Migrate your enterprise imaging to the cloud

welcome everyone to today's Webinar died

cloud migration and enterprise

imaging. Evolution's not revolutions

on behalf of Becker's healthcare. Thank you for joining

us. Before we begin. I'm

going to walk through a few quick housekeeping instructions.

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and we'll have time at the end of the hour. For a question

and answer session.

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the Q and a box. We're here to help

with that. I am pleased to turn the floor over

to Tracy buyers,

senior vice president and general manager of

Enterprise Imaging at Change Healthcare.

To introduce our presenter Tracy. I'll

turn the floor to you.

Thanks, Brian.

Well, I'm really excited and pleased

to introduce Dr Elliot Siegel.

My simple intro is that he's

a unique combination of a teacher,

a clinician,

a tech geek and a disrupter.

He's the professor and vice chair

at the University of Maryland School of Medicine

and the Department of Diagnostic Radiology,

as well as the chief of radiology and

nuclear medicine for the Veterans Affair Maryland

Health Care System.

He's the director of the Maryland

Imaging Research Technologies Laboratory

and has adjunct appointments

as professor of bioengineering

at the University of Maryland College Park

and as a professor of computer science

at the University of Maryland, Baltimore County.

Dr Siegel was responsible

for the NCS National Cancer

Image Archive and served as the workspace

lead

of the National Cancer Institute. See

a big in vivo imaging

workspace.

He's been named as radiology researcher

and radiology educator of the year

by his peers, as well as one of the top

10 radiologists.

Under his leadership,

the Villa Maryland Health Care System

became the first film Bliss

Healthcare Enterprise in the World.

He has written over 200 articles

and book chapters about packs, picture

archiving and communication systems and

digital imaging, and he's edited

six books on the topic, including

the film Lys, Radiology and secure

issues in the digital medical enterprise.

He's made more than 1000 presentations

throughout the world on a broad range of topics

involved in computer applications and imaging

and medicine.

Dr. Siegel served as symposium

chairman for the Society of Photo, Optical

and Industrial Engineers Medical Imaging

meeting for three years

and is served on the board of directors of

the Society for Imaging Informatics in

Medicine, or Sin.

He is a fellow of the American College

of Radiology and the Society

of Imaging, Informatics and Medicine.

Oh, as a leader in Clinician,

you serve two very important health

care organizations.

Tell us first about the University of Maryland

Academic Medical Center and the Veterans Affairs

Maryland health care system.

Sure happy to do that. And thanks

for the nice introduction. I appreciate

that. Um, so the University

of Maryland Medical Center is located

in Baltimore

and the it's comprised of two

hospitals. One is sort of the main

flagship institution

in 800 bed teaching hospital,

and then we have a 200 bed

community hospital. The midtown

campus, and were a major

referral center, were probably the largest

trauma center

in the country and were a major referral

center for Cancer care, neuro

care, cardiac, diabetes, endocrinology,

women and Children's health. And we

have one of the oldest and longest

running transplant programs

in the country. All the faculty

on staff, such as myself, are

also faculty physicians of the

University of Maryland School of Medicine,

and we essentially have 10

affiliated hospitals that are part

of the University of Maryland Medical

System.

I also, um,

and so in that capacity

vice chair of research

on information systems.

And then I also have a second role

in charge of radiology and nuclear

medicine for the V, a Maryland

health care system.

And in that role, I

have responsibility for radiology

nuclear medicine for the V

A hospitals in Maryland and also

in Washington, D. C and all the V

A hospitals in West Virginia,

Virginia, Maryland Health Care System

essentially is

comprised of the Baltimore V

A medical center, Loch Raven and Perry 0.5

community based outpatient clinics,

and we serve all of Maryland, including

Maryland's Eastern Shore.

We have over 1100

residents, interns and students

that rotate from the University of Maryland,

and we're physically connected by a bridge

that spans between University of Maryland

and the Baltimore

V A medical center.

And so it's interesting

for me, sort of

being at both of these institutions

for decades to sort

of see and compare and contrast

the federal facility

with the University of Maryland and academic

facility. I think the to work together, hand

in hand, synergistically, and

it's given me some combined experiences

at multiple facilities because

of all the affiliated hospitals.

Okay, well, certainly seems like it's keeping

you very busy.

Um, so you have a

proven track record? Dr. Siegel

is success. And as a thought leader,

how have you been able to bring together

all of your passions? The teacher,

the clinician, the leader And if I may say,

the technical geek side

to be on the leading edge of medicine?

Yeah, well, thanks for that. And

I think my very

favorite thing

is actually being sort of a teacher and

a mentor.

And what's been wonderful for me over

so many years is being

able to have had

so many of my students,

in turn, become teachers and mentors

for others,

and I think

that's probably the most satisfying

part of my career, and I really have had

the opportunity, I guess, partly

because health care and radiology

and specific is a relatively small community

of being able to keep up with. And I'm

really so proud of hundreds

of my former

students who

gone on to do some really amazing things.

But the next and second theme of

my career beyond

teaching and sort of being a mentor

has been as sort of a positive

disruptor,

and I know that the title of today's

discussion is Guide to Cloud

Migration and Enterprise Imaging.

Evolution's not Revolution,

but actually what's been fun for me is to

foment revolution

and that level of disruption.

And so during my career,

I've had multiple opportunities

to do that.

So, you know, one of the first opportunities

to be sort of disruptive is

one that I think is an interesting example

for our discussion.

And that is, I had the opportunity

coming right out of radiology

residency at the University of Maryland

to create the world's first film,

this radiology department.

And so it was just an incredible

paradigm shift.

And, you know, here I am just coming out of residency

and, you know, asking the question

Well, I had a background

in computer science as an undergrad

and work my way through medical school,

and it just seemed as though film was

so constraining. I mean, films

got lost, films got damaged,

films could only be in one place at a time.

And it was one of the biggest

challenges in radiology. And

that infrastructure question you

know about managing films was

something that created a lot of issues. The

other thing that I was really excited about

as a computer science geek

or computer science major

was the idea of being able to have the computer

help us out with image

diagnosis and image

interpretation and to make us better

radiologist by combining our

efforts with computers.

And, you know, this was back in the

late 19 eighties when we actually first

started shopping

for a brand new way to operate

radiology in a brand new

radiology department. So I simultaneously

came out of residency, became the head

of the department, which is sort of a strange

transition,

and then had the opportunity

to design a whole new radiology

department and to design it as

being the first department that was filmed

Liss. And so some of the disruptions associated

with that, you know, And

it was No one had done that in the world at

that point was to have images

anywhere at any time to review

all images on computer monitors

to use this standard Dycom for

all modalities, which hadn't been

really implemented

to essentially perform all studies

using digital X rays or CR,

because those were originally acquired on

film.

And, you know, we even had to work

with the lawyers who essentially told

us that one of the challenges was that

the letter of the law was that we have to save,

um, five years worth of film.

But since we weren't making film, the lawyers

couldn't figure out how we could

actually save five years worth

of film if we weren't printing it. And so

all sorts of expected and

unexpected things went associated

with this huge paradigm shift.

One of the challenges that we had was

that there was no Ethernet

at that point,

and so there was no hospital network,

and so we had to essentially set

up a completely proprietary

radiology network throughout

the hospital. And I think this is going to become

important as we talk about cloud computing

because in many ways, you know, sort

of the first tier of my experience

was I had to, within the radiology

department itself and then outside through

the rest of the hospital, do my own

wiring for the network

essentially create my own storage, my

own backup and

all the things that we take for granted.

We had to essentially all do

in the imaging department.

And so we ended up managing

to do that, managing to interface with

multiple different vendor solutions

using sort of emerging standards.

And that worked really, really well.

And then after some period of time,

essentially we were told, Well,

g, you

guys in radiology aren't really

the experts in networking.

We've got great news. The hospital has

networking people. You can join our

network. You guys in radiology are

not really the experts. And it shouldn't

be your core expertise

to store

imaging studies. And we have challenges

in radiology. Whereas the

media changed as we went from a Kodak

optical jukebox holding

a terabyte of data.

Um, and we went from these really

large platters to smaller platters

to spinning disk. You

know, the idea of us managing

all of our own migration in the radiology department,

you know, was a challenge. And we ended

up having major issues as

we ended up having to keep up

with the latest in storage technologies

and hardware and software. And

I can tell you I had probably more meetings

as the head of the radiology department in

infrastructure than I did

in issues related to radiology percent.

And so you know, somewhat ironically

today, given today's topic,

you know, the hospital. If people

made a really strong and convincing and compelling

argument that I should just be

in the role of radiology and that

I should not have to worry about

backups and archives and couldn't

I just do sort of what my own core

expertise was, and so

again we'll kind of get back to that. But I think

it's ironic that we're seeing now

this kind of next successive

discussion about the hospital now

being told that its core

is taking care of patients and medical

expertise and health care issues,

and maybe

the hospital itself, just as I

as a radiologist,

the hospital itself should not necessarily

be in the business of

archiving and backups

and networking, et cetera and

So I think you know, we can talk

about that a little bit more detail.

And so, um, I think

you know this whole question of as we

end up seeing a migration

from within the radiology department

within the hospital, to the Enterprise, to

the cloud, it's been interesting for

me to see how this

is changed progressively

during my career.

Um,

we also had some issues in disruption

between connecting the electronic

medical record, which was just emerging

for us in the media.

In around 1993 when we started,

our real hospital opened and we started

our packs operations.

And then we had an image enabled electronic

medical record

and so other things that I've had fun disrupting

in my career. Sort of, you know, since

that 27 years ago has been creating

the world's first enterprise wide

three D advanced visualization

pack system. Being

on the IBM Jeopardy came when

we play Jennings and Roger and essentially

kind of disrupting the whole idea

of what machine learning might be

able to do, you know, in

health care. And we actually did some projects

together with IBM synthesizing

the electronic medical record to summarize

the important points of it using AI

and natural language processing.

We also essentially were major

disruptors in artificial intelligence

applications and diagnostic imaging

and, more recently,

looking at augmented reality and virtual

reality technologies and

implementing them

being able to look at C T

as a substitute for conventional X rays.

And so we're now using a CT scanner,

essentially to be able to scan

with the quality of CT but

using the similar dose

with CT that we would for playing

film studies and implications of that.

And so in all of these different types of sort

of revolutions or disruptions,

it's been really fun in my career

to be involved in trying

it first and then seeing colleagues,

you know, in the hospital, other facilities,

and then having that go throughout the world and,

you know, certainly is the world's first film, this department.

We experienced tremendous amount

of media attention associated with it

and visits from all around the world

looking at sort of this new paradigm. And so

for me, I'm kind of excited at the

idea of the cloud now

essentially becoming the next example

of a really cool, disruptive technology,

and I would have to say a revolution,

you know, in addition to being a revolutionary

approach to

So it's so interesting to hear,

uh, hear your perspective and

makes me kind of laugh to think about your

favorite role as a mentor and trying to educate

your new radiology students

what it was like to operate in a world

of film. But, um,

it's, uh, it's certainly

interesting how history is continuing

to repeat itself.

It's how many

current amazing how many of my current

students have never really seen an X

ray on fame. And

when you tell them that you know,

the one of the things that was sort

of historic at the hospital was

making the transition from film to digital.

They can't really wrap their heads around

images not being digital and on

the computer. So it's kind of

fascinating to see that perspective. I

guess every once in a while, you see still see a

film on E. R. Or Grey's Anatomy

or something. But it's been

fun seeing your,

uh well. Speaking

of disruptors, one of the greatest disruptors

of late is the pandemic.

It has certainly influenced the practice of medicine

and imaging greatly. Can

you tell me a little bit about how

the pandemic has influenced the

shift to the cloud.

Yeah, well, so that pandemic has had

many different

direct areas of

impact on the practice of diagnostic

radiology.

The first thing that we saw was that the hospital

actually ended up mandating

us to significantly

curtail

our radiology operations

in some areas, for example, screening.

We stop doing screening studies.

We also stopped

doing, um, having

patients walk in that made all

of our appointments

all of our imaging studies

by appointment.

We also significantly

decreased the number of studies that were

being done in the department, especially

during the greatest peaks of

the pandemic. And the other

thing that the hospital did is it encouraged,

strongly encouraged. It's workers, including

radiologists and anyone who could

to be able to work remotely.

And this idea of working remotely

was in many ways, ironically,

something that we had wanted to do for a while.

But particularly at the

Department of Veterans Affairs, there

was a fair amount of reluctance to

have radiologists work remotely

because of

concerns about security

and privacy and and,

you know, even performance

of the systems with limited bandwidth

and So you know, the advent

of the pandemic

essentially made us

accelerate our efforts.

And so we were able to have

policies changed and get permission

to be able to do image interpretation.

We had work stations set up

when we were never able to

get them to be set up to connect

into the pack system.

Previously, and I've personally

been working at home,

you know, more days that I'm in at the hospital

over the past year and so

this transition to working remotely

has certainly opened up everyone's

eyes, not only for interpreting

radiology studies but doing tele video

conferences,

for example. And so most of the hospital

meetings that we still have

are done. Probably 99%

of the meetings I have are done remotely.

And so this created additional

strain on a limited

network,

particularly as practitioners were

making the transition to seeing their patients in

the cloud. And so the Department of Veterans

Affairs needed to sort of beef up its network.

Its capabilities modify its

policies, and all of these things

essentially encouraged cloud

solutions.

And so the idea of being able

to do interpretation and collaboration

in the cloud was really important.

I think it also demonstrated for the

data that one can

successfully stay secure

and maintain patient privacy,

you know, still, while using the

general Internet and still while utilizing

the cloud, I think of a had been

very reticent to do that.

And we've demonstrated because of these

emergency situations

that indeed we can. We're

even seeing

applications directly in patient care

where we've been able to take iPads,

put them in the intensive care so that patients

are able to interact with their families,

as in patients.

For the first time, the V A has allowed,

you know, being able to utilize programs

that can allow a patient

to be able to directly communicate

with loved ones.

And the other thing that has happened

is that we've seen an incredible amount

of variability in our volume

of studies. You know, the studies

have decreased dramatically and

then popped back up and then gone down

as different waves of the transition have occurred.

And so the potential for

the elasticity provided by

the cloud to allow us to

be able to have other people essentially

called in to help out with image interpretation

or for us to essentially provide

assistance to other hospitals

within the system. Over

the cloud has been really exciting. So

really bottom line has been that

the pandemic has certainly

been a major, major

challenge to so many of

us. But when you look at adoption

of technology and when you look at ability

to be able to utilize cloud resources,

it's really been, you know,

extraordinarily,

um, powerful accelerator

of our move to the cloud, which

I think is a good thing. I've been a major

proponent for Cloud

Technologies for quite a while,

and some of the constraints,

you know have been lifted. And I'm hoping

and expecting that many of

those will continue or well past the

pandemic so that this

acceleration towards the

cloud will not decrease.

Nor will the enthusiasm as the pandemic

starts waning over time.

Yeah, I think, Yeah, I think you're so right about

that. I know you've seen

so much change in health care and, you

know, specifically in in enterprise imaging

and such a short amount of time, from from

film lys to cloud platforms

with a i technology.

When colleagues and peers are thinking about

a cloud strategy and their vetting,

the solutions What are some key

elements that they should consider?

You know, maybe in terms of

influence on patient care, security,

scalability, efficiencies.

Yeah. So

one of the points that I'd like to emphasize

is the fact that

we think of the cloud

as being essentially a

surrogate for the way

that we handle image information.

Currently, in other words, could we do what

we're doing today? But do it,

um,

more efficiently, more cost effectively,

for example, potentially more securely.

And I think the answer to all those is yes.

But to me, I think that the cloud

offers us an opportunity to kind of think

outside the box or maybe open the box up

a little bit

and to do things that maybe we weren't before.

For example, when we made the transition

from film to digital imaging,

one of the things that we found

was that instead of looking at the images

in a static format, for example, a CT

scan of the chest,

we were able to take all the images

and stack them on top of each other.

And so, rather than moving our eyes across

the successful successive frames

of an image you can create sort of

this movie view in this movie view

allowed us to be able to see changes

because our eyes can detect change when

there's a nodule or lesion that sort

of pops in and pops out.

We also found that when we could

stack the images up, we could essentially

read more images per time because

we could read more images per time.

CT NMR were able to essentially

create thinner sections and

more complex images. And so we

saw this feedback, whereas

the switch to

imaging digitally wasn't just

that we had film, but it

was portrayed or depicted

or shown on a monitor. But we had

new capabilities with digital that we didn't

have before. Certainly, ai

types of applications are a great example of

that. And so you know, what

I would encourage colleagues to do

is to think not only of the cloud

is being infrastructure outside of the

hospital,

but also maybe provides

new possibilities for us that we don't

have locally one of the first things that

occurs to me there in radiology,

our ai types of applications,

where many of them are only available

over the cloud, the potential to be able

to do speech recognition

over the cloud, the potential to

be able to do more sharing

of data and to be able to

allow peer review, for

example, of cases or

super sub specialist consultations

to occur in the cloud. Those are all things

that are enablers that allow

us to do new things in the cloud,

not just essentially create more

efficient ways

of doing the previous things that

we had done. The idea potentially

of looking at storing genomic data,

proteomics data, other things that we don't

really potentially have storage for,

or have the expertise for the ability

to be able to work with. Third parties

that could potentially help us do analytics

and things where they could access things

safely and securely in the cloud rather

than reaching into our networks

are all really cool applications.

Um,

and so I think that we do need to

think, rethink how we're using

the cloud. And I personally

think that the same way

that we in radiology,

we're told that image

storage and image computer networking

is not our core expertise

and essentially those things moved

to the hospital level. I personally

think that hospitals should be concentrating

on health care and that hospital

it folks who are incredibly

valuable and incredibly important

should essentially be spending more of their time,

you know, with essentially hospital

applications and and doing

things that allow us to be able to be

better at analytics at safety,

etcetera.

So I think, and one of the other

examples I think is security.

And I know that there have been a lot of concerns

about security of data outside

hospitals that so many of us know,

particularly with the recent ransomware

hacks that hospitals themselves

maybe less,

um

secure than maybe

some of the most secure third

party vendors. And so it may

be that hospitals are actually easier

to access

to get in and access data

in hospital systems than in, say,

an Amazon cloud or

or Microsoft or Google Cloud,

for example. And so, you know, I

think that as, um, hackers

and ransom, where folks get more and more

sophisticated, it's going to require an

even higher level

of expertise and security.

I think it's time goes on. It just doesn't

make sense for each hospital in each

health care system

have to try to maintain that

the data has made the decision, for example,

that it's getting out of the

electronic medical record software

business. And essentially, it's going

to Cerner famously after

the data has sort of done its own

development of software.

And I think it's a great idea

to essentially go private just

because it doesn't make sense

for healthcare system to maintain

software development. And I think similarly

with regard to security, it makes sense

to essentially outsource that

scalability. The idea of efficiencies

that are, you know, gained as we

scale up and scale down. And we've seen that during

the pandemic with nature volume

chefs.

And, you know, I think of the

idea, you know, having access

to new systems, new artificial intelligence

software, all sorts of different third

party software, you know, really makes

sense also getting space

back.

I know one of the things that happened with us

is we first had our film room,

and then that film room essentially

gave us back space to be able to expand

with an MRI scanner and put some

radiology equipment. And I know

our hospitals the ones I work at,

spaces in an incredible premium,

and the potential to be able to give

back some of the incredible amount of space

that's required just for image storage.

You know, I think, is a tremendous,

um, key thing that I think we

can do with regard to

the cloud strategy.

All great points, you know. And I think about

security. I also think about

how quickly can you deploy

a fix and knowing what

the cloud really enables. You know,

thinking about how fast hackers

move and being able to instantaneously

deploy a fix rather

than having to patch all kinds of systems

across the globe, is, uh,

it's really amazing when you think about the efficiencies.

So you've obviously had experience

moving and organizations and new technologies.

So now let's talk about key stakeholders.

What are some of the features you suggest

showing stakeholders?

Yeah, so I think

some of the ones are sort of the obvious ones,

and that would be savings and, you

know, decrease in total cost of ownership.

I certainly think that from the administration's

perspective that you can really make

a compelling argument. The cost of storage

has gone down so tremendously.

I mean, if you just look at Amazon

storage, for example, it's something in the order

of magnitude of two cents a gigabyte

for standard storage. But it's about

4/10 of a penny

per gigabyte

for their glacial storage

and about a quarter

No. 1/10 of a penny per

gigabyte for their

longer term glacial archive.

And so, you know, I think it's time

has gone on, you know, whether it's Amazon

or so many other services that essentially

are offering, you know, storage.

I truly believe that when you look

at all of the different costs

that it's actually less expensive

to essentially migrate data

out to the cloud and do storage

there, particularly given the fact

that such a large percentage of hospital

information does not need

instantaneous retrieval.

But so much of it is essentially being archived.

And I think rethinking some of their strategies

can do that. You know the cost of

the space, the cost of the hardware,

the cost of keeping up with

software. One thing that nobody

seems to keep um to take

into account is the cost of the

energy and the power

related to so many

of these hardware devices. And as

we're increasingly thinking

green and being encouraged,

you know, for these energy savings.

I think that this could

be a huge way to decrease

our carbon footprint, which I think

so many of us are being more

aware of. The idea of being able to get

cutting edge applications is really important.

And I think being able to redeploy expertise

is going to be critical. So if

you ask me specifically some of the key

stakeholders and what I would talk about,

I mean for the CEO, I would just

remind her or him that data

storage is not their core business

and that I think computers,

not their store business. And I think outsourcing

those to the cloud allows hospitals

and CEOs to focus more

on what our core business actually

is. Um, staying, you know, in

the business of caring for patients, I would

tell the CEO

that from a cyber security and hospital

infrastructure perspective

that essentially it would make us

less vulnerable to attacks and less

vulnerable to all the legal

and medical implications associated

with those. I think for a c m i o.

I would tell r c m I O

that essentially the potential

to be able to utilize AI

applications Analytics, third party

applications that can essentially

extract insights from the data

is really where we should be going. And, you

know, I think a C M I o

should be spending less time worrying about

infrastructure, and you should be able

to concentrate more and have a flexible

A system as possible. And I think going

to the cloud gives us access to

so many more providers. It

also gives us access to being able to pick

and choose best of breed applications.

It used to be if I heard a really cool song

on the radio and I wanted to have

it. I'd have to go out and buy the record

or the CD.

Um, and I get maybe

my favorite song to songs that I kind

of liked a little bit and a bunch of songs that

I really didn't care that much about. Wouldn't it

be amazing to be able to go into a marketplace

where we could essentially consume on the

cloud a variety of different decision

support analytics packages,

And so that's what I tell the C m I o.

As far as the C I O. I mean, I

would speak to the C i o. Again

about essentially concentrating

their expertise and experience

and decision making on

you know, what are the best ways

that we can make our healthcare information

systems better and safer?

What are ways that are C I o can

make really good decisions about what's out

there and have the cloud as part of

our seat IOS armamentarium

to be able to deploy

all sorts of different applications the CIA

might want to have.

And to essentially reassure the c i

o that I think the future of cybersecurity

is going to be increasing

reliance on the cloud

for better security.

Yeah, I think you are. So right

now we know many people listening

today are

getting ready to take that incremental

step to get to the cloud.

So looking ahead and helping others

with their migration to the cloud, what advice

do you offer them to take one

or two steps to start that journey?

Yeah, I think the first steps

would essentially asking

these facilities to define

their own expertise. I mean, what

are the core goals of your hospital?

What are the issues? You

know, that might benefit from

the switch to the cloud. I mean, do that sort of a swat

analysis and take a look

at where you are today. And

then I think it would, you know, I would

strongly recommend that they consider

a migration strategy. I think in

this case for most facilities,

it will be in evolution. I'm

sure most facilities are already

doing so many things in the cloud already.

I mean, certainly, you know, Internet

access. Google searching,

you know, resources.

Um, for information are already,

you know, on the Internet the

idea of, um, you know,

programs such as office 3 65

that they may already be using that

essentially, I think are phenomenal examples

of the success of being able

to have hybrid systems

that allow you to be able to operate

both in the cloud but also be able

to operate when the cloud is not

available, or

in times when you

know you need to have things done

locally. I think you know, finding

another facility like yours

that has already made the transition to the cloud

is really important. And to hear

you know, what were the challenges that they

had as they ended up making

the migration and looking

at doing it incrementally deciding

whether you want to do storage in the cloud computing

in the cloud, Decide whether you want to

consume some of your applications. Microsoft

Office is one example of many many

that allow you to consume either locally

or in the cloud or a combination of two,

and then look to others who have implemented

and garner lessons from

that as well.

And so you know, I think

one thing that we tend to

do in hospital systems because we're also

busy and were also involved

in a critical mission of the hospital,

is to think, Sit down and

ask yourself the question If you were setting

all these things up from scratch

and didn't have legacy systems,

but we're pretty much starting a new

how would you set it up? And

if you know how you would set it up,

is there a pathway to being

able to get to what you

would do if you could just start today

without those legacy systems?

And I think thinking about all of those things

and then you know, finding some

really outstanding examples

of facilities who have gone to the cloud

and who have seen really tangible

gains and have done essentially

measurements of performance. There are lots of studies

that are out there that delineate,

you know, specific cost savings, performance

savings and others. I'm having

gone to the cloud, and I think paying attention to that

can be really important.

So great, thank you. This has been

really insightful, so

I'm gonna turn it over to Brian.

He's gonna offer some further instructions

because we've got some time for some Q and

A. Cool,

Yes, absolutely thank you,

Dr Siegel and Tracy for that

engaging and really informative exchange,

we will now begin today's question and answer session

as a reminder. You can submit any questions you have

by typing them into the Q and A chat

in the box on your webinar council there.

So let's go ahead and get started here. The first question

I'm going to throw out, the attendee asked.

We have struggled to handle outside films

coming from multiple areas and having multiple

PCs, systems packed systems.

Have you any experience in a similar situation,

and if so, what efforts have you

implemented to address this type of issue?

Since many of our physicians do not want to go

to multiple systems, to find their images.

Thank you.

Yeah, that's a terrific question.

And I think that this

is something that many of us have struggled

with and there are multiple

ways to be able to deal with that. But

I think the best way is to

essentially look at the ability

to be able to harmonize these

various systems

and to create a single

system that allows you to be able to

intake and input images from

multiple different packs and

to be able to integrate them into

a single system. This was a challenge

for us at the University of Maryland, where

we essentially as we ended up incorporating

additional facilities in the Baltimore

and Maryland area

into our system, we ended

up essentially finding ways

to ingest new studies that

were done interface with the pack

system and then be able to

essentially consume all of them

in one place and then send the reports

back through varying reporting systems.

And so I think this is, you know, one

area where there could be the potential

again of cloud based systems.

And so, um, rather

than just telling the radiologist

to learn how to read

from five different tax systems per se

and to sign into those systems.

Um, I think that our

experience has been consolidating

all of that into one not suggesting that these

other facilities essentially abandoned

their packs. They can continue

to have those systems,

but there are a variety of different ways

to be able to combine those.

For example, in Maryland, we have

health information exchange called Crisp

C R E S P,

and it allows.

It essentially ingests studies

from all of the different

hospital systems in Maryland

and keeps all those studies. And so

it's possible to be able to

be at anyone facilities,

a University of Maryland. And we have the capability

looking not only at reports but imaging

studies using that crisp system

obtained at Hopkins or all sorts

of other systems. And so in a similar

manner. You know, I think it's possible

to be able to do that consolidation not necessarily

at the h i t level, but even

within your own enterprise. And so

what I found is that an increasing number

of systems are doing that.

We're seeing lots of colleagues

in radiology farming, really large

groups and the tele radiology groups

increasingly paying attention to

efficiency and productivity.

And what we're finding is that the really

by far the best way to do that is

to consolidate those into a single system

and reading system.

I know that it's not easy to do that.

It's easier to say than to do.

But I think that there are a number

of entities, including entities

that provide Vienna's

vendor neutral archive solutions

that could allow you to be able to do that.

And that might not mean keeping all the data

redundantly forever. But just new studies

could be shown on your packs, and then one

could go back and retrieve their studies again. The

standards are all there to support that HL

seven and I calm.

And so I do believe

that ultimately, the best way to do that

is to combine into one system.

There's one practice that I know of in Chicago

that's incredibly efficient,

and what it does is

they have multiple different scribes

assigned for each radiologist,

and those scribes call up studies

from, say, the five hospitals

in my hypothetical case and those

imaging studies are already called up and the radiologist

just bounces from one scribe to another

and the studies are all pre arranged. But

you know that that seems like a fairly elaborate

system to get around the multiple

tax issues. But in general,

I think that the solution

moving forward is to consolidate.

And I do think there are providers that are

available to assist you

in a multi system

to be able to set that up.

So thanks for the question. It's a really good one.

Yeah. Yeah, definitely was. Thank you, Dr

Siegel. And there's been a ton of great questions. We've

really got a lot of great engagement here.

So I really appreciated

this, uh, this level of engagement from all the attendees.

So we'll dive right into the next question.

The attendee ads with more image storage

moving to the cloud. Do you see a time when

a workstation will become a single pane

of glass working from a single work list

in multiple packs. Environments using

one VR system?

Yeah, I was

keeping up with the question until it

was V r system. And so

are you talking about virtual reality system? I'm

not sure exactly what VR refers to, but

let me try and answer the question.

Um, a little bit differently.

And that is to say that, um,

I think the answer is going to be

that we will have many

different personalized

solutions for interpreting

different types of studies moving forward. So

if your question is getting at, how will

radiologists interface with

imaging studies?

I think what we're seeing already are

all sorts of different advanced visualization

companies ai companies etcetera,

coming up with their own applications. And so

if I'm doing a cardiac CT,

I may want a sub specialist

applications specifically for

that. There may be five out there, and maybe my favorite

is number three.

Um, but maybe someone else's favorite is Number

two. If I'm reading a ultrasound,

um, study that I may want

something different if I'm reading a CT study

looking at lung nodule, something different.

So what I think the future is going to

be is going to be

a work a applications

orchestrator. So I will have that piece

of glass in front of me,

and I will essentially have

the ability to program for

whatever type of radiology

study it is. I'll have an application

or maybe more than one application

that will essentially be used to

visualize and interact with that

is going to operate a lot like a

smartphone, where different people

have different favorite programs,

for whether it's email

or whether it's looking at images or

doing all sorts of different things. And

you'll be able to pick and choose what

your favorite is, um,

from many different types. And so

I think what we'll all have in common is a workflow

orchestrator. And I think there are a number of platforms

that now are emerging from some of the big

vendors, like Siemens and GE and Philips

and Cannon et cetera. But also,

other vendors are coming up with platforms,

and I think we'll all be consuming

using these types of

application orchestrators.

Um, your question

about VR. I'm assuming that

you may be talking about virtual reality

or augmented reality. It's

an area of my particular interest,

and I think at some point,

rather than having glass monitors

in front of ourselves as the resolution

for I've mentioned reality

and virtual reality increases, we've

done studies already at the University of Maryland,

where we've shown that a Microsoft

hololens, we just use the number

one version of it. There's a whole

lens to that's out now could essentially

allow you to create virtual workstations

anywhere. Stay in your office, and

you could literally move around in your office

as though they were real workstations.

And yet be able to essentially

interact with have as many monitors

that you want kind of in your virtual space.

So if we're going well into the future,

a lot of the applications that are being applied

in military applications,

for example, for a jet cockpit

are now becoming less and less expensive.

And so give it 10 or 15 years.

And I think VR or augmented

reality a r will be the way that

we interface. But it's not going to be

one size fits all. It's going to be personalized

to you, and you'll have your favorites.

And those favorites may change over time. So

really cool question. Thanks.

Yeah. Thank you, Dr Siegel. And

I think that, uh,

part of the VR could have also stand for

your voice recognition. Right. Uh, and

that would sort of feed

into that. That broader sort of augmented

reality sort of you're talking about, right? We

giving them to add to that

question based on the idea of voice recognition

being a piece of that. Yeah, thanks. I didn't think

I guess I'm sitting in future mode and didn't

even think of

a voice recognition or speech

recognition. So

thanks. And I think different

speech recognition systems will

also emerge as time goes on.

And, you know, we may be able to

essentially drive our applications

with things that are integrated in

speech recognition. I know some of the PACs

vendors are already looking at integrating

speech recognition of their own so

that you could have the images and voice

combined to create multimedia

types of reports and applications, which

is really powerful. So

I do think in the future

that will have much more flexibility.

Rather than being constrained with only one

voice recognition or one display

set of software, I think we'll have

a window into a variety

of all sorts of different types of applications.

And one thing we've done some research in is something

called gesture based reporting.

So rather than as

I'm looking at a chest X ray, you

know, dictating what I'm

seeing with a speech recognition system

to be able to have a stylist

and a tablet sort

of interface and then I could just draw little

symbols like we used to with a red wax

pencil on film.

And then those symbols themselves would

end up creating the report. We've documented

that that could be significantly faster

in a graphical way to be able

to issue a variety of reports. So

I think that, you know, we're

dealing with really all sorts of

different exciting possibilities, particularly

as we move to the cloud. So I think

both we are in visualization.

Applications are going to expand,

and we'll have lots to choose from

so that

thank you so much, Doctor Siegel. Let's

roll right into the next question here.

So the attendee asked, How long

does migration to the cloud take? What

is the resource to show to hospitals?

That cloud is the solution for future.

Yeah. I mean, I think we could probably spend the next couple of hours

on answering, Um,

some of those questions. And

I think, really, the bottom line is, is that

the benefit to the cloud

is going to depend on,

you know, your own situation, your own hospital

and your own needs. As far as rolling

things out, I think some facilities

will want to move it at slower rates

and some at faster rates. It's going to depend

on the resources that you

have the type of applications that you have.

It turns out that our

the tax system that we're using at the

Baltimore V A medical center,

um, is, uh,

change healthcare system and our vendor

change Healthcare is indeed moving,

you know, to the cloud, and it's offering

us the capability. The

tax system that we have. A University of Maryland is

currently not offering that moving forward.

And so I think to some extent it really depends

on your own information systems

and a pack systems, and

you know what their offerings are and how

they're going to be in the cloud. I would

predict in the next relatively short number

of years everyone is going to be talking about

cloud, and whether those are DNA

is whether those are packs providers. I think

even our friends epic concern

er and some of the really big E. M. R

s are going to increasingly provide

offerings that we can consume over the cloud.

So how quickly to move it over? I think really

depends on who your vendors are

what you have currently,

and I think moving over

judiciously but guided

by the experience of other facilities

is really the best way to go. As

far as documenting the benefits of the cloud.

Those cost studies are really tricky

to do because you have to take so many

things into effect. I mentioned, for example,

power savings,

Um, you know, with energy and one of

the biggest consumers of energy actually

turns out to be like. And so

there's so many subtle things that are difficult

to put into a return on investment.

Um, I just think it's going to become community

standard to be in the cloud moving

forward. And I'm applauding,

You know, some of the early pioneers who have done

that who have tried to do really good,

scientific, well thought out logical.

Um, you know, studies

to try and document

on what their savings are. I'm absolutely

convinced, based on the data that we

have, that there will be savings,

and I think that we're going to have

more efficient ways to store data

than just throwing up the dycom

repository. I think that Dycom itself

is going to be essentially changing

to a form that's still interoperable

with the legacy systems, but

that will have new mechanisms of

storing images, interacting with images

for machine learning and also

for, you know, rapid retrieval

and storage. And so I think the cloud

allows us the capability to be a lot more creative,

and I think you're going to start

seeing more and more cost

saving studies over time. When

we first had our pack system,

we were asked to do cost effectiveness

studies because no one had

one. But now nobody really

justifies attacks with a

cost effectiveness study per se,

because it's so much

taken for granted that that really is the only

way to go. And I think in 10 years

that we're all going to be moving to the cloud

without necessarily needing those, because it will

be self evident.

Great, great points there, Dr

Siegel. And with just a few minutes left,

Tracy, I want to get your take on this question,

too. So just to restate,

how long does migration to the cloud

take? And what is the resource? You

can show the hospitals that the cloud is the solution

for the future?

Yeah, that's a great question. And It's

actually one of the places in some of

our early beta site

work where we've seen huge advancements

where we're able to

make major migrations

in days instead of months.

And so historically,

when hospitals

were looking at different vendors, they were

really looking at months and sometimes years

to transition all of their data

to a new system. Uh, and

that's really a game changer now with the

cloud based on the advanced

technology. So it's very exciting. Uh,

you know, as a different

hospital systems think about making this transition.

Absolutely. Thanks for for

tackling that one, Tracy as well. Uh,

we've got just a few minutes left. We might have

time for one or two more questions

the next one

that I can be my

inbox if I can interrupt from

Stephen Link. That says, How can we best

deal with turnaround time issues for

stroke type cases when transmission times

for the new case in each prior

one, maybe 3 to 4 minutes each?

It's okay with you. I'd be happy to tackle that

one because I think it's an interesting question to

Yeah, yeah, for sure. Go ahead.

Thanks. So one of the

technologies that is,

I think will be emerging with dot

com is going to be image

compression, and I know we've had it around

for lots of years, but I

think it's very much underutilized.

And, you know, there have been lots of studies that have suggested

at compression ratios of,

you know, 8 to 1, maybe 15

to 1

for C T and M R studies.

You really can't even discern a difference

using some of the more advanced

lossy compression technologies. So

from my perspective, I think

we could probably get

transmission rates in

the cloud that were comparable

to transmission rates that were getting

locally. The other thing is that I wouldn't

advocate necessarily keeping

all new studies only in the cloud

I would advocate for a hybrid. So if

someone has just done a new study at your

facility, then rather

than having to go up to the cloud and then back

again, I think that

the hybrid approach allows you to cash

a relatively unlimited number

of hours or days of studies or some

subset, and to keep it so that

a brand new study shouldn't necessarily

in any way be dealt seriously

affected by the fact that it will eventually be

stored on the cloud. And I think that's really

the strategy for some of these hybrid

approaches. So you can store 99% of

your studies in the cloud

and still be able to have super fast turnaround

times by cashing studies

within a certain number of days or

weeks from when they're done.

So important question. Because I

think performance over the cloud

is a major issue

that we need to be really cognizant of as

we move forward. I think we can definitely

achieve similar or even improved

performance by utilizing the cloud.

But I think we just need to be judicious,

absolutely some

important distinctions there. I appreciate you

you grabbing that one for us. And

you know, we are just about out of time.

Dr. Siegel and Tracy, thank you so much

for an excellent presentation. Truly appreciate it.

Yeah, Thank you very much, Doctor Siegel.

This was excellent. And so many really positive

comments. So I appreciate you

taking the time and helping

us guide through what I think is the next

inflection point of innovation

in the enterprise imaging. So thank you.

Yeah, My pleasure. Thanks for a great job moderating.

It really made it fun. And thank you

so much for those questions

that you ask. The questions

were really perceptive and help

me underscore points that I thought were important.

So I really appreciate the

questions from the audience, too.

So thanks so much.

Yeah, we had we truly had some great

engagement on behalf of Becker's

Healthcare. I want to thank Change healthcare

for sponsoring today's webinar

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