To get a “40,000-feet-up” perspective on the evolution of imaging management in hospitals and health systems, Mark Hagland gathered a distinguished panel of CIOs and other IT leaders from across the country (see box). In Part 1 of this three-part series, presented in December, the panel discussed a wide variety of topics, including prioritizing resources and ramping up to meet future needs. This time, panelists focus on the broad and intensive challenges facing CIOs, their teams and clinician leaders, as their organizations move towards enterprise-wide management.
Hagland:We talked in the first part of our discussion about some of the issues around clinician workflow. What type of progress needs to be made on the software side, on the tools side, with regard to workflow?
Tim Zoph: My hypothesis on (the enterprise-wide management of imaging) 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 these tools aren't necessarily well thought-out, but tools are 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.
Ed Shultz, M.D.: 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 there will be that meta-layer.
Hagland:How difficult will it be to build that meta-layer of software?
Lynn Witherspoon, M.D.: It will be pretty darned difficult, I would say. We've been on this path (at Ochsner Health System) for a decade. We attempted to build this meta piece — we've called it an enterprise-wide display and storage capability — with one vendor, and the first attempt failed. And the reason it floundered wasn't so much about building a common set of tools or the user interface piece of the thing; it really was about data structure. We were able to pull some significant percentage of images into the meta repository, and get a subset back to the individual user; but we were not able ever to accomplish 100 percent of the task. We're doing it over again now, with a different vendor. And we chose to do it with our PACS vendor. What's more, there's an additional level of challenge, figuring out what that enterprise-level image management layer should look like turns out to be different for different sets of doctors. One group of physicians needs more complexity in the tool, one needs less. So it's a long journey. And we should bear in mind that we're really talking about managing medical images, so it's not just DICOM-based items. We've got jpg files, scanned documents, quasi-DICOM images, and even proprietary images. So this is a very complex problem. But it's imperative that we try to do this; otherwise our physicians will really struggle to use the system, and they can't manage that level of complexity.
Hagland:In other words, getting down to a granular level here means confronting a huge mountain in the middle of the road?
John Podesta: Yes. Managing the enterprise-wide data challenge was easier with regard to the EMR, and look how long that took; and that involved just one kind of data. With imaging management, you've got data fidelity issues, among other issues. What fidelity is needed in an ER, an OR, versus data coming in from a referring physician? You've got to take all that into account in terms of middleware. Then you've got the hardware issues. Will the same types of hardware components be needed out in geographically dispersed locations, versus with EMR, where you could do thin-client? It's a far more complex environment.
Scott Grier: The needs, in second- and third-generation implementations, are driving innovation. This started out as a radiologist's tool, and quickly migrated outside the walls of the radiology department to outpatient, etc. And now with the failing of RHIOs, there will be even more requirements to provide images across borders. And with resource limitations, there will be a greater need to do this very intelligently.
Hagland:What kinds of staffing issues are emerging at this point in time, as organizations like all of yours attempt to move towards enterprise-wide imaging management?
Witherspoon: We've struggled to create an IT leader for image management, not only at the ‘ology’ level (radiology, cardiology, gastroenterology, etc.), but above it as well. We've struggled to find people with the skills, but we've also been struggling in terms of being able to pay them well enough.
Hagland:What kinds of professional and technical skills are going to be needed going forward among imaging management professionals in your organizations?
Shultz: Just as we've tried to consolidate storage and we've created storage farms for economies of scale and personnel, we've tried to do that in image management. The individual PACS do not talk very well to each other in terms of deletion of images and communication of images, so that is a challenge that will have to be mastered. There are also challenges inherent in increasing the scale of these systems. That remains a problem, including on the vendor level. Some of the vendors are saying that you could consolidate your imaging management staffing, if only you folded everything into our particular product.
Podesta: And with regard to current PACS administrators, they all started in radiology, and to get them to step outside radiology and look at image management and IT, it's tough. We have five PACS administrators at Fletcher Allen; they report to IT, but they actually sit in radiology, and the radiologists view them as ‘their’ staffers. And we're trying to spread PACS across other ‘ologies,’ but the radiologists view them in a proprietary way. So in contrast to our previous experience with EMR, everyone now ‘gets’ the EMR piece, but they don't yet ‘get’ the image management piece as much.
