to a dedicated workstation to access images. In the post-PC era,
images follow radiologists wherever they go.
Some of the primary
features mobile devices provide radiologists with are remote desktop
access, DICOM viewers, file upload, and screen sharing and consulting
with referring physicians in real-time.
“The ability to use an
iPad or mobile device to download information will improve communication
between radiologists and referring doctors as they can instantaneously
gain access to medical information for their patients. I think it’s
going to increase turnaround times and make the entire system more
efficient because physicians will no longer need to wait over the
weekend, even for non-stat findings,” said Dr. Bravo.
devices have already transformed patient care at leading institutions
like Mayo Clinic Arizona, located in Phoenix and Scottsdale, AZ. The
hospital has implemented a pilot program using mobile software for diagnosis.
had a need for clinicians to access images almost immediately after
they completed a scan and before the radiology report was finalized in
order to make clinical decisions. So the main driver was our telestroke
program with our stroke neurologists and neuroradiologist who were on
call. They needed to make clinical decisions as soon as a stroke patient
presented in the emergency department,” explained Amy Hara, MD,
Professor of Radiology, Mayo Clinic Arizona.
Doctors there deploy
Calgary Scientific’s ResolutionMD, which acts as a mobile PACS
workstation, streaming data from imaging modalities to devices on both
Android and iOS platforms, yet the data is never stored on any device.
the emergency setting prompted the inception of the program, today all
of the radiologists, several of the surgeons, neurologists, oncologists,
and gastroenterologists are on the mobile platform.
radiologists mainly use the mobile imaging solution for after-hours and
weekend coverage when they are asked to give an opinion on a case. We
have even had a radiologist on an airplane connect to Wi-Fi and render a
second opinion using ResolutionMD,” said Dr. Hara. “Mobile imaging is
breaking down a lot of physical barriers to get an opinion or diagnosis
She added, “We are also looking to use the technology
for physicians to collaborate from remote locations. With ResolutionMD,
both the physicians and radiologists can interact simultaneously,
allowing them to collaborate in real-time. It’s a much more efficient
and accurate form of communication when you’re not in the same
Mobile devices for imaging are transforming the way
physicians deliver bedside care. Orthopedic physician assistants at Mayo
are now able to show patients their intraoperative images to explain
the surgery while the patient is in the recovery area. “It has
transformed the way they can communicate with patients; it’s much more
effective to show patients their own images. It has really helped
improve patient communication,” said Dr. Hara.
also provide advanced visualization tools. TeraRecon provides iPad
support for its Aquarius iNtuition advanced visualization server-based
software suite with the release of AQI 4.4.5. The app is designed to
provide a convenient and expedient way to obtain access to images,
advanced visualization, and other advanced techniques, through an
intuitive, mobile, multi-touch and image-centric user interface.
can benefit from multiple image viewing apps, such as OsiriX HD, Intel
AppUp Center, RadSnap, ClearCanvas, AbbaDox Rad, and many more.
Residents can tap into teaching files like Radiology 2.0: One Night in
the ED, iRadiology, MIRC Viewer, and Surgical Radiology. GoodReader and
iAnnotate-PDF are useful for reading and making annotations. Clinical
radiological journal apps, such as the Applied Radiology Mobile Edition,
are DICOM-enabled, allowing readers to launch a DICOM viewer and scroll
through full DICOM datasets right on a tablet or smartphone.
Getting to the next level
platforms are key components to bringing medical communication to the
next level. One can only imagine how workflow might change in the era of
mobile devices that use augmented reality like Google glasses, or with
collaborative social networks that deploy cloud-based services.
According to Athenahealth CEO Jonathan Bush, the big break in
cloud-based adoption will come with the introduction of a proprietary
network where doctors access services by “friending” a laboratory,
specialist, or pharmacy to allow the entity to start paying for and
receiving online clinical information [as a] cloud-based service.
Essentially creating a bridge to the cloud.6
devices may empower radiologists to play a critical real-time role in
the health care continuum,” said Dr. Bravo. “In the end, the
requirements for meaningful use and the increasing requirements for
efficiency within the entire health care system are going to push this
technology to the forefront.”
- Cloud computing market in healthcare industry (IAAS, SAAS, PAAS,
CIS, NCIS, PACS, EMR, RIS) - global industry analysis, size, share,
trends and forecast, 2012 – 2018. Transparency Market Research.
Accessed April 25, 2013.
- Heart IT and Johns Hopkins Medicine announce the Award of NIH Grant
to include images in the Nationwide Health Information Network (NHIN).
Heart Imaging Technologies.
http://www.heartit.com/index.php/news?start=5. Posted November 30, 2011.
Accessed May 2, 2013.
- Kharat AT, Safvi A, Thind SS, Singh. Cloud computing for radiologists. Indian J Radiol Imaging. 2012;22:150-154.
- New survey finds: Hospitals see need for streamlined management of
medical images from beyond the enterprise. ETIAM.
Updated April 22, 2013. Accessed May 13, 2013.
- Zero footprint applications. Sensagent.
Accessed April 25, 2013.
- Kamp J. Boss talk: Updating doctors’ offices with the help of cloud services. The Wall Street Journal (U.S. edition). April 17, 2013:B7.