As the leaders of patient care organizations move forward to evolve forward their IT infrastructures, they face a range of choices, challenges, and opportunities. When it comes to the imaging informatics sphere, most patient care organizations are moving to some version of a vendor-neutral archive-based strategy, in order to reorganize imaging informatics for more optimal data and image sharing and storage. VNAs are, over time, replacing outdated structures that have been radiology-centric and based on PACS (picture archiving and communications system) architecture, and putting instead in their place enterprise-wide architectures that encompass all the “-ologies,” as insiders refer to them: cardiology, dermatology, gastroenterology, and so on.
Moving forward on the journey into more advanced imaging informatics is certainly the reality at the 17-hospital, Indianapolis-based Indiana University Health (IU Health), where Kenneth Buckwalter, M.D. and David Hennon are helping to lead a transition towards a more advanced imaging informatics architecture. Dr. Buckwalter, a radiologist who has been practicing nearly 30 years, works at IU Health Physicians, the largest of IU Health’s four physician groups. Together, there are 2,500 physicians in the four groups, with 1,700 of them working within IU Health Physicians. Buckwalter works part-time within system informatics at the health system, on the same team as Hennon, who is IS director for clinical technologies. That division encompasses “pretty much everything except for the EHR,” Hennon notes, referring to the organization’s electronic health record.
Buckwalter and Hennon are leading the broad imaging informatics upgrade, moving through a variety of steps on what everyone acknowledges is a journey over time. Recently, in an internal document summarizing the organization’s overall strategy in this area, Buckwalter and Hennon wrote, “We are uniquely poised to take advantage of our existing VNA infrastructure and catapult our organization forward into the developing realm of Enterprise Imaging [EI]. Sharing images acquired in the current department silos opens up the potential to reduce costs, improve patient care, enhance our educational mission, and create opportunities for unique clinical research.”
What’s more, they wrote in the strategic planning document shared with colleagues this spring, “Building upon the lessons learned from our point-of-care ultrasound pilot will enable us to develop an appropriate governance model which is essential to set institutional priorities and serve as a clearing house for EI projects. If we can catalyze the momentum, we can build upon the enthusiasm of our early physician champions of EI and begin to coordinate activities.”
Recently, Buckwalter and Hennon spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the strategic journey around imaging informatics at IU Health. Below are excerpts from that interview.
Tell me about the clinical technologies division at IU Health?
David Hennon: Our division manages pretty much everything except for the EHR, including most of the clinical applications except for the EHR.
Kenneth Buckwalter, M.D.: And so that includes PACS, and the enterprise archive. And, in that context, I’ve worked with Dave for nearly 20 years.
Tell me a bit more about the initiative that you’re all involved in, to create an enterprise archive?
Hennon: We had been seeking funding for the infrastructure for an enterprise archive for several years, but had received the funding last year to stand up the software infrastructure to stand up an enterprise archive. And Dr. Buckwalter started our first endeavor to implement point-of-care ultrasound at one of our facilities.
Are you live with the full enterprise archive now?
Hennon: It’s live, but our spread of the technology among the various service lines is just really starting, and we’ve learned a lot of things in our first foray in integrating the systems. Ultimately, we’re making these images accessible and discoverable from within our EHR. We’re also making sure to optimize order-based, encounter-based workflows, so that everything is correctly documented.
What needs did you come into this initiative with, from a strategic standpoint?
Ken Buckwalter, M.D.: That’s a really interesting question. I would say that radiologists are both peripheral and central to enterprise imaging. It’s a bit of a paradox. This is peripheral, in that it represents a part of the infrastructure that we don’t generally roll up our sleeves and mess around with; but it’s also very much central, because, as with cardiology, we have the most experience dealing with issues like security, compliance, data integrity, and process, which are pretty much foreign for the ordering physicians, in terms of the non-radiologists. Folks who do point-of-care ultrasound, for example, are not radiologists.
The other thing that enterprise imaging does for radiology is to provide us access to images outside of radiology, which remains incredibly frustrating to us today, in terms of the silo-ing of images. We have no access to images or reports outside of what we do ourselves. So from a patient care standpoint, this is really important; this is hugely helpful. And from a quality standpoint, for the first time in this institution, there will be some transparency around how other specialties are acquiring and interpreting images. And I’m not saying they’re doing a bad job; I’m saying that for the first time, we’re able to see what they’re doing. So that if we have a CT scan of a bowel, we can correlate our findings with other data and information available. This is like the EHR for medical images. And we’re pretty convinced that this is what has to happen, and that the consolidation and implementation of all the images into this archive will be extremely helpful. What’s more, we’re going to run out of space with our PACS, so this will be extremely helpful. Eventually, all the diagnostic images will be in the enterprise archive.
What’s the timeline of the evolution of this initiative?
Hennon: Part of our challenge is really getting some attention and focus on this on a system level. This reminds me of the development of PACS in the early days—of all the arguments we made for implementing PACS. And at that time, it was all about replacing film. Of course, then as now, it’s about improving medicine, to potentially improve patient care. The problem is that it’s really difficult to put a financial ROI on this, so we’re looking to put additional resources on this.
We finished our pilot in December for point-of-care ultrasound and are getting some information on that. Next, we’re working on retinal screening for diabetics. And we’re working with the vendor that provides that diagnostic technology. That area impacts our star ratings and scores for the quality rating for the hospital—what percentage of diabetic patients do we screen annually? So there is a potential return there.
So you’re about to put the retinal screening images in. When will that happen?
Hennon: We’re working to put them into a test database. So by the end of August or beginning of September, we’ll have the images screen in one location and read by ophthalmologists in another location. We’ve been working on that project for about three months. After that, we’re looking at a video pilot—video laryngoscopy. We’re trying to get our feet wet in a variety of modalities. We’ve already worked on x-rays, putting them into the archive. That wasn’t a big deal, really.
Five years from now, what would you like to say you’ve done? What’s your Nirvana, in terms of the ultimate imaging informatics architecture that you’re working on?
Hennon: The Nirvana is that every image taken in the clinical environment is in the enterprise archive and viewable from the EHR in some logical process. So it will be the EHR of clinical images.
Dr. Buckwalter, I know that you and your fellow practicing radiologists are under intensifying pressure to move faster and better, and to provide ever-better service to referring physicians. Will this ramping up of architecture and capabilities help in all of that?
Buckwalter: Yes, it will, by eliminating process waste. A patient comes in for a biopsy of a nodule. The patient arrives expecting a biopsy; and there may be wasted time, calling the physician and making sure of what the past communications were with the ordering physician. And actually, radiologists won’t necessarily be the prime beneficiaries of all this—it will be all the physicians providing care for the patients. Plus, for a hospital system that has a medical school attached to it, for a learner, this is a fantastic tool for learning. So all of these things are extremely positive and helpful.
What would you like to say to your colleagues who are healthcare IT leaders in patient care organizations across the country, about what you’ve learned so far, and where all of this is headed, at your organization, and across the healthcare system?
Hennon: People think that it’s all about the technology, and in fact, it’s not; it’s about the people and the governance process. PACS is a well-established, mature technology. It’s really about the process around the communications and the image availability. People don’t realize what’s involved—you have to establish workflow for a particular type of imaging across the enterprise. What about order-based and encounter-based workflow, to make sure that processes are occurring as needed, and that you’re doing the right things in terms of documenting for reimbursement? The technology is actually the simple piece. It’s all these other things that are the difficult piece, as you roll out things like this across an organization.
