“Will the next generation of PACS be sitting on a cloud?” asked James
Philbin, PhD, Co-Director, Center for Biomedics and Imaging, Johns
Hopkins, School of Medicine, in an article he wrote in 2011 for the Journal of Digital Imaging.1
year later, Johns Hopkins is in fact implementing cloud technology to
house its own medical data and “to allow other institutions to use the
cloud to share medical images,”2 said Philbin, who went on to declare, “We think the cloud is the future of medical imaging.”2
Hopkins may have acted at just the right time, as major trends and
policy changes will significantly impact medical imaging and accelerate
adoption of cloud-computing in radiology. Not only are volumes of
diagnostic imaging data tripling in size annually, but the importance of
imaging as part of the medical record has also gained industry
recognition. Recently, meaningful use (MU) requirements added imaging to
the list of optional criteria.
cloud computing market for medical imaging in the United States (U.S.),
valued at an estimated $56.5 million in 2010, is expected to grow at a
compounded annual rate (CAGR) of 27% through 2018.3 As
diagnostic imaging extends across medical specialties, imaging data will
account for 35% of all medical data by 2015, up 7 percentage points
from 28% in 2010.3
There is clearly a need to simplify
image sharing across healthcare organizations. All of these factors
point to cloud computing. Adopting a cloud-based picture archiving and
communication system (PACS) can benefit radiology by removing upfront
software licensing fees, mitigating maintenance costs, overcoming
departmental silos, improving collaboration and data sharing with
referring physicians, and enabling upgrades with minimal downtime.
cloud can furthermore provide enhanced security because more expertise
can be put into securing the server. Once data migration to the cloud is
completed, it may be the last migration ever needed.2
addition, the cumbersome process of CD production, involving multiple
viewers and potential for file corruption, viruses, and image loss, as
well as the associated courier costs, can be all but eliminated.
the latest iteration in MU policy, the need to streamline PACS with
electronic health records (EHR) has come of age. In April, the Center
for Medicare and Medicaid Services (CMS) and the Office of the National
Coordinator (ONC) for HIT added medical imaging to the Stage 2 criteria
for MU. Imaging is now one of 10 possible objectives doctors can put on
their list of 5 objectives aimed at demonstrating MU. Specifically,
>40% of all scans and tests ordered by eligible providers (EPs) or
hospitals are accessible through certified EHR technology. Since 90% of
radiologists are classified as EPs, and eligible for the $44,000 per
physician by complying with MU criteria before 2015, many are scrambling
to participate in the Medicare EHR program. If $1.5 billion in
available incentive payments4 wasn’t enough of a carrot, heavy payment reductions for failure to meet the criteria is the stick to get radiologists going.
Where does cloud computing play a role in all of this?
those EPs who don’t already have an EHR, the biggest obstacle is
sticker shock – the initial cost of installing an EHR is high.
Client-server systems can cost $40,000 or more just to set up, and then
licensing fees, maintenance costs, updates, and patches must be added.5
But in a cloud-based PACS or EHR, since there is no hardware
installation or software licenses, the cost of implementation is
significantly less. Practices pay a monthly fee, like a utility bill, as
part of an arrangement called software as a service (SaaS).6 For a small- to mid-size radiology group, a cloud-based platform may be more appealing than a client-server system.
a cloud-based system, data are stored on external servers and can be
accessed via the Web, requiring only a computer with an Internet
connection, whereas the client-server systems store data in house,
requiring a server, hardware, and software in the physician’s office.
Although in-house servers have traditionally been the norm, practices
are increasingly switching to the cloud for a number of reasons.
benefits of cloud computing include cost and energy savings, rapid
deployment, and customer empowerment. According to the working
definition by the U.S. Commerce Department’s National Institute of
Standards and Technology (NIST), cloud computing is designed to enable
“ubiquitous, convenient, on-demand network access to a shared pool of
configurable computing resources (eg, networks, servers, storage,
applications and services) that can be rapidly provisioned and released
with minimal management effort or service provider interaction.” Simply
put, cloud technology allows users to access applications from any
computer with Internet access.
The 5 essential cloud-computing models that NIST7 lists are:
• on-demand self-service
• broad network access
• resource pooling
• rapid elasticity or expansion
• measured service
a radiology department or group adopts a cloud solution, it is
essential that it match one of these models as closely as possible to
the NIST list to reap the benefits the cloud offers image and data
3 key cloud scenarios
There are a few
different cloud solution scenarios: public, private, and hybrid. Each
has its advantages, but privacy issues often dictate which type is most
suitable for a specific industry, and how quickly an industry adopts the
In the public cloud scenario, an organization
migrates its existing IT structure to a public cloud. The
characteristics of this category include a low-level of sensitive data,
and users often represent early adopters of the technology.8
second wave of cloud adopters use the hybrid model, which combines
private and public cloud platforms. Typically, 75% of data is considered
sensitive and is migrated to the private cloud, and the remaining 25%
with less sensitive applications is sent to the public cloud to provide
Finally, departments with sensitive information
will build their own private cloud or interdepartmental private cloud.
These represent the late adopters of cloud platforms.
In all three scenarios, data transfer involves uninterrupted migration.8
PACS in the cloud is actually the “zero client” or “zero footprint
client” model, which is a Web-based PACS. The cloud-based PACS
integrates diagnostic viewing, addressing the radiologists’ need to make
diagnoses at any time from anywhere.
The sharing and
communication approach is appealing with its inherent vendor neutrality
for data storage. This allows hospitals to easily send data from the old
PACS vendor to the new PACS vendor without worrying about
A widely popular model is SaaS, or the
pay-per-use model, in which healthcare organizations pay only when they
use the solution. Although subscription fees do not necessarily include
maintenance or operating costs, SaaS lowers the high cost of software
Carestream Healthcare recently launched Vue cloud
solutions for medical imaging, a managed cloud services platform for
PACS with a pay-per-use structure. Carestream’s managed cloud services
for PACS delivers a zero footprint viewer that requires no download to
enable a quick review and exchange of clinical notes on virtually any
device, such as the iPad, without patient data residing on the hardware.
Radiologists can securely access image data, and use reporting tools,
including dictation or voice recognition, as well as advanced
3-dimensional postprocessing and automatic volume registration
comparison. Its patient-centric design enables access to disparate PACS
on local systems, regardless of location. With the vendor-neutrality
capability to take over a legacy solution, it also mitigates the need
for costly migration and enables radiologists to view prior exams
seamlessly and quickly.
Similarly, MIMcloud by MIM Software is
designed to provide a secure, low-cost way to manage, retrieve, and
archive DICOM images while sharing with colleagues. MIMpacs functions as
a central DICOM repository for imaging, registration, and contour data,
with automatic redundancy and backup.
Dell offers Dell InSite
One with an archiving-as-a-service capability, which is a cloud-based
medical archive. By consolidating and moving long-term medical archiving
to the cloud, hospitals can simplify their infrastructure and reduce
storage and retention costs.9
Depending on your
facility, a hybrid model may be just what the doctor ordered—the best of
the both worlds. “You need both the private PACS and a cloud-based PACS
if you work with specialists from other systems, and it’s easier to
collaborate through a secure cloud-based viewer,” said Joel E.
Barthelemy, Founder and Managing Director of GlobalMed, which recently
acquired EMDTransfer. Emergency Medical Data Transfer’s solution
supports an internal private cloud to exchange image and data within a
hospital network. It also provides a public cloud, ViewAnywhere Image
Access, where physicians can conduct remote clinical consultations, and
then transfer the images to another medical facility using
TransferBridge. The cloud-server can be used to post comments and write
CoActiv offers its vendor-neutral, cloud-based
EXAM-VAULT archive where images are stored locally, and offsite on
CoActiv’s cloud archive for fast access to authorized users. “The
dual-archive architecture offers us speed and affordability, not to
mention disaster protection and 100% uptime, while bringing us an
important step closer to meaningful use,” said Howard Lee, MD,
president, Northeast Radiology, Brewster, NY.
image archive was recently launched as part the existing Synapse
platform by FUJIFILM Medical Systems U.S.A., Inc. The company’s new
cloud-based image storage service, Permivault, is a service designed for
health and medical data management and supports radiologists requiring
The RIS fix
In other scenarios,
radiological information systems (RIS) may be the missing link to
connecting all of the disparate systems. Cloud-based RIS offerings can
provide an additional option to bring down the total cost of ownership
while still allowing a specialty department like radiology to use a
Siemens Healthcare recently introduced a new cloud-based option for its RIS, which is called syngoWorkflow. The
radiology department at The Chester County Hospital and Health System,
West Chester, PA, has been hosting Siemens’ enterprise
clinical/financial health IT solutions, and has now implemented the syngo Workflow cloud solution.
allows the customer easier access to one of the best RIS’s without the
headaches and difficulties of having to set up and manage the expensive
and complicated backend hardware. In addition, the customer gains
superior stability and uptime with syngo Workflow cloud
solution’s inherent high availability,” said Paul Russell Morris Jr.,
MSHA, Radiology Information Systems Administrator, The Chester County
Hospital and Health System.
Morris added, “The platform will provide a stable, cost-effective, long-term solution to our radiology information system needs.”
A cloud-based RIS/PACS SaaS model by 7 Medical Systems provides a low-cost model with a low barrier to implementation, which is particularly helpful for cost-effectively centralizing data across multiple sites.
had 3 locations using disparate systems. We chose 7 Medical Systems
because they offered an all-in-one integrated, cloud-based RIS, PACS,
and revenue cycle solution,” said Aatif Rahman, administrator of Chicago
Ridge Imaging, Oak Lawn, IL. “They also helped us migrate data from 3
systems into one. Now these locations are centralized and operate out of
the same system from scheduling to billing. Not only were we able to
automate workflows among all locations, we reduced overall costs,
improved our billing accuracy, and shortened the billing cycle.”
He added, “We are encouraged by the prospect that the solution will enable us to comply with meaningful use requirements.”
Additionally, RIS can enable radiologists to meet MU requirements by operating as a modular EHR. Fujifilm’s Synapse® RIS
Version 6.1 recently received modular EHR certification for
radiologists. Solutions receiving modular EHR certification meet
multiple criteria, whereas complete EHR certification meets all 33 ONC
criteria. “Having our Synapse RIS receive modular certification is a
tangible step towards receiving complete certification,” said Jim
Morgan, Fujifilm’s Vice President of Medical Informatics. “This means
that our radiology clients can address their meaningful use requirements
that ensure an improved workflow and allow them to more quickly qualify
for the incentives set forth by the ONC.”
Bird’s eye view
are several advantages to the cloud-based architecture, and, as Philbin
predicted, it looks like the future of medical imaging. With the recent
inclusion of imaging as an optional meaningful use objective, radiology
groups and departments are expected to turn toward cloud-based PACS,
EHR, as well as RIS platforms as a low-barrier to implementation, highly
scalable, and cost-effective option for optimizing the use of imaging
in the clinical environment.
- Philbin J, Prior F, Nagy P. Will the next generation of PACS be sitting on a cloud? J Digit Imaging. 2011;24:179-83.
- Cloud Computing in Medicine. HIT Exchange Media. http://hitexchangemedia.com/video/dHHgWxVQdXs. Accessed May 2, 2012.
- The US cloud computing market for medical imaging.
January 5, 2012. GlobalData.
- Meaningful use for radiologists. radiologyMU.org. http://www.healthmu.org/radiology/index.php. Accessed April 19, 2012.
- 5 Advantages of a cloud-based EHR for small practices. Power your
Accessed April 17, 2012.
- 5 Advantages of a cloud-based EHR for small practices. Power your
Accessed April 17, 2012.
- Final Version of NIST Cloud Computing Definition Published. IST Tech
Bet. NIST. http://www.nist.gov/itl/csd/cloud-102511.cfm. Updated
October 25, 2011. Accessed April 12, 2012.
- Alford, TA, Morton, G. The economics of cloud computing: Addressing
the benefits of infrastructure in the cloud. Booz, Allen, and Hamilton.
Updated October 26, 2009. Accessed January 3, 2012.
- Dell InSite One Medical Imaging Enterprise Archive Reaches a New
May 23, 2011. Accessed April 12, 2012.