Photo courtesy of Carestream Healthcare
Sharing — it’s a quality we all learned at a young age to aspire toward. Our parents, our teachers, our friends and our siblings (OK, maybe not our siblings!) all challenged us to learn to share. Over the past few years with implementation of the Affordable Care Act (ACA), even our federal government has created an impetus to share — to share information, to share patients, to share revenues, to share responsibility. With the scramble toward Meaningful Use (MU), which inherently requires exchange (sharing), we are finally seeing that the theory is much easier than the execution of that idea.1 Many large organizations are still struggling to share information
internally across specialties, practices and affiliates; so it’s no surprise that most are well behind the curve in understanding how to share data externally.
Whether we choose terms like exchange, interoperability or even integration, we all essentially understand the importance of data liquidity: The ability to move data across systems, and organization for the purpose of providing better patient care via access to an aggregate longitudinal patient jacket. We’ve observed health information exchanges (HIE) stand up and fall down to the tune of millions of dollars since 2009. What should be of concern is that most exchanges have, to date, focused primarily on clinical and report data. Only now is the industry beginning to tackle the challenge of image data and enablement within the exchange environment. The first step for any organization should be an internal image management strategy that provides object management that ensures data is accurate, accessible and normalized across the enterprise.
The first place most organizations start with this effort is radiology. This makes sense. Radiology has been managing image data for years. In most environments radiology was the first specialty to embrace digital systems and workflow going back to the late ’90s and early 2000s. The move to picture archiving and communication systems (PACS) and digital image management — image capture to quality control to interpretation to reporting — required that radiology move away from paper and film workflow. So it makes sense that leadership would first start there to begin developing a strategy for imaging. This approach can serve an organization well as long as it understands the inherent challenges and risks of starting at the department level.
Much has changed in the past two years related to medical imaging management. For years, the model for systems was to find a large industry solution that could provide a single integrated system (PACS, RIS). This brought value in several ways. First, it provided a simplified implementation model. Second, it put the entire onus of success on one vendor, which assisted with vendor and contract management. And finally, it provided a simplified support model giving everyone a single number to call for service and support. While this propelled the success of digital imaging into a space that was resistant to change (from film to digital), it came with baggage. Large corporations are great at selling and providing a sense of security — but most struggle with innovation. As the industry changed due to the rapid implementation of electronic medical records (EMR), HIEs, mobile technology and multiple vendor stack integrations, many large vendors began falling behind. This provided space for startups and emerging technologies to grab attention and begin to demonstrate true value to the care continuum and organization.
The subtle shift in market dynamics has continued to gain traction to the point that the term “Imaging 3.0” is part of the imaging vernacular — as introduced and defined by the American College of Radiology (ACR),2 or as others have defined it, enterprise imaging transformation (EIT).3 In its basic form, I would describe Imaging 3.0 as the move away from single vendor platforms to a modular or software stack model that includes multiple vendors, emerging technologies and rapid deployments — the ability to be nimble and to accommodate organizational changes. Many new technologies and vendors are emerging in this space and provide real solutions beyond simple radiology imaging as it was practiced for more than a decade.
The challenge with this new ecosystem and vendor pool is obvious. As with all specialties, change is slow and often resisted. As the organization moves toward an enterprise and even global strategy, old paradigms must be revisited and revised. The go-to methodology for radiology also falls into this old paradigm of resistance. If there is not sufficient in-house expertise or understanding of these emerging technologies, the old standby option is to engage a vendor (most often an incumbent) to provide a solution that meets some, maybe even most, requirements in this new imaging landscape. This, however, often results in a solution that falls short of providing an elegant, long-term solution that meets the goals and objectives of the department, organization and enterprise.
The challenge for leadership is to ensure there is a full discovery of all options prior to choosing one. One model for this is to understand the status quo: What if we do nothing? Using that benchmark, leadership can begin exploring options: Integrators, big iron, emerging technologies, outsourcing, SaaS, PaaS and cloud. Considering the components of total cost of ownership (TCO), complexity, security, interoperability, performance and support across all options, a best path will begin to emerge.
This requires a commitment of resources and seed funding. But the outcome will ensure you’re not adopting old technology models that will be expensive to support, fail to meet long-term strategic goals, and lock your organization into a long-term relationship that is both expensive and disruptive to replace.
Imaging is no longer just radiology — we all know that. Images come from everywhere: X-ray, ECG, video clips, smartphone photos (wound care), digital pathology and endoscopy just to name a few. The standards of medical imaging (DICOM) — which began in the radiology specialty to ensure protocols, image quality, accuracy and normalization — are not standard in most other specialties. As a result there are challenges around how to view, manage, and archive and share these non-DICOM objects. One model for addressing this is to force DICOM onto all objects — and this comes with its own set of problems that must be understood. Another model is to adopt IHE standards and utilize XDS and XDS-I for non-DICOM objects. This too comes with a set of problems and challenges.
On top of standards there are systems managing data everywhere across the enterprise — some integrated, some siloed, some even homegrown applications. Many decisions must be made related to how your enterprise imaging platform and initiative will be adopted across specialties, practices and the enterprise. This requires a robust and proactive governance structure. Historically, imaging has been managed at the department level. As such, the default for many organizations is the continued practice of handing the baton of responsibility to radiology for imaging oversight. The problem with this model is that a radiology-like workflow and dataflow is unique to the specialty. In addition, there are important enterprise decisions to be made related to enterprise image management that require top-level executive involvement.
Enterprise imaging governance can be expected to address many issues and decisions throughout the selection, contracting, design, build, implementation, support and rollout of its imaging strategy and software stack — especially in the Imaging 3.0 or EIT paradigm. These decisions will include adopting integrated service level agreements (SLA) across multiple vendors, imaging normalization models across systems, enterprise rollout strategies, systems evaluation for participation in the enterprise platform, data management and informatics, fiscal models for cost sharing and exchange policies locally, regionally or globally.
This governance should include executive leadership, departmental leadership (multiple “ologies”), IT leadership and clinical leadership.
John Kotter states in his book “Leading Change” that communication in an organization is typically under-managed by a factor of seven. As providers move to adopt enterprise technology there are specific communication methods that must be utilized well beyond a departmental initiative. Issues everyone faces include politics, territorialism, “us vs. them,” specialty-specific vernacular, information exhaustion and change-adverse cultures. Communicating a simple departmental initiative can be difficult; moving from department to enterprise can be Herculean. And while most have attempted to address this with an EMR initiative, it is often lost as a value in an enterprise imaging initiative. Understand that while imaging may not be as deeply imbedded across all workflow to the level that EMR/EHR might be, it is a critical and robust data pool that is utilized at every point along the entire care continuum and a communication strategy should be no less robust.
Radiology, while often the best starting point, may not fit your strategy. Many organizations have begun moving down the enterprise imaging path utilizing radiology resources, but not necessarily radiology systems. I have worked with organizations that have adopted enterprise image management in cardiology simply because it made sense with the adoption of a new system. It can make sense to leverage systems adoption as a way to fund and implement an enterprise image management platform, and in many cases radiology is not first in line. Rather than wait for your next system upgrade or replacement in radiology, you may choose to begin somewhere else. This decision requires an enterprise vision and a strategy that is fully integrated across all systems, specialties and structures. Radiology simply does not have that view of the horizon or the ability to envision an enterprising solution. This effort is more strategic and demands the engagement of senior leadership to momentarily peer away from the promise of the EHR and embrace the next big enterprising challenge of managing a critical dataset to diagnosis, treatment and disposition — namely “imaging.”
Enterprise Imaging Initiative
The more critical to the enterprise an initiative, the more carefully it must be executed. Your enterprise imaging initiative will have high visibility. It will be seen as mission critical. Leadership will expect it to propel the organizational strategy, and stakeholders will expect it to provide a competitive advantage. As you begin your efforts, your best first step is to understand the importance of this as it lives outside of radiology. Utilize your best radiology resources, but understand this is much bigger than PACS, and its success depends on moving it outside the department and out through the enterprise.
1.Versel, N. “Stage 2 Meaningful Use Off To A Slow Start”. www.healthcareitnews.com/news/ehrs-stuck-clinical-quality-reporting, accessed March 11, 2015.
2. Haines, B. “The Big Question: What is Imaging 3.0?” www.healthimaging.com/topics/practice-management/big-question-what-imaging-30, accessed March 11, 2015.
3. Fornell, D. “The Transformation to Enterprise Imaging at HIMSS 2014.” www.itnonline.com/content/transformation-enterprise-imaging-himss-2014, accessed March 11, 2015
Jef Williams is the chief operating officer at Ascendian Healthcare Consulting. He received his MBA and is a certified imaging informatics professional (CIIP) as well as project management professional (PMP). Williams has a proven track record of leading complex projects including strategic, operational and tactical large scale health IT projects.