At MD Anderson Cancer Center, Managing Image Flow on a Grand Scale

Feb. 17, 2016
Moving diagnostic imagines around and making them appropriately available is an inherently challenging prospect at the big, complex University of Texas MD Anderson Cancer Center. Kevin W. McEnery, M.D. explains how he and his colleagues are innovating in that area

Transporting, sharing, and storing diagnostic images is an inherently challenging prospect at an organization like the University of Texas MD Anderson Cancer Center, one of the world’s preeminent cancer centers. Patients who come to MD Anderson most often come by way of other patient care organizations, and often with long electronic health record (EHR) and referral trails. Not surprisingly, leaders there have been working on some of those challenges recently.

One of those leaders, Kevin W. McEnery, M.D., is a professor and is the director of innovation imaging informatics at MD Anderson. During the RSNA Conference, held in December at Chicago’s McCormick Place Convention Center, Dr. McEnery spoke with HCI Editor-in-Chief Mark Hagland regarding some of the current innovations taking place in this area. Below are excerpts from that interview.

Tell me about the challenges of moving diagnostic images around at a large, complex patient care organization like MD Anderson Cancer Center.

Well, to begin with, we’re involved with an Epic install right now; we’ve scheduled a March 3 go-live. The thing about MD Anderson is that our typical patient is from outside the Houston area; and typically, they weren’t initially diagnosed at MD Anderson. So they’ve already got a data trail. In some cases, it’s a newly diagnosed patient. And the decision to come to MD Anderson generally comes after they’ve already been worked up pretty heavily out in the community. Or they’re biopsied in the community, and are then sent to MD Anderson. Or they failed first-line community-based therapy, and will try to enter clinical trials. And that can span years.

Our conundrum was that the logistics of moving these images into our system were pretty overwhelming at times. Imagine 25,000 studies coming on CD a month, and another 5,000 coming in via the cloud a month. And we had a pretty robust way of getting these images into our system, but it required people physically moving things into our system. And it would take time to make them available. So we really needed a solution that better allowed us to take care of the logistics of the disks, and then make things much more seamless. Patients literally come to the ED or hospital with disks or flash drives. With the solution we have now, the logistics are so much easier to manage. We have a low 900 number of active users per month at MD Anderson. Users of lifeIMAGE (the Newton, Mass-based solutions provider), the solution we’re using, are the people managing the logistics of patients but a lot of clinicians will use lifeIMAGE even before their images are in the PACS [picture archiving and communications system].

You have to have a way to use and share images that isn’t so hardware-based, then, correct?

Yes. Some huge percentage of these images don’t even end up in PACS. And some of those may be, the person brought three years’ worth of images, but the doctor only needs one year. The institution doesn’t regulate what gets sent to PACS.

What are the biggest challenges you face with image transport?

In general, the biggest problem is that it gets in the way of delivering the best care to the patient. And having the images available is important for radiologists—these images are invaluable. And it’s also very important to try to understand the complex history of a patient—rather than just hypothesizing. Radiologists need to have the entire context of a patient when they interpret. Without that context, they’re speculating. And having the prior images available diminishes the speculation. lifeIMAGE makes the barrier of entry to the logistics so low that there’s no qualm about sharing images.

What’s your biggest focus as an imaging informatics leader, as we move into the future?

It’s this whole idea of the “radiologist 3.0”—the radiologist adding more value to healthcare To me, it means the radiologist actively participates in the care of the patient, becomes a legitimate colleague to the clinician and helps the clinician deliver better care to the patient. It’s a report, but it has to be in the context of being a colleague to the other clinician.

Out in the community, there are a lot of radiologists just being given two lines of history—“pain and pain.” They so often have no context. But I’m hoping as EHRs move forward that more is available. And radiologists are asking for more information. And an accurate report—if two radiologists give an accurate report, that’s one thing but if the second radiologist integrates more context into his report, I firmly believe that outcomes will improve And the radiologist needs to be more of an integrator of clinical information, and the information about the patient in order to deliver to the clinician a product that allows them to be a better and more efficient clinician. Because the clinician is trying to figure out a better way to figure out what’s going on with the patient. And the radiologist can be the sous-chef or whatever term you want to use—can help prep the clinician—that’s a good thing.

Does working with radiologists sometimes feel like the proverbial herding of cats?

We have over 100 radiologists, so sometimes, yes, it is like herding cats. But I’ve learned over the years is, you don’t herd them—just show them what they need to know. And in innovation, you don’t always get it right the first time. And don’t be wedded to one single solution. And we’re even using lifeIMAGE differently from how we first used it. People are coming up with different use cases. That’s innovation. And lifeIMAGE created a single universal viewer, and then the images go into Philips iSite. The iSite is our PACS. When the outside images get sent to PACS, they get saved permanently.

What should CIOs and CMIOs around the country know about these issues and challenges?

Radiologists want to be active participants in the care of patients, and the CIOs and CMIOs need to find active ways to get the radiologists involved in the care of the patient. And not to get the full value out of the specialty is leaving value on the table. So they should actively seek out their radiology colleagues to find out how they can better collaborate to achieve the goals of their institution.

With regard to the impending 2017 federal mandate around the requirement for referring physicians to use clinical decision support tools when ordering diagnostic imaging studies, what impact will that mandate have when it is actually implemented?

It’s going to change the relationship between radiologists and referring physicians in ways we don’t understand right now. It’s going to be a two-way street. It’s an opportunity for radiologists to add value. But the onus will also be on the radiologists, in their reports, to make recommendations based on the criteria. Someone who has a lung nodule and the referring physician wants a CT of the chest, that won’t make sense. So the radiologists need to be able to share with the clinicians what the next study is that would be best, to order. So I hope there will be more and better tools for the radiologists to support the referring physicians. So when a radiologist says, “lung nodule,” why not give the clinician a button to trigger the referring clinician to order a certain type of CT, since it was based on science and on that patient. So what you’ll see is that these are 1.0 decision support tools. I’m hoping we’ll get to more patient-specific decision support tools over time.