storage for electronic health care systems
TRANSCRIPT
8/4/2019 Storage for Electronic Health Care Systems
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STORAGE FOR
ELECTRONICHEALTH
CARE SYSTEMS
With all of the uncertaintysurrounding electronic healthrecords, one thing is for sure:You’ll be storing more data, withmore protection and for longertimes. Learn how to accomplishthat without breaking the bank.
By Al Gallant
INSIDE :
+ STORAGE FOR
HEALTH CARE
APPLICATIONS
+ RADIOLOGY
INFORMATION
SYSTEM/PICTURE
ARCHIVING AND
COMMUNICATION
SYSTEM
+ TIERED STORAGEAND BACKUPS
+ EMERGING BEST
PRACTICES
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Storage for Health CareApplications
if you’re a health care CIO trying to understand your organization’s future stor-
age requirements, you have to consider some data points that CIOs in other indus-
tries would never worry about. For example, what is the age of majority in the
states in which your organization operates?
According to legal dictionaries, the age of majority is set by statute as the age a
person first gains the legal rights and responsibilities of an adult. But for health
care CIOs, it also marks the end of the legally required data retention period for
patients born in your facility.
The New Hampshire medical center where
I work services approximately 400 births each
year. Some of these births require extensive
medical imaging diagnostics such as a com-
puted tomography (CT) study. Typical CT
studies are made up of 256 slices, each a 500
KB image. A single study would require 128
MB of data storage. Now, for a single infant
born in New Hampshire in 2009, this 128 MB
study’s images would need to be retained until seven years after the infant reaches
the age of majority. In New Hampshire, that’s 18 years old. The total years of re-
taining this image study in storage as required by HIPPA and New Hampshire
state law is 25 years. How many non-health care CIOs do you know who worry
about their storage requirements out to 2034?
Now, take the same patient and increase the storage requirements based on the
patient’s electronic health record (EHR), which could include multiple diagnostic
images, physician orders, prescription lists, progress notes, X-rays, MRI and lab
results for every clinical visit, and all of a sudden the EHR storage requirements is
in gigabytes. Multiply this by the number of patients born each year, and the num-
ber can quickly move to terabytes.
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How many non-
health care CIOs
do you know who
worry about their
storage requirements
out to 2034?
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For many health care institutions, that’s a long-term problem. My hospital, for
example, began with digital storage of radiology images only. Now we have imagestorage requirements for cardiology, neurology, cancer, obstetrics, cosmetic sur-
gery, the spine center, orthopedics, the lab and the trauma center, with more and
more departments requesting image storage.
The largest image storage requirement we manage is for the neurology center.
Our neurology center has a process that synchronizes patient video monitoring
with electroencephalography (EEG) imaging captures, allowing the neurologist to
study a patient’s physical symptoms as the EEG records neurological events. Some
of these studies use continuous monitoring for up to four days. These video im-ages require significant amounts of disk storage. We are managing 8 terabytes
(TB) of video storage for approximately six to eight months of patient visits.
These types of health care video/imaging storage requirements are substantially
different from the data retention and storage requirements for banking, tax return
and credit cards records, and what companies like Amazon.com Inc. keep on file
regarding client purchase records.
So where does a health care CIO keep all this storage? Three places: tiered stor-
age, tiered storage and tiered storage. Image storage is static storage. Once theimage is captured, it will not be modified. Typically, the process is to capture the
image on Tier 1 storage and keep it there temporarily during clinical review. At
some point, usually within a month, the images are moved to Tier 2 storage. After
six months, the images are then moved to Tier 3 or higher because future clinical
review would not require instantaneous access to the medical images. We do this
quarterly with scripts, so that it takes very little staff time to do.
In Figure 1 (page 4), you can see an example of how to use tiered storage in a
hospital information system. Definitions of tiered storage vary greatly from ven-dor to vendor and medical organization to medical organization. This example of
tiered storage is based on raid levels, performance and cost:
I Tier 1 15 KB or greater, 146 GB Fibre Channel (FC) disk with RAID 5 and
shadowing (approximately $15 per gigabyte).
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I Tier 2 10 KB, 300 GB FC disk with RAID 5 and shadowing (approximately
$10 per gigabyte).I Tier 3 10 KB, 300 GB FC disk with RAID 5 and no shadowing (approximately
$5 per gigabyte).
I Tier 4 1 TB FATA disk with RAID 5 and no shadowing (approximately $3 per
gigabyte).
The most cost-effective way to manage image storage is with an enterprise stor-
age area network (SAN) solution. Some image vendors, especially those that want
to manage the entire imaging system, will insist on a direct-attached storage array.Most imaging vendors realize the investment a health care institution makes to a
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Figure 1: Tiered Storage for Health Care Institutions
Dual Fiber Core SANS
VideoCaptureAppliance
EHRSystem
PACSSystem
FiberDiskAppliance
Tier 1 Storage
Tier 2 Storage Tier 3 Storage
Tier 4 Storage
Fiber
DiskAppliance VirtualTapeLibrary
DeDupAppliance
Fiber
DiskAppliance
FiberDiskAppliance
Dual Core Network
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SAN solution and will work with its information systems department to use
SAN storage. One of the important things to remember when is that the Food andDrug Administration (FDA) does not require an approval process for disk storage
for medical images. If your vendor tries to tell you the storage has to be FDA-
approved, feel free to show it the actual regulation in Figure 2.
One last consideration is whether to mix clinical and other data on the same
SAN. While some device and medical application vendors will push you away
from that, the increasing integration of health care data demands at least some co-
mingling. The key is to always make sure your storage for clinical data is deliver-
ing the performance you need. I
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Figure 2: The FDA and Storage Devices
Contrary to what
you may hear from
some vendors,
the FDA does not
approve specific
storage devices for
medical use. The
language of the
regulation merely
describes generic
data storage
technologies.
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Healthy Storage Cures PACS,EMR Data Growing Pains
ALAN HOWARD
IT Director
Princeton Radiology
Better Care ThroughBetter Storage
www.compellent.com
Data-intensive image archiving, administration systems and
electronic medical records have exponentially increased
data storage and recovery needs in the healthcare industry.
Compellent is on call for the always-on IT departments at
hospitals and clinics, giving them the easy-to-use, flexible
storage system they need to provide the best patient care.
Is your storage ready for explosiv
data growth?
Read this IDC report to see how
Princeton Radiology prepared.
Analyst Brief: Dramatically Improve
Recovery and Reduce Storage Cos
for Patient Imaging Environment
Learn why easy provisioning, auto-
mated tiering and continuous data
protection give you the power toput patients first.
With the Compellent SAN, we were
able to simply add drives and allocate
that capacity without reprovisioning
servers.
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Radiology Information System/Picture
Archiving andCommunication System
a radiology information system/picture archiving and communication sys-
tem (RIS/PACS) manages medical images. RIS/PACS pioneers started serious de-
velopment work in the mid-1980s. Researchers at universities across the country
saw digital imaging as the practical solution to storing medical images. They knew
film-based medical imaging had serious limitations: It could be in only one place
at a time, usually not where it was needed. The time it took to get the film to where
it was needed was a lengthy process, and film was easy to lose in transit. Storage
of the film-based images was difficult to manage. It was bulky, heavy and fragile.
Exposure to heat, cold and sun would easily damage films.
Digital imaging eliminates these issues. The biggest benefit of digital images is
the ability to be seen by anyone, wherever they were, as long as the images adhere
to the Digital Imaging and Communications in Medicine (DICOM) standard.
DICOM also came about in the mid-1980s, created as a standard for digital imag-
ing by the American College of Radiology (ACR) and the National Electrical Man-
ufacturers Association. These two associations created a much-needed successful
relationship between the clinicians who needed digital imaging and vendors who
could build it.
DICOM PS3 is the present standard. It covers just about every medical modal-
ity, the type of medical equipment that can acquire images of the human body. A
short list of DICOM image modalities would be ultrasound, magnetic resonance
(MR), positron emission tomography, CT, endoscopy, mammograms, digital radi-
ography and computed radiography.
RIS/PACS systems are specialized computer systems that can capture DICOM
images from a host of modalities and store the images in a hierarchical file struc-
ture/database for clinical review. Even though DICOM has been around since the
1980s, it was not until 2004 that the Food and Drug Administration approved the
first RIS/PACS. Since then, all the major modality manufacturers—GE, Philips
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and Siemens, for example—have developed FDA-approved RIS/PACS systems.
The components of a RIS/PACS system that acquire FDA approval are the com-puter system that interfaces with the modality equipment and the image review
monitor. The disk or SAN storage does not require FDA approval.
RIS/PACS systems can now be found in all sizes and specialties. The vendor
market has greatly expanded from the large medical devices vendors like GE and
Philips to the niche market vendors. The cost of PACS systems is also diminishing.
At one time, the large vendors pretty much controlled the market because of their
custom interface to their modality equipment, but with the DICOM standards de-
velopment and FDA approval process, moreand more vendors are competitively driving
the market to provide lower-cost solutions.
The most significant changes are newer, Web-
based RIS/PACS systems that greatly expand
the image viewing availability by providing
cloud-based storage with Web/Internet image
viewing.
These cloud-based RIS/PACS systems aredriving down the cost of medical image storage. However, the costs of RIS/PACS
systems are still driven from the process developed in the old film image days.
Most RIS/PACS vendors still charge by the image—so it doesn’t take long for a
RIS/PACS system to become very expensive. This is why most advanced
RIS/PACS systems are limited to large health care institutions that benefit from
the long-term total cost of ownership of the hardware. They also benefit from hav-
ing many different modalities. Smaller health care providers might have only X-
ray and ultrasound modalities, making a RIS/PACS system just too costly.That’s why Web-based service providers of RIS/PACS are getting a lot of atten-
tion. The RIS/PACS provider can service multiple smaller health care service
providers easily over the Internet, sharing the central hardware resources and
spreading out the total cost of ownership.
The fasting-growing imaging development in PACS systems is three-dimen-
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Most RIS/PACS
vendors still charge
by the image—so it
doesn’t take long to
become expensive.
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sional imaging and video. Although 3-D imaging has been around since the early
1990s, it has been making dramatic health care advancement in the last four years.I have recently seen two vendors offering 3-D MRI and CT PACS systems. The
smaller vendor’s system priced out at $400,000, and the other was almost $1 mil-
lion. Keep in mind, 3-D PACS systems are not cheap.
Why 3-D? The biggest benefit and greatest impact of 3-D imaging is in surgery.
Neurological surgeons are seeing the enormous benefits of 3-D imaging when
dealing with difficult and invasive surgical procedures. Having a precise 3-D
model of a patient’s brain allows the surgeon to be more precise and less invasive
during an operation, equating to less trauma and less collateral damage. The bene-fit of a 3-D PACS system doesn’t stop at brain surgery. Three-dimensional volu-
metric images allow plastic and cosmetic surgeons to build more precise facial
models that could not be accomplished with two-dimensional scans of dental and
facial images. Three-dimensional CT modality of the gastrointestinal tract has great
benefits in bowel diagnosis. Clinical applications of 3-D CT allow for early diagno-
sis and evaluation of lymphoma, gastric carcinoma, ulcers and lesions. Three-
dimensional ultrasound is also now becoming popular and beneficial for obstetric
exams. Besides allowing parents to see very clear 3-D images of the fetus, the 3-Dultrasound also allows the clinician to visually see the fetus body development.
New surgical procedures are being developed hand in hand with the 3-D RIS/
PACS systems. Sunnyvale, Calif.-based Intuitive Surgical Inc. developed a 3-D op-
tical robotic assist surgical instrument in 1999. In 2006, the company released the
da Vinci S System model and followed that in 2009 with the da Vinci Si System
model. This robotic surgical instrument provides minimal invasive surgery for
procedures that historically were very invasive. A surgeon sits at a workstation
console using an enhanced, high-definition, 3-D optical vision endoscope and fourrobotic arms perform surgery with incisions of only 1 to 2 centimeters. The da
Vinci HD display allows for 3-D video viewing of the operative target, as well as
additional 3-D video modalities like electrocardiograms and ultrasounds. Accord-
ing to Intuitive, its system is “currently the fastest-growing treatment for prostate
cancer, which is the second-leading cause of cancer-related death in men.” I
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Tiered Storage and Backups
if your initial question was “where does a health care CIO store all this imaging
data?,” then your second question has to be, “How do I protect all this data and
make it available whenever it’s needed?” These are the main components of a data
retention and protection strategy for health care:
Tiered Storage: There are additional benefits, besides performance and cost
when using tiered storage. Tiered storage in a SAN environment allows for storage
management you wouldn’t see in a standalone storage environment. This includes
on-the-fly backup snapshots, performance
monitoring, storage reassignment across dif-
ferent tiers and multilevel SAN redundancy.
Migrating SAN logical units from mirrored
sets to nonmirrored is also easier to manage
in a SAN environment when you want to
economize on capacity for data that no longer
needs mirroring-level redundancy.
Data Snapshots: Snapshots are copies of
data elements at a point in time. The term, now heavily used in describing backup
storage, has been borrowed from photography vernacular. Good snapshot solu-
tions allow a system environment or a protected health information (PHI) data en-
vironment to take a backup at a point in time without pausing the system or
database. Virtual machine platforms such as VMware and Microsoft’s Hyper-V
can snapshot the whole operating system state to a backup file on the fly without
downtime. This backup state allows for fast restoration and full-state recovery.
Image storage solutions do similar snapshots that maintain state from a point in
time, again without taking the RIS/PACS system down. That is the correct solu-
tion for high-availability systems, which is what you should consider most
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Good snapshot
solutions allow a
system or a PHI data
environment to take
a backup without pausing.
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RIS/PACS systems. It provides one of the best high-availability options for safely
backing up PHI data.
Deduplication: Deduplication is a fairly new approach to data management. It is
simply the deletion of duplicate data elements. Backup or near-backup storage can
require a large amount of disk. Deduplication can dramatically reduce the amount
of disk storage required for backing up PHI data in a disk-to-dedupe disk environ-
ment. That’s why data deduplication is especially effective for longer-term archival
storage.
Deduplication is becoming more popular with virtual tape library (VTL) solu-tions. VTL is somewhat of a misnomer, since most VTL solutions use Serial Ad-
vanced Technology Attachment (SATA) or Fibre Attached Technology Adapted
(FATA) disk drives in a tiered storage array. SATA and FATA drives allow for
greater storage for the lowest cost. I am aware of several clinical institutions that
have completely eliminated tapes and tape drives as a backup solution. Instead,
they have installed VTL systems with deduplication as their backup strategy.
The advantages are pretty straightforward:
I Significant reduction in data backup storage;
I Very quick restoration of data from disk compared with tape;
I More secure storage in a VTL than with tapes; and
I Easy management of backup data.
Consider that tapes can be easily lost or stolen, whereas low-cost SATA or
FATA disk storage appliances are not typically lost or stolen.
Deduplication is rapidly maturing, with major vendors providing solid solu-tions. IBM, Hewlett-Packard Co., NEC Corp. and EMC Corp. all have good dedu-
plication offerings. I am biased toward the target appliance method of
deduplication where the data is pulled to an appliance and deduped at that point.
This means large amounts of data are being pushed to the appliance over a Fibre
Channel or IP SAN. Some CIOs prefer the “source” method of deduplication, in
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which the dedup software resides on many source computer systems and the
data is deduped before being sent to an appliance to be placed on the SATA andFATA storage systems. I don’t feel the distributed method of managing the dedu-
plication software is wise. A central deduplication appliance is easier to manage
and provides the best secure method of storing data. One important reminder:
Most deduplication software offerings cannot process encrypted data. This can
be a significant problem for CIOs trying to manage EHR systems and PHI data,
but it can be overcome by a topology in which data is first deduped and then en-
crypted.
DICOM Image Compression: DICOM images are PHI. Managing the compres-
sion of this type of PHI is very important for a health care CIO. Some deduplica-
tion vendors say they can dedup DICOM images, but in reality most have limited
ability to do so. There are FDA-approved third-party compression offerings avail-
able for DICOM images. The major RIS/PACS systems vendors can and do pro-
vide these compression tools to manage the backup storage of DICOM images.
This is usually offered as a backup process for DICOM images when moving the
image data from a Tier 1 storage level to an archiving or higher-tiered storage level.When working with your RIS/PACS vendor, make sure to go over this process.
Not compressing the archived medical images can become very costly.
DICOM Encryption: DICOM images can and should be encrypted. Many health
care CIOs focus only on PHI data, not PHI images. I wouldn’t forget to encrypt
any medical image when backing up or archiving the images. Losing medical im-
ages would be considered a breach of PHI data and would require a health care or-
ganization to be subject to the procedures and penalties defined under HIPAAregulations and the HITECH Act of 2009.
I really feel confident in the tape backup and archiving solution that uses hard-
ware encryption. This solution really makes any PHI data stored on tape fully
encrypted. In the event of a tape being stolen or lost, I am fully confident that the
encrypted PHI data on the tape cannot be compromised. I
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LEARN MORE ABOUT DATA DEDUPLICATION
Data deduplication1 is a relatively new technology that has two main advan-
tages: shorter backup windows and less storage consumed for backup and/or
archive. Both of those benefits can be very attractive for health care institutions
with around-the-clock medical care, extensive digital imaging requirements
and, of course, more data to come as EHR systems take hold.
Here are several resources that can help you understand this technology
more, or help your team evaluate the best solution for your organization:
I This data deduplication tutorial2 explains the basic approaches that you
have to choose from, such as inline deduplication or post processing. You’ll
also get an understanding of the hardware choices you have, along with a
table of the major vendors and their products and product features.
I If you want to get a little more depth on the same issues and understand
some of the more popular deduplication products better, “Data deduplica-
tion approaches in backup today3” will help you with that.
I For IT managers in large institutions, or with very large data stores that will
require multiple deduplication devices, an emerging approach is global data
deduplication. To understand how this works and what the main product/
technology choices are, read “Global data deduplication can simplify ad-
ministration of multiple deduplication devices4.”
1 “What is data deduplication?” http://searchstorage.techtarget.com/sDefinition/0,,sid5_gci1248105,00.html
2 “Data deduplication tutorial” http://searchdatabackup.techtarget.com/generic/0,295582,sid187_gci
1346356,00.html
3 “Data deduplication approaches in backup today” http://searchdatabackup.techtarget.com/generic/0,295582,
sid187_gci1353079,00.html
4 “Global data deduplication can simplify administration of multiple deduplication devices,” http://searchdata-
backup.techtarget.com/generic/0,295582,sid187_gci1367467,00.html
D
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When it comes to data de-duplication, most companies only offer one kind of solution. But with Quantum, you’re in control.
Our new DXi7500 offers policy-based de-duplication to let you choose the right de-duplication method for each of your backup
jobs. We provide data de-duplication that scales from small sites to the enterprise, all based on a common technology so they
can be linked by replication. And our de-duplication solutions integrate easily with tape and encryption to give you everything
you need for secure backup and retention. It’s this dedication to our customers’ range of needs that makes us the smart choice
for short-term and long-term data protection. After all, it’s your data, and you should get to choose how you protect it.
Find out what Quantum can do for you.For more information please go to www.quantum.com
© 2009 Quantum Corporation. All rights reserved.
De-boxed in
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Emerging Best Practices
in 2007, the Radiological Society of North America established at the American
College of Radiology’s (ACR’s) Intersociety Conference a Radiology Reporting
Committee (RRC) to identify and promote best practices in radiology reporting.
Here is an excerpt from the RRC report published after the committee’s June 2008
workshop:
“In order to define the best practices in structured reporting, a
technical framework is needed to store, disseminate and imple-
ment reports in software applications. A knowledge representa-
tion that enables software applications to guide radiologists as
they report cases is essential. One of the simplest and most prac-
tical knowledge representations is the report template: a list of
reporting element placeholders that prompt radiologists as they
create reports. The workshop participants recommended that
such a knowledge representation be part of a broader technical
framework for structured reporting that is based on open, stan-
dardized Web technologies such as the Extensible Markup Lan-
guage (XML). XML documents can be viewed in Web browsers
and can be edited in standard word processors (13). XML also fa-
cilitates interchange among health information systems through
industry standards such as the Health Level Seven (HL7) Clinical
Document Architecture and the Digital Imaging and Communi-
cation in Medicine Structured Reporting (DICOM-SR) protocols.”
My interpretation of this report is the ACR is focusing on establishing image
storage best practice recommendations for EHR systems. I believe using XML will
not only meet the goals for structure reporting, but it will also address authentica-
tion to software applications by integrating Security Assertion Markup Language
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TIERED STORAGE
AND BACKUPS
EMERGING BEST
PRACTICES
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with structured reporting and establishing a Web-based standard for digital image
storage management and viewing. The ACR report further states:
“The clinical report is an essential part of every imaging procedure. A
radiology report documents the study’s important components and
the interpreting physician’s analysis of the findings; it communicates
information to the referring physicians, records that information for
future use and serves as the legal record of the episode of care. In ad-
dition to its clinical function, the radiologist’s report may be used for
billing, accreditation, quality improvement, research and teaching.”
This information is confirming that images and radiology reports are legal
medical records and need to be defined as PHI and managed as such in all EHR
computer systems.
On Sept. 10, the DICOM Working Group Ten Strategic Advisory board met in
Athens, Greece. The American College of Radiology, represented by Dr. Charles
Khan, presented its latest report on structure reporting initiatives.
“[Dr. Kahn] noted that RSNA is developing a library of some 60-70 re-
porting templates and some XML middleware using [Relax NG]. He
emphasized that these templates were not standards telling one how
it must be done. Rather, they provide a record of best practices.
RSNA believes that this initiative will stimulate greater demand for
DICOM Structured Reporting that can demonstrate the benefits of
intervention and have a strong positive impact on healthcare.
Dr. Kahn also indicated that RSNA has submitted an applicationfor membership in the DICOM Standards Committee and offered to
provide support for a newly constituted Working Group Eight on
Structured Reporting.” 1
1 Minutes from the DICOM NEMA DICOM Working Group Ten Meeting Sept 10 2009 Athens Greece
17 STORAGE FOR ELECTRONIC HEALTH CARE SYSTEMS
STORAGE FOR
HEALTH CARE
APPLICATIONS
RADIOLOGY
INFORMATION
SYSTEM/PICTURE
ARCHIVING AND
COMMUNICATION
SYSTEM
TIERED STORAGE
AND BACKUPS
EMERGING BEST
PRACTICES
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EMERGING DICOM IMAGING TECHNOLOGIES
Many RIS/PACS vendors are looking at 802.11 technology to wirelessly transmitDICOM images to their PACS systems. Most RIS/PACS vendors confirm that
wireless network LANs are a critical component to manage and view images in
EHR systems.
More EHR vendors are developing procedure workflow integration to include
DICOM storage capture as well as multiple modality capture, allowing clinicians
to expedite clinical orders for labs and medications. Clinicians will be able to man-
age other EHR components such as patient demographic information before, dur-
ing or after multiple modality procedures.Emerging storage best practices are focusing on speed of DICOM image capture.
RIS/PACS systems vendors are seriously looking at solid state storage, where in
the past they relied on high-speed mechanical disk drives for initial storage cap-
ture. Solid-state storage is becoming more cost efficient and has increased dramat-
ically in size offerings. Presently, it is not unheard of to purchase 4 TB of solid-
state storage without breaking the bank. Solid-state storage brings to DICOM
image capture speed in the range of 100,000 I/O operations per second; terabytes
of flash RAID, 2 GB or better in sustained channel bandwidth to the solid-stateflash and double data rate cache measured in gigabytes. All of these improve the
speed of a RIS/PACS system to capture multiple modality DICOM images as well
as dramatically increase the speed of delivering the images for viewing.I
18 STORAGE FOR ELECTRONIC HEALTH CARE SYSTEMS
STORAGE FOR
HEALTH CARE
APPLICATIONS
RADIOLOGY
INFORMATION
SYSTEM/PICTURE
ARCHIVING AND
COMMUNICATION
SYSTEM
TIERED STORAGE
AND BACKUPS
EMERGING BEST
PRACTICES
ABOUT THE AUTHOR:
Al Gallant is the director of technical services at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
Storage for Electronic Health Care Systems is produced by CIO/IT Strategy Media,© 2009 TechTarget.
Mark Schlack, Vice President, Editorial
Al Gallant, Contributing Writer
Jacqueline Biscobing, Managing Editor
Linda Koury, Art Director of Digital Content
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