Nobody likes downtime, particularly with a critical system such as PACS. But the effects of PACS outages have been significantly lessened at Cincinnati Children's Hospital Medical Center, which adopted a new comprehensive business continuity process based on a dedicated backup PACS that's only used during downtime.
Since adopting its new PACS business continuity process in the summer of 2011, the institution has seen improved communication, functionality, and patient care when its main PACS isn't available. The system was also judged to be cost-effective.
"It's important to note that the communication component is equally important as the technical process," said Jay Moskovitz. He shared the center's experience during a scientific session at the recent Society for Imaging Informatics in Medicine (SIIM) annual meeting in Grapevine, TX.
Cincinnati Children's is a 587-bed pediatric hospital that also includes 12 outpatient facilities and full radiology services. The institution has used PACS since 2000 and performs 225,000 imaging studies per year. It replaced its PACS in 2010.
Traditionally, Cincinnati Children's had relied on a test system as its downtime PACS to provide access to current and historical studies. This required planning, however, as the test system's IP address differed from that of the production PACS, and it wasn't straightforward to reconfigure imaging modalities to send studies to the test PACS, Moskovitz said.
Furthermore, PACS client and PACS Web viewers had to be redirected to the test PACS, and there were also tedious data reconciliation issues and licensing limitations associated with this method.
Seeking a better business continuity plan, Cincinnati Children's sought to minimize PACS downtime and simplify the use of the downtime PACS to lessen the impact on end users and improve transition and support. The center also wanted a cost-conscious solution and hoped to improve communication during downtime, Moskovitz said.
A new approach
Cincinnati Children's decided that it made the most sense to purchase a dedicated downtime business continuity PACS server, which would provide full functionality and an equivalent user experience to the production PACS during downtime, Moskovitz said. Located at an offsite disaster recovery data center, this system was purchased from the same PACS vendor (Merge Healthcare) that provides the current PACS.
The downtime PACS could offer a large subset of historical studies, which could be expanded, if desired, he said. It was also cost-effective.
The institution wanted to continue with some of the successes of the prior test PACS approach, such as continuing to perform standard end-to-end workflow and providing its cost-effectiveness. However, the new solution also had to address the issue of maintaining data integrity and ease the impact on end users, Moskovitz said.
Data integrity with the new system was maintained with the use of replicated HL7 interfaces to accommodate patient updates, orders, and results. This approach keeps patient metadata up to date, and it enables business continuance without access to the production PACS.
Flipping a switch
To reduce the effect of downtime on end users, Cincinnati Children's implemented a content management switch (F5 Networks, Seattle) to manage communication between the different servers. The switch provides a virtual IP address that all modalities and workstations are configured to communicate with, and it takes approximately a minute for the switch to redirect images from the production PACS to the downtime PACS, Moskovitz said.
"It's almost transparent to the end user," he said.
Historical studies for up to a year and a half are available to users with the new method, and the use of the virtual IP address obviates the need for client or modality configuration changes. Automatic data reconciliation is performed, as opposed to the manual reconciliation required under the old test PACS approach.
While standard planned downtime for the test PACS took an hour and was performed in the middle of the night, the new method has virtually zero downtime and tasks can be performed at any time of day. On the downside, the downtime PACS and content switch cost approximately $40,000 in equipment and licensing costs.
"Even though it seems like a lot of money, it's well worth the investment, certainly in terms of our disaster business continuance and in terms of how we do routine maintenance," Moskovitz said.
Better communication
Seeking to improve downtime communication, Cincinnati Children's developed an internal communication application it calls the Radiology Alert System (RAS). RAS, which runs on all department computers, allows radiology informatics staff to send alerts and messages using message templates and varying message priorities. These alerts and messages are sent to targeted recipients such as radiologists and technologists, as well as to high-volume providers (such as in the emergency and orthopedic departments).
Pop-up alert messages arrive in a large dialogue box to grab the user's attention. They are color-coded based on priority.
In contrast to the old method, which made it impossible to reach target groups and required multiple people and phone calls, RAS easily targets affected users and eliminates phone calls and pages to support staff, Moskovitz said. It allows support staff to be able to work on problems and provide status updates, and it can be deployed in less than a minute.
Overall, the comprehensive business continuity process has significantly improved communication, functionality, and patient care during PACS downtime, Moskovitz concluded.
