To get a “40,000-foot” perspective on the evolution of imaging management in hospitals and health systems, HCI Senior Contributing Editor Mark Hagland gathered a distinguished panel (see box) of CIOs and other IT leaders from across the country. Among the topics discussed in this first section of the roundtable include the push towards enterprise-wide imaging management, recent learnings regarding clinician workflow, and questions about prioritizing resources.

Mark Hagland:The broad industry trend is in the direction of strategizing towards enterprise-wide management of imaging, across medical specialties and clinical services. How do you see that trend evolving in the next few years?

Chuck Podesta: What I'm seeing and have been dealing with in that area is that it's similar to what people have been trying to do from an EMR standpoint, they're trying to do with imaging. And, of course, the EMR process is a lot further along, because we've been at it for a lot longer, but the goal is to link everything together, including images, voice documents, and text. The challenge is that vendors aren't as far along in the imaging space in terms of integration. McKesson has bought up MedCon, so you have the radiology and cardiology piece under one umbrella, but it's still not integrated. And we can store images on a single platform, but making everything flow together is a different proposition.

Scott Grier: One thing that we see across the country is that, in the last 10 or 12 years, as people have moved into the PACS arena — and at least 80 percent have already done so — is that the word “strategy” is somewhat misused in this area. A lot of folks have gotten into PACS in order to keep up with their competitor organizations, to please the physicians, etc. And so we find we're doing a lot more post-implementation strategizing than pre-implementation strategizing. Now, given the current state of affairs of investments, people are asking themselves, what are we going to do to forge this enterprise world? We're going to have a lot of non-DICOM images to deal with as well as DICOM images. So the question is now, what do we now want to do in terms of acquisition to cover some other “ologies”? But it seems to us that, had there been more time from the beginning strategizing on what they wanted to do, a lot of hospitals wouldn't have to be doing what they're doing now.

Tim Zoph: We should look at how we got here, with regard to workflow. When you look back at the early evolution of PACS, it wasn't clear years ago that the workflows in radiology, cardiology, and pathology might need to be streamlined, so not only do you have diverse images, you have diverse workflows as well. And I think what will happen is what happened in the early stages of EMR development. First, you'll be building common archives; and over time, I see a maturing of the departmental workflows, in order to build common workflows and approaches.

Ed Shultz, M.D.: Yes, and we're going to see whole individual departments become like modalities, where they'll centralize their viewing and customer use as well. So there will be the individual department, plus long-term archiving with a single storage strategy, and unified access to images, as well as deep storage, so that will be a meta-layer. We will need unification at a management level as well as at a physical level, including in terms or storage.

Hagland:What are the particular challenges of unifying these processes across large health systems?

Alan Soderblom: There are many. We have 18 hospitals spread out over four states. So in the last few years, we've been taking an enterprise-wide strategic look at this, looking at performance, business continuity, and cost. For performance, being able to display remotely; for business continuity, preventing going down, copies, etc. And cost is an issue. So we've built a centralized archive using Cerner MMS. And we're creating that central archive solution, to address all the three key areas.

Hagland:What have the learnings been with regard to workflow, and actions that need to be taken?

Lynn Witherspoon, M.D.: I have a couple of thoughts. I think that “workflow” is a euphemism for understanding what doctors do — how they think, what they need to do to get their jobs done, and, at what points in the process things happen or have to happen, and how a system should respond. We've had physicians directing this process historically — and my concept, as a physician, is, yes, that's what it's all about. With regard to imaging, I paid a visit to Mayo-Jacksonville several years ago, in the context of a Siemens implementation there, and the process there was all around hanging protocols, and what image needed to appear, and where, and when. So for Mayo, in that setting, it was all about workflow, if you will. Interestingly, they had implemented, electronically, a very cumbersome process. I don't think this is revelatory. I would suggest that in circumstances where there has not been significant physician involvement in system conceptualization, design, implementation, and after-care, things haven't worked well. It would be as if I were to design a system used by architects; and I don't know anything about architecture. Certainly, this has been a pervasive issue and one that we recognize and understand requires extensive reworking. At Ochsner, we've recently acquired additional hospitals into our organization, and we're running smack into that kind of issue right now.

John Doulis, M.D.: Dr. Witherspoon is absolutely correct. What we're really talking about is thought flow. You want to click into the appropriate image as quickly as possible; you don't want to waste your time making 5,000 clicks trying to get to a single answer. What happens is, as physicians, we're interrupted in our workflow all the time. So you're there, you're muddling around trying to figure something out on the computer, and someone interrupts you anyway, or your beeper sounds off. Ed has talked about the presentation and storage layers; another issue is a services layer. That's what we're working on at Vanderbilt. We're trying to work on a services approach, just like the integrator programs.

Witherspoon: We absolutely agree with that, and we're doing the same thing here. You know, we have all the parts and pieces that we need, both for the core EMR and for PACS, but we don't have them put together. And the navigation and ability to do that is clumsy, so that architecting those services I want to access, in a way that I can go anyplace anytime as I need, and fetch what I need, that ability is really important. And in our current environment, where we've acquired a number of hospitals, and are very rapidly incorporating their needs and wishes, we're incorporating a single-sign-on context, record locator, etc., to make that happen. Our EMR is increasingly a set of services to provide a user experience that is much more integrated with the work we're trying to do, but that is hugely challenging, and requires us to think about what doctors need and when they need it, and insofar as the system can be smart enough, and can “pre-fetch” things, that's good.

Soderblom: I agree. We need to have a single set of data, but we have multiple audiences, so the way we look at it is a single source of truth in the middle of a wheel, serving different audiences as to their needs.

Hagland:How do you all feel about the issues around the resources available to pursue all these goals, and around the question of prioritization?

Soderblom: We have a mixed (clinical IT vendor) environment here, so we've formed task forces. We're actively working in cardiovascular services on unification and integration, with everyone working together; but also, we understand that different hospitals within our health system might be working with different vendors. So all of our imaging vendors realize that they need to interoperate. Part of this involves recognizing that the EMR needs to be king. We work primarily with Cerner, and we can provide for that interoperability, while working to maintain a single architecture and standards within the system.

Podesta: Things in imaging are going the same way as they did with EMR. Imaging is going in the same direction, where you're going towards single core vendors, along with image management middleware, that would pull this together into a kind of enterprise-wide imaging record.

Zoph: My hypothesis on this is that automation, the introduction of technology, and a convergence of tools, will initially make workflow more complex before it makes things better. You have multiple tools, and many demands, and these workflows now are more complex, and it's impacting productivity; and it's begging the need for standards. So I see a process where, even though these tools aren't necessarily well thought-out, they're introduced from below because of the need for image management and from above because of the need for the EMR, so you're forced to painfully work through all this to achieve optimized workflow. It will take a lot of work to make things come together in that regard.

Shultz: Yes, that's why I believe there's going to be an emerging layer of software. The idea is that in general, the departmental systems will want to maintain their optimized workflow. We don't ask the laboratory to change how they work, for the physicians. In the same way, pathologists and every other specialist group will keep their own workflow optimized. Then there will be a service layer. With 18 hospitals or multiple departmental systems, it may be that I don't even want Hospital A to see how Hospital B works, for business reasons. So we will need to build that meta-layer.

Part II Coming in January

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Roundtable Participants