Christus Health is the fourth-largest Catholic healthcare delivery system in the United States. Based in Dallas, it includes 44 hospitals and 30,000 employees. Christus was formed in 1999 through the merger of two Catholic health systems - Sisters of Charity, based in Houston, and Incarnate Word, based in San Antonio. Christus Health Senior Vice President and CIO George Conklin spoke with Healthcare Informatics contributing editor Mark Hagland recently about the challenges and opportunities of forging a unified imaging management strategy across such a large and diverse health system.

MH: What do you see as the top three challenges facing your organization?

GC: The challenges involved are really more general and global, because we don't really parse imaging out from the rest of what we're doing. The first major challenge is the integration of vast amounts of information from a variety of different locations. You and I had talked about the concept of taking Mark Hagland's information from across many different settings, acute-care and non-acute-care, and making that information appropriately available everywhere at the point of care. So the challenge is the integration of different information from a variety of different sources. The second challenge, a related one, is developing a standardized language base that lets us identify that information in a meaningful way. It's really about standardizing how we describe something, coming up with a standardized clinical vocabulary. And the third challenge, and this directly pertains to imaging, certainly, is the quantity of data and images involved. And we're seeing that that quantity of data could conceivably begin to increase at a logarithmic rate, and that's very challenging.

MH: Do you have any 32- or 64-slice CTs yet?

GC: Yes, we do, and we have a 132-slice CT in Mexico (where the system has several hospitals, in addition to the 44 in the U.S.).

MH: What are your storage strategies, going forward?

GC: Getting information to the point of service is a direction, and storage is a piece of that. So we're approaching that from the standpoint of building or buying commodity types of storage capability. You hear people talk about cloud computing. And that's kind of the intent. Cloud computing is a little bit different in the sense that while it talks about storage, it also focuses on processing capabilities.

MH: And you're moving towards some broader geographic management, then?

GC: Yes.

MH: One thing that strikes me is that all your hospitals in the United States are in tornado- or hurricane-prone areas.

GC: That's absolutely correct; I think about it all the time. We opened a new data center in San Antonio for the whole system, on Nov. 1. And over the next several months, we're really going to begin to roll things into there. We're also going to sell those capabilities possibly for several other large healthcare organizations spread across the state of Texas. Given the ARRA opportunities, we could possibly help them develop their capabilities faster, though in a way, that would compound our storage problems.

MH: Do you have any mirroring for the San Antonio data center?

GC: Presently, we're mirroring in three locations. One location is onsite at the hospital, where they collect the initial images, and that's for a year's worth of images. Every time we create an image, we have that mirrored to San Antonio and to Houston. The hospital holds onto a year's worth of images, the San Antonio and Houston sites hold the images indefinitely. We're buying services from a co-location company in Houston, and that's temporary until we migrate all those services to a mirrored site in San Antonio, sometime in 2010, and that will be 25 miles away.

MH: What has the level of satisfaction of radiologists, cardiologists, and referring physicians, been so far with your PACS and RIS capabilities?

GC: We've maintained “five 9s” reliability - 99.999 percent of the time. And the clinicians have virtually 24/7 access to images. And they access them all the time. We have physicians working collaboratively with each other, within and outside our regions; it's easy for a physician to receive an image and to look at an image at the same time as another physician.

MH: Do you have, in effect, some teleradiology?

GC: We are using a teleradiology system in some of our smaller hospitals, but those smaller hospitals do have radiologists to do their own reads for them. But they are consulting more broadly with physicians across the system. And you raise an interesting political question as well, because even in these little tiny communities, there are radiologists there, and even though they may not be as qualified as radiologists who read hundreds of images a day, those towns want to keep their local radiologists active.

MH: How many IT professionals do you have active across the whole Christus health system?

GC: We have about 450 people in the entire system. We created a kind of matrix format to the organization when we were formed 10 years ago. There are regional staff focused on regional strategic and tactical issues, but also regionally staffed people. And the regional staff are divided between being regionally and system focused. We have a headquarters site here in Houston and one in San Antonio at the data center, and people regionally located as well.

MH: Looking at the next few years, what will be your organization's big projects in imaging?

GC: Well, we're going to continue to grow our basic imaging capabilities, along with the application of new modalities. For example, as 128-slice modalities become available, we'll add those into our sites. And we'll also expand into cardiology, oncology, and pathology as well. All the images generated by those particular disciplines will begin to move into our imaging database. So slide slices and films taken of smears, in pathology, will be digitized and entered into our database. And oncological images of tumors and other elements will come online - cardiology, the full array of images and data. All those will grow and become a part of that imaging database. All those today are still stored in separate databases.

MH: Have you achieved any cardiology integration yet?

GC: We have a cardiology IS product from one vendor, (Birmingham, Ala.-based) Emageon (recently acquired by the Boston-based Amicas), and we're presently considering moving that into the (Alpharetta, Ga.-based) McKesson base, so that we have a single archive for Mark Hagland's X-ray and other diagnostic images and cardiology images.

MH: What have been the biggest lessons learned so far, and what would your advice be for other CIOs, with regard to those lessons?

GC: There are a couple. First, around ARRA, there's going to be a limited window of opportunity when all the stars are aligned, from an operational, clinical, and IT standpoint, to successfully implement information technologies, and that will probably be within the next three or four years. Those that don't move forward fast enough won't be able to achieve that.

Second, have a focused plan, well-thought out in terms of information technologies, that gets into ARRA's still-yet-undefined, meaningful implementation of an electronic health record. And think about the size of the databases, and how you'll be able to very quickly bring monstrous amounts of information together to only bring the right information to the clinician at the point of care. And think that through very carefully, because there really aren't the tools out there to do that today. And that's why I struggle with any meaningful definition of an EHR. Because I think people view the EHR in terms of a meaningful implementation, through the lens of CPOE implementation. But to me, what makes for a meaningful implementation is the actual leveraging of the technology for both clinical and operational benefit - that's when you have an EHR. And there's not just the money piece of it, but the attention being applied to defining what meaningful means. That has not been the case to date; we've always defined it in terms of how many doctors you have using CPOE; and that, to me, is wrong.

MH: Finally, how do you handle prioritization issues across such a large and complex organization?

GC: We have a very strong and a very active strategic planning function, where lots of people get together from across the organization, to determine the strategic direction. And once we create that strategic direction, it's something that we all buy into and move ahead on.