A look at how cloud computing is helping the medical imaging industry. The cloud is changing old mindsets, and allowing technologies, such as a vendor-neutral archive (VNA), to make health facilities more efficient and provide higher quality care.

1. Imaging In The
Cloud: A New
Era For
Radiology
Doug Rufer – Region Business Manager –
Radiology Solutions, US&C

2. Introduction
Approximately 7,300 Carestream employees
serve customers in more than 150 countries
worldwide
We hold more than 1,000
patents for technology andpatents for technology and
intellectual property
Our products are at work in
90 percent of hospitals and
clinics worldwide
We have a customer centric culture

3. Who We Are…
When you think of the world’s first proven wireless digital
radiographic detector, the first packaged X-ray film, the
first digital dental detector, or the first medical dry laser
imager…healthcare professionals around the world think
of Carestream.of Carestream.
We are a world leader in:
• Medical imaging … digital and film
• Healthcare information solutions
• Dental imaging and dental practice
management software
• Molecular imaging
• Non-destructive testing

4. Our Industry In
Transition

5. Think Back a Few Years…
Remember when there was film? And Processors?

6. To Get This?

7. Things Changed and Today Looks
Like This…

8. But Change Brings New Challenges -
Consider:
• Data is growing exponentially demanding new storage solutions
• Organizations are managing multiple silos of storage which increases
costs significantly
• Location/department focused vs. patient driven workflow
• Strict legal, retention and security requirements – how do I keep my
data safe, yet share it?
• Data Neutrality and Interoperability
• High demand for Image Exchange and Access

9. What’s Next On the Horizon?
Site C
Site D
Site A
HL7
DICOMSite D
Site B
DICOM
HL7
DICOM
•Centralized vendor neutral archive
•Storage in the “Cloud”
•Improved mHealth through access
•Higher standards of interoperability
•Focus on patient centered workflow
Central
Archive
RIS
PACS

10. Cloud Services are Changing Old Mindsets
Cloud-Based Services….
Ownership Usage
Do-It-Yourself
Services
Rendered
(SLA)
Capital
Expense
Fixed Asset
Operating
Expense
Service
And Future Financial Models

11. Cloud Services are Changing Old Mindsets
Cloud-Based Services….
Do-It-Yourself
Services
Rendered
(SLA)
Pressured by demands for lower costs, quality, safety, and care
integration, the industry has embarked on a fundamental
transformation
This paradigm shift in care and financing has driven senior
executives to rethink how they do business, where they do
business, and how they connect with others
This information revolution is focused on the goal of more
informed, patient specific decision-making

12. Cloud Services are Changing Old Mindsets
Cloud-Based Services….
Do-It-Yourself
Services
Rendered
(SLA)
The demand for IT skills is increasing rapidly
Regulatory efforts like Meaningful Use and ICD-10
Strategic EHR implementations, connections to HIEs and
necessity to join ACOs
Demand is spiking while budgets are shrinking – focus on
driving costs down while improving outcomes

13. Cloud Services are Changing Old Mindsets
Cloud-Based Services….
Do-It-Yourself
Services
Rendered
(SLA)
The infrastructure modifications required to resolve storage
growth challenges for “Big Data” and PACS images must also
produce new healthcare IT solutions that can evolve as
disruptive innovations
The developing trend in IT is away from buying technology
and towards buying the results that technology delivers and
communicating these results to their internal customers

14. Cloud Services are Changing Old Mindsets
Cloud-Based Services….
Capital Expense
Fixed Asset
Ownership
Operating
Expense
Service
Services Contracts• Cash Purchase
• Bond Financing
• Loan Financing
• Capital Lease Financing
• Pay per Procedure Payments
• Services Contracts
with predictable Unit
Price/Study and a
defined SLA
Organizations will continue to struggle with growth financing
Cloud Services is a FASB-13 Compliant method for
organizations to grow while staying nimble and managing their
cash as well as their balance sheet

15. Rise of the VNARise of the VNA

16. •A VNA is a standards-based archive that works independent of the
PACS provider and stores all data in non-proprietary interchange
No clear cut or widely accepted industry definition
What is a VNA (Vendor Neutral Archive)?
formats
•A VNA also provides context management so that information can
be transferred seamlessly between disparate PACS via DICOM and
HL-7

17. Different Archive Types
•DICOM Archive – supports storage of radiology images in
a DICOM format; most archives available today
•Multi-department Archive (radiology/cardiology) – serves
multiple department’s imaging needs
•Multimedia Archive – expands the DICOM archive to•Multimedia Archive – expands the DICOM archive to
incorporate other data types, such as JPG, MPEG, DOC,
PDF, etc. files
•Enterprise Archive – Becomes the backbone of a health
network and incorporates an MPI
•VNA – Patient-centric, open architecture archive that
supports cross document (XDS) protocols
Oosterwijk, Herman. What Is a VNA, Anyway? Publication. N.p.: Www.Healthimaginghub.com, n.d. What Is a VNA
Anyway. OTech and Teramedica. Web. 28 Mar. 2014.

18. A “True” VNA:
1. …is a medical device
2. …is scalable
3. …provides image, information, and lifecycle management
4. …manages both images and related information in a patient centric4. …manages both images and related information in a patient centric
manner accompanied by cross departmental workflow
5. …supports open standards and multiple departments with infinite
expandability
6. …maintains patient privacy and is highly secure
7. …does not require PACS migrations, new interfaces, or data
conversions when technology changes
8. …offers cloud access capabilities and works with universal viewers
Oosterwijk, Herman. What Is a VNA, Anyway? Publication. N.p.: Www.Healthimaginghub.com, n.d. What Is a VNA Anyway. OTech and
Teramedica. Web. 28 Mar. 2014.

19. Vendor Neutral Archive
Provides a centralized, redundant, clinical information
management control and archiving solution that is:
Fast, secure, independent, and scalable
Provides for patient centric workflow
Radiology:
DICOM / HL7
Other Clinical:
“Other” data, XDSCardiology:
DICOM / HL7 / “Other “data
Laboratory:
“Other” data

20. Interesting Facts…
1. 1/3 of US hospitals have a VNA1
– Today’s cost is barrier for smaller facilities
– Need to adopt cloud-based VNA solutions to contain costs
2. 1/3 of all imaging produced in the US will reside on a VNA by 20162
3. Global Cloud computing market was valued at $1.8B in 2011 and expected to grow to $6.79B by 2018 –
that’s a 21% growth rate!3that’s a 21% growth rate!3
4. Medical Images are expected to require 30% of ALL storage globally and represent 10% of US
healthcare costs4
5. 2012 KLAS survey said VNA would be central strategy of 27% of respondents5
6. Global VNA market is estimated at $165.3M in 2013 and expected to grow to $335.4M by 20186
7. Enterprise PACS purchase decisions are outpacing departmental PACS decisions7
1Vendor Neutral Archives: Strategy for health info exchange, by Ifetayo Freeman - http://www.auntminnie.com/index.aspx?sec=sup&sub=pac&pag=dis&ItemID=105215
2Benchmarkes: Imaging IT sees a sea of change, by Mike Miliard - http://www.healthcareitnews.com/news/benchmarks-imaging-it-sees-sea-change
3,4Cloud PACS and mobile apps reinvent radiology workflow, by Cristen Bolan - http://www.appliedradiology.com/Issues/2013/06/Tech-Trends/Cloud-PACS-and-mobile-apps-reinvent-
radiology-workflow.aspx
5,6,7A view of the future image exchange - http://www.appliedradiology.com/Issues/2013/11/Tech-Trends/A-view-of-the-future-image-exchange.aspx

21. Site C
Site A
CARESTREAM
Agent
HL7
• Central, consolidated archive across disparate sources
• Endless number of data sources
• Unlimited storage volume
VNA Benefits
Site D
Site B
DICOM
HL7
DICOM
DICOM
HL7
“Other” Data
XDS
CARESTREAM
XDS Registry
Clinical Data
Archive
• Data replication and complete security
• Vendor Neutrality: Data format, platform, PACS
No more data migration costs
• Integrates data from disparate clinical vendors via:
DICOM, HL7, IHE XDS Framework, XDS-I, Other
• All data types managed through one centralized system
• Patient centric view of data with clinical lifecycle management
• Backbone to true mobile healthcare

22. An Interesting Thought….
So…is PACS as we know it dead?
Will the VNA become the be-all backend
infrastructure for your enterprise?infrastructure for your enterprise?
Will “PACS” simply be a universal viewer with tools
specific to the specialist (referring, radiologist,
etc.)?
Only time will tell….

23. So is this technology takingSo is this technology taking
off?

24. Healthcare Technology Online
Top Health IT Trends
p.24

25. Are We Ready
for Imaging infor Imaging in
the Cloud?

26. Seems like the Cloud is Everywhere…
Cloud BasedCloud Based
PACS ServicesPACS Services

27. License Software vs. SaaS
Purchase a software license
Install software on a local server
HW compliance
OS requirements
Maintain software
Apply security patches
Purchase Software as a Service
Register on-line with a browser
No HW risk
No OS requirement
Software maintained in the cloud
No security patchApply security patches
Upgrade software
Downtime
Potential compatibility issue
Sharing documents by sending
Multiple copies / Version control is
difficult
Data protection depends on user
(backups)
No security patch
Upgrade in the “backcloud”
No downtime
No compatibility issue
Sharing docs by on-line access
One copy
Data protection depends on service
provider at data center

28. CIO’s biggest issues
with imaging IT
• Ensure Availability of Patient Data over a Lifetime
• Manage Unpredictable TCO with Unexpected Capital• Manage Unpredictable TCO with Unexpected Capital
Expense
• Protect Regulated Data (PHI)
• Enable Physicians Collaboration across Sites & Systems

29. On-going Cost of PACS (Archive)…
• Continuous expansion of storage capacities to absorb
the exploding production of imaging data
• Upfront capital investment in capacities which stay
unused and idle during most of their lifetime
• Unpredictable Total Cost of Ownership over the lifetime
of data (Investment, Maintenance, Expansion, Migration, Replacement)

30. Yet the Need for Collaboration…
• Ever frequent demand to get faster results on-site
or on-the-go delivered to the caregiver at the point of
care
• Disparate legacy imaging systems across multiple
distant locations.
• Difficult single-point of access across the
continuum of care

31. On-demand and Ad-hoc Collaboration
• Referring physicians can access enterprise imaging patient portfolios, including comparison
of images, reports and other supporting data
• Enables real-time collaboration between clinical users
Physician Directed Exam Sharing
Or Disruptive Innovations for Access
Simple to deploy and
maintain
• Zero overhead for high-speed performance
• Latest enterprise-access technology without
replacing legacy PACS or archives
Easy to Use
• Simplify workflow as an independent viewer or
embedded within EHR or HIS
• Simple, easy to adopt, intuitive user design
that doesn’t require dedicated training

32. Patient Directed Exam Sharing
Patients will control their individual health information portfolio.
A patient may be interested in sharing their exam information with
another person (physician or non-physician). The person with whom the
exam data is shared would have access to all the tools available for
manipulating images.manipulating images.
Report Information …

33. Access to Full Patient History, Reports, and
Notes

34. Market Demands are Creating Transitions
There are initiatives to fuse legacy Imaging IT
(PACS) and Healthcare Information Exchanges
(HIE) for patient data without fork-lifting the
existing infrastructures
There is a growing number of healthcareThere is a growing number of healthcare
organizations with a need for an information hub
supporting global workflow & ad hoc demand for
access to mobile portals for comprehensive
enterprise review and collaboration
There is a consolidation of healthcare organizations
with a need for Vendor Neutral Archives (VNAs) to
replace disparate archives and provide business
continuity with disaster recovery protection

35. Meaningful Use – The Basics
What it is – simplified…
• Guidance for health entities and providers to use medical information in a meaningful way
to improve patient outcomes
How we will do this…
• By digitally transforming our paper based healthcare system through the adoption of EHRs• By digitally transforming our paper based healthcare system through the adoption of EHRs
– Providers (Eligible Professionals)
– Hospitals (Eligible Hospitals)
• Exchange key patient information through Health Information Exchanges (HIE)
– Benefits
– Better physician collaboration
– Reduce repeat exams
– Track key data within a population
• HIPAA – Health Insurance Portability and Accountability Act – sets standards and assures
patient data communication is secure via electronic exchange

36. Why CIO’s are Considering Cloud
77%Reduce
costs
• Pay only for what we use
• Software License Savings
• Lower outside maintenance costs
• Hardware savings
• Lower labor and
support costs
To what degree would each of these factors
induce you to acquire commercial OpEx Cloud
Services?
1
Respondents could rate multiple drivers items
50%
72%
Improve
reliability
Faster time
to value
Source: IBM Market Insights, Cloud Computing Research, July 2009. n=1,090
2
3
• Improve system reliability
• Improve system performance
• Take advantage of latest functionality
• Simplify updating/upgrading
• Speed deployment
• Scale IT resources to meet needs

37. Functionality & Workflow in the Cloud
Sharing Data and Workflow
Consolidated Patient Portfolio, across multiple
departments, sites and IDNs
Single, Shared Global Patient Worklist
Common access from any location
Patient
Access
Mobile
Access
Medical
Consult
Access
Superior Clinical Imaging Functionality
Common access from any location
On site and remote Diagnostic and Clinical Review
No fork lifting existing Imaging IT infrastructures
Data Consolidation and Central
Management
Industry consolidation to replace disparate archive
infrastructures with Scalability and Redundancy
Integration with multiple systems and sites
Multi-format, flexible content Multiple Ingestion Points

38. Imaging
ConsiderationsConsiderations
of the Future

39. Imaging 3.0
What is it?
•Change process led by the ACR to ensure radiologists play a key role
in healthcare delivery and quality patient care
•Mandate to ensure radiologists remain relevant in tomorrows
healthcare delivery and not irrelevant
•
healthcare delivery and not irrelevant
•Initiative to focus on being a key consultant in the delivery of a
patient’s care once the decision has been made that imaging will play
a role
• Pre-exam consultation
• Post exam interpretation with improved recommendations
• Assisting with the care plan of the patient and consultation with the
referring physician
Source: Allen, Bibb. Speaker Toolkit Imaging 3.0 Overview and Script. Reston, VA: American College of Radiology, 14 Feb. 2013. PPT.

40. HIE – Why This Initiative Matters
1. Created as a collaboration between HIMSS and RSNA organizations
2. Sought to improve the way computer systems in healthcare share information
3. Provide data to the clinician when/where it’s needed and all patient information
can be searched based on specific standardscan be searched based on specific standards
4. Addresses areas outside of medical imaging (for example, Cardiology,
Opthamology, Pathology, Dental imaging, IT infrastructure, Pharmacy, Patient
Care Devices, etc.)
Source: IHE.net/FAQ/

41. Interoperability – XDS-I; Your VNA Must
Support This
What is XDS-I?
• XDS
• Created by IHE (Integrating the Healthcare Enterprise)
• Refers to a family of profiles that support document and image exchange in healthcare• Refers to a family of profiles that support document and image exchange in healthcare
systems
• XDS-I specifically addresses medical image communication between healthcare systems
• But What About DICOM and HL7
• Both are part of the XDS profile.
• Consider this example: DICOM and HL7 are the vocabulary and basic grammar of
integration; XDS provides the technical framework for how the language fits together and is
communicated to others
Source: Mik. “What Is The Difference Between XDS, XDS.a, XDS.b, and XDS-I?” What Is The Difference Between XDS, XDS.a, XDS.b, and XDS.I? Healthcare
IT Systems, 22 May 2012. Web. 28 Mar.2014

42. Why is Interoperability Important?
Optimal Patient Care
• Requires access to all relevant information at the right time
• Necessitates the need to share information openly to those who need it
• Eliminate redundant data entry
For IT
• Standardizes the way systems will communicate via strict adherence from vendors for
communication protocols
• Allows for best of breed solutions to be purchased while ensuring standards based
integration and communication
• Improves and simplifies system implementations and support

43. What you will get out of all this….What you will get out of all this….

44. Business Intelligence
For Radiology?
• Radiology practices have turned from “cash cows” to “cost centers”
• Outcome based models of care (like those previously mentioned) are forcing
providers to slash costs due to declining reimbursement of Medicare
payments
•• There is urgency today for radiologists to understand where inefficiencies
exist in their radiology operations; all while boosting quality and cutting costs
• Analyze 3 key areas:
• Clinical – what exams are more urgent; catching duplicate studies; educating other care
providers on best practices
• Operational – understand your modality utilization to effectively manage staffing
• IT – monitor your IT systems to be pre-emptive and avert disasters
• Start now before your CIO finally gets around to radiology
Source - Fluckinger, Don. "RSNA 2013: Radiology Survivors Will Embrace Business Intelligence." RSNA 2013: Radiology Survivors Will Embrace
Business Intelligence. TechTarget, 04 Dec. 2013. Web. 28 Mar. 2014.

45. Business Intelligence
So why is this important?
• In 2012, about 500 petabytes of data exist globally; that will expand to
greater than 25,000 petabytes by 2020*
•That much data will require tools to better analyze the stored data so
healthcare providers and facilities can make better, more informed decisions
– with the ultimate goal of reducing healthcare costs while improving patient– with the ultimate goal of reducing healthcare costs while improving patient
outcomes.
•If medical images will truly represent 30% of all data stored electronically,
there is huge opportunity for BI to be used to improve patient care, length of
stay, etc.
* Source: Gardner, Dana. "Healthcare Turns to Big Data Analytics for Improved Patient Outcomes." ZDNet. HP, 12 Dec. 2013. Web. 28 Mar. 2014. /

46. VNA: Why
Invest; What toInvest; What to
Look For

47. Why Move to a VNA?
Top 5 Reasons to Purchase a VNA
• Long Term Storage Format: A Vendor Neutral Archive is based on the DICOM industry
standard file format and protocol and XDS-I protocol.
• Reduces Risk of Data Migrations: Data migrations will be a thing of the past since a
proper VNA will mitigate the need for a site to perform one in the future due to the
standards based approach of this solution.standards based approach of this solution.
• Prevents Vendor Lock In for PACS Vendors: No more proprietary data formats. You are
free to choose what vendor/viewer/etc. best meets your organizations needs.
• Long Term Redundancy: Data replication, redundancy, life cycle management, and
business continuity. All offered when coupled with a cloud based solution. The benefit to
you: rent the long-term storage, instead of invest in storage that may not be used for years,
requiring upgrades downstream.
• Integration: A good VNA will allow for easy integration to virtually any system you have, be
it HIS, RIS or PACS solutions plus utilize open standards such as HL-7, DICOM, etc. and
be patient centric to deliver all patient information to the caregiver where and when they
need it.
Source: DeepWellArchive. "Vendor Neutral Archive: Top 5 Reasons Why to Implement a VNA." DeepWell Archival Services Electronic Medical Record
Storage Powered By ClvrTv. DeepWell Archival Services, 04 May 2011. Web. 28 Mar. 2014.

48. A Few Considerations
Look for Vendor Neutral Archives that:
•Offer an on-site and off-site (cloud) architecture
•Benefits:
Prevents your data from being in a “silo”Prevents your data from being in a “silo”
Disaster recovery built in
As technology changes, so does your archive
You don’t have to “own” the technology to move forward since
the cloud vendor makes those investments for you
Moves capital expense of an archive to an operating expense
“Own” your on-site storage for current studies and “rent” the rest
Source: Calhoun, PhD, August. "Don't Create a Vendor-neutral Silo: Why Your Image Archive Should Include the Cloud." Healthcare IT News.
Healthcare IT News, 04 Nov. 2013. Web. 28 Mar. 2014.

49. Checklist
What departments will store data on the VNA?
Have you considered workflow for all those departments when querying or
accessing data?
Will your VNA be local or in the cloud – or both?Will your VNA be local or in the cloud – or both?
What are your plans for disaster recovery?
Does your vendor support open standards?
How does your vendor index patient information on the VNA? Remember, now
all departments use accession numbers and order exams for images?

50. Checklist - Continued
What universal viewers will you use to access the data on your VNA?
Does your vendor support XDS and XDS-I protocols?
How will you manage document/image life cycles? Does your vendor support
this for long-term strategy?this for long-term strategy?
Will you connect your VNA to a local registry for cross enterprise document and
image sharing?
How will you manage access and security? Mobile access and security in
compliance with HIPPA and PHI?
Are you planning to replace your PACS? If yes, have you considered a VNA as
a driver to do that so storage and migration costs are no longer a concern for the
future?