Bringing down the walls

The refresh of picture archiving and communications systems triggered by the end of national contracts is almost at an end.

Trusts are now turning their attention to sharing images with different ‘ologies’, with different trusts and – shortly – other services, such as primary care. Kim Thomas reports on some of the different approaches that trusts are taking.

The dust has almost settled on the refresh of picture archiving and communications systems occasioned by the end of the contracts negotiated under the National Programme for IT.

That means trusts can now take advantage of their independence from their local service provider to innovate. So what are they doing with their new PACS – and how are vendors responding?

National policy, local impact

A common theme is the desire to ‘remove the walls’ between different disciplines within a hospital, between different trusts and – though it’s early days yet – between secondary and primary care.

The basic idea is that anybody who needs to see a particular image, wherever it’s from, should be able to do that, without having to jump through hoops.

Jane Rendall, managing director of Sectra, says a lot of trust business cases have been driven by NHS England’s ‘Five Year Forward View’ plan to close a multi-billion gap between funding and demand by 2020-21.

The report, issued towards the end of 2014, talks about the need to “break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care.”

Rendall says: “If you understand the Five Year Forward View, you basically understand the NHS market.”

A more integrated approach entails looking at imaging from the perspective of the whole enterprise, says Bernard Algayres, GE Healthcare’s general manager, radiology and enterprise imaging solutions for EMEA.

“Decisions that were taken a while ago purely by the radiology department or the cardiology department have moved one step ahead. Now we see the chief information officer defining strategy for imaging.”

Starting with the ologies – City Hospitals Sunderland

Integration of PACS with other “ologies” (ophthalmology, cardiology, medical photography, endoscopy and others) is on the cards for a number of trusts, usually starting with cardiology and gradually adding in other disciplines.

Often, this integration is supported by a vendor neutral archive to store the different images; although the big challenge is to provide solutions that can cope with the very different workflows in different disciplines.

As Charlie McCaffrey, Carestream’s managing director, notes: “A dermatologist will want a different toolset from what a radiologist wants, and from what a cardiologist wants.”

Carestream’s Clinical Collaboration Platform integrates images from its vendor neutral archive with existing workflow, while also making them available through the electronic medical record.

As well as upgrading its PACS, City Hospitals Sunderland NHS Foundation Trust is tackling the integration of images by adopting Agfa Healthcare’s Enterprise Imaging platform, a vendor neutral archive that also allows access to the images through the electronic medical record.

In the next two years, the trust plans to roll out the platform across 12 disciplines as well as radiology.

Grant Witheridge, Agfa’s UK managing director, says: “They can see the clinical and patient benefit of having all their imaging on one consolidated platform and then automated and published into the EMR so that clinicians will always see any relevant imaging.”

Linking up radiology and pathology – Salford

The ability to share images between disciplines can transform clinical practice, as Salford Royal NHS Foundation Trust found when it piloted integrated diagnostics between radiology and pathology.

As part of a trial of Sectra’s digital pathology software, the trust manually imported radiology images from its GE Healthcare PACS into the digital pathology system (a process that would be automatic in a full implementation).

This enabled clinical pathologists to review the relevant radiology images before multidisciplinary team meetings.

Dr Shahid Bashir, consultant histopathologist at the trust, believes that the ability to see radiology images is helpful, particularly in breast screening where it’s important to make sure that the appropriate area has been sampled.

But the digital availability of pathology slides in itself represents a big time-saving on current procedures. “What happens at the moment is you physically have to find the slides you need for a particular MDT.

“I need to review them before the MDT, select the slides that I am going to demonstrate to the physician, and then take them with me physically down to the MDT room.”

The digital system means that he can simply select the images he needs on the computer. A digital pathology solution, he adds, will make it easier to seek expert opinion for difficult cases and share pathology images with specialist units and colleagues in other departments.

Phil Bell, deputy CIO at Salford, sees the benefits of consolidating images from multiple disciplines in one platform, and is planning to look at a “Single PACS solution for radiology, pathology and potentially all the other areas that capture images.”

Regional approaches – Yorkshire and Manchester

As tactical extensions of LSP contracts come to an end, some trusts, including Greater Manchester and a consortium of Yorkshire trusts, are set to opt for collaborative procurements ¬ – driven, in part, by a desire to share images regionally.

Trusts want to be able to access expertise and second opinions – particularly where there is a trust with a tertiary specialism – says Richard Dormer, managing director of Insignia Medical Systems.

“For a patient to be able to say: ‘My patient record is available to the best available clinician in a region’, I think that’s where a lot of the value is.”

Equally importantly, trusts want to improve efficiency by allowing one or two on-call radiologists to serve a whole region rather than a single trust – a solution made more urgent by the shortage of radiologists.

Clouds and standards – East Midlands and Cheshire and Merseyside

Although the Image Exchange Portal is still widely used, the challenge of image-sharing is now being tackled in different ways.

The EMRAD consortium of seven trusts in the East Midlands is adopting a cloud-based PACS and VNA that will enable clinicians in each trust to see patient images held by any other trust.

The addition of the GE Centricity 360 collaboration tool means that they can also confer securely on particular cases.

Insignia has been one of the major beneficiaries of the PACS refresh, winning contracts with several trusts in the South West and Midlands.

It has developed a solution that uses DICOM and HL7 messaging to build an index of studies, enabling trusts with the Insignia PACS to share images with trusts using PACS systems from other vendors, says Dormer.

“Using these readily available, standard messages Insignia delivers a workflow engine on top to ensure that images and reports are available where and when they are needed.

“The source site is able to control which studies it is prepared to share – perhaps it only wants to share paediatrics with one other location but all studies to the local tertiary referral centre.”

A consortium of trusts in Cheshire and Merseyside uses both the Carestream PACS and radiology information system and shares a global worklist; Carestream’s Vue Connect.

But two trusts in the region currently using PACS from a different vendor can also share images, because a Carestream agent broadcasts the metadata from the two sites, enabling clinicians at all the connected trusts to access patient images.

The increased interest in allowing trusts in a region to share a single on-call radiologist is also driving a move to PACS-led reporting, says McCaffrey.

Trusts’ use of a different RIS traditionally makes it harder to report remotely, but if a radiologist uses a Carestream PACS to report on another trust’s images, the PACS will use HL7 to convert the report into a format that can be exported into the host trust’s RIS.

Next stop, the home?

Once the appropriate infrastructure is established, the logical next step will be to allow the sharing of both radiology and non-radiology images with GPs, community nurses and even with patients, in line with the Five Year Forward View.

Rendall gives the example of a community nurse visiting a patient at home, taking a picture of a bedsore and uploading it to a shared store.

It is already technically achievable, and, says Rendall, trusts are already talking about it. “More community-based care and home-based care is going to be the change in the future,” she adds. “Five years isn’t a very long time.”