Enterprise Imaging: The “New World” of Clinical Imaging & Imaging IT

April 24, 2015
A serious paradigm shift has surfaced throughout the world of medical imaging, being described as “Enterprise Imaging” (EI). What is EI? Why is it important? What are the benefits? How does one construct and effectively manage an EI strategy / program?
A serious paradigm shift has surfaced throughout the world of medical imaging, being described as “Enterprise Imaging” (EI). What is EI? Why is it important? What are the benefits? How does one construct and effectively manage an EI strategy / program?  
The foundations for building an effective EI program can be leveraged from traditional imaging and IT best-practice fundamentals. The following lays out the deliberate, innovative alignment between “imaging & imaging IT Fundamentals,” such as acquisition, management, distribution, archive, and governance, with evolving industry conditions impacting imaging and IT, such as the demand for centralization, standardization, interoperability, data integrity, and governance. 
Evolution of Imaging Technology 
For decades, medical imaging technologies and services have evolved in technology, service delivery models, and user expectations. The once siloed, analog, film, paper and manual process-based product, service and radiology-centric model has now evolved into an instantaneous, on-demand, interoperable, yubiquitous, and enterprise access-expectant demand for the most sophisticated of imaging datasets; anywhere, anytime, on any approved device, from any appropriate location and to/from any/all authorized users, internal and external to the organization.  
At the same time, medical imaging has also expanded into dozens of disparate, decentralized clinical imaging services, loosely interconnected (or not) through a maze of integrations, shared management and governance models. These are often void of imaging-centric, workflow and best-practice models. Clinical acquisition, distribution, archive, asset, and workflow management exhibit disparate environments, often without seamless interoperability. The challenge is how to effectively secure an enterprise longitudinal patient image record, throughout an enterprise environment that unites these disparate environments.  
Enterprise Imaging (EI) – Strategic Self-Assessment 
Healthcare executives are entrusted to deliver the highest quality, performance-driven imaging services throughout the enterprise, while at the same time, combat diminishing reimbursement and ever-increasing costs in doing business. The growing demand to secure physician and patient-centric access to PHI (patient health information), of which imaging data constitutes a rather significant proportion, further illuminating consideration for the development of an enterprise imaging strategy / program. To achieve this we must first clarify current state and consider the following: 
Are you confident in your organization’s ability to manage, govern, sustain, and advance imaging technologies, systems, integrations, distributions, assets, data content, services and support that meet and/or exceed your physician and patient imaging demands across the enterprise for all clinical imaging disciplines?  

Is there a recognizable EI strategy that effectively mitigates pains resulting from redistribution of imaging workflow processes and data integrity governance from a local to an EI services environment, which limits your ability to secure a data-integrity rich enterprise longitudinal patient image data record? 

Are you equipped with talented and accomplished EI professionals, well positioned to lead and govern this “new world” of imaging, while collaboratively aligning with, IT and other allied healthcare professionals influencing, or influenced by, imaging programs?  

Does your imaging information management system(s) lifecycle, SLAs (service level agreements) and image data content integrity effectively serve your entire enterprise? 

Traditional Imaging vs. Enterprise Imaging (EI) 
Let’s compare traditional imaging (TI) with the emerging trends in EI leveraging current “imaging foundations,” which are deemed essential, regardless of clinical imaging discipline:
Acquisition - (Clinical Imaging Modalities & Technologies) 
(TI) Medical imaging services have often been recognized as radiology disciplines, such as radiography (now CR or DR), CT, MRI, ultrasound, fluoroscopy, PET, Interventional, etc., or cardiology such as Echo, Cath, EP, etc. (EI) We have witnessed an explosion of clinical disciplines (gastroenterology, ophthalmology, oncology, pathology, dermatology, etc.), generating ology-specific image data; exhibiting workflow, dataflow, image data formats, archive, image management, distribution and integration models (or lack thereof), unique to each ology.  
Management - (Workflow, Dataflow, QC, Systems Administration, Integrations, Normalization & Neutralization) 
(TI) The TI model exhibits mature best-practice and standards-based processes and integrations; patient data entry, and integrity, image acquisition & QA/QC, imaging equipment and system vendor selection and management, report management, image data management, image archive and distribution. (EI) Non-traditional, disparate clinical imaging “Ologies” often reveal non-standardized, non-best practice clinical imaging workflow, dataflow, and image data management processes and practices; designed for each siloed ology workflow model. 
Distribution - (Access, Presentation, Security) 
(TI) Radiology / Cardiology image and report distribution models are also well-established, with varying methods for image distribution based on entity and service-specific PACS/RIS/EMR/Viewer sophistication, physician utilization preferences, and/or existence of HIE and/or ambulatory electronic medical records (EMRs). (EI) Access to ology-specific, non-standard or best practice based clinical imaging data content, often remains just that –ology-specific. Clinicians must typically maneuver through many independent, non-optimal integration models and toolsets to retrieve and utilize valuable, clinically-relevant image data through the course of their practice. 
Archive - (Longitudinal Patient Data Image Record, Information Lifecycle Management [ILM]) 
(TI) Image data content storage, archive, disaster recovery, and business continuity models are also well established through a variety of radiology or cardiology service models. (EI) Similar to the condition of multiple image viewer platforms, multiple storage and archive models are seldom well-integrated or integrated at all and thus require special access (if at all) to isolated equipment to access and utilize valuable patient image data. 
Governance - (Service Delivery, Resource, Assets, Process & PHI Ownership) 
(TI) Historically, every aspect of imaging services were managed and governed by a seasoned radiology or cardiology director, in close alignment with a Chief Radiologist or Cardiologist. (EI) In today’s enterprise arena, imaging services management is shared by imaging services (radiology or cardiology), the IT Department, imaging vendors, and clinical EMR specialists, such as registration and scheduling. Specialized imaging systems administration varies from the most advanced to virtually non-existent or unrecognizable, with experience and ownership varying considerably, depending upon size and complexity of organization, enterprise and/or operational culture.  
Enterprise Imaging (EI) – (New World Paradigm Shift) 
Let’s align EI trends with technological and market influences from evolving industry conditions, such as centralization, standardization, interoperability, data integrity, and governance. 
Centralization - (Enterprise vs. Ology or Entity-specific Environment) 
Attempt to visualize a multi-entity healthcare provider organization (e.g.: two to 200+ hospitals and/or clinics) whereby each entity, and associated clinically imaging disciplines within each entity, creates, distributes, and manages dozens of disparate clinical imaging datasets; each with their own data management and workflow practice model. Now consider the numerous infrastructures (systems hardware and archive), software platforms, service and support agreements, and the resource and costs demands to manage such diversity. Then factor in the cost of maintaining multiple (often duplicated) clinical imaging infrastructures, software and support models all while attempting to deliver a seamless, single-access, universal image data management and viewing process.  
Standardization - (Best Practice Standards – Enterprise vs. Ology or Entity-specific) 
Standardization (within the EI context) must address (1) normalizing patient demographics within the context of an EMPI (enterprise master patient index), (2) neutralizing imaging metadata profiles from digital imaging and communications in medicine (DICOM), Health Level-7 (HL7) and non-DICOM data formats and (3) securing any/all imaging data content through infrastructure systems, software intelligence and SME (subject matter expertise) to more effectively manage and sustain assets and support costs. Now imagine attempting to secure a single enterprise longitudinal patient image record across the enterprise while numerous entities and their respective clinical imaging services create, manage, share, and ingest image data by siloed, unique standards. In other words, no enterprise standard for managing imaging metadata or data management processes. Then imagine what happens when site, or ology-specific imaging hardware or software upgrades and/or conversions occur without a standardized enterprise governance model exercising oversight in validation testing of any/all clinical PCs or support infrastructure; often disrupting clinical services. 
Interoperability - (Seamless Ubiquitous Access – to any/all Clinically-Relevant Image Data – across Enterprise) 
Clinicians thrive upon access to any/all clinically relevant image data in a single access instance – utilizing a single viewing and data management system, enhancing their practice patterns. Clinically relevant is defined as; “Any diagnostic image data and/or supportive image data content, resulting in image data PHI (protected health information) influencing progress notes, diagnostic reports, or associated treatment plans.” 
Clearly, interoperability is essential and may be described as “ensuring vendor and organizational exchange of patient image content and demographic data such that any/all clinically-relevant data may be seamlessly accessed and managed – sensitive to each clinical ology workflow and dataflow demands – while ensuring integrity of each patient’s longitudinal patient image record throughout the enterprise.” 
Data Integrity - (Normalization & Neutralization – Enterprise Longitudinal Patient Image Record for all Imaging Ologies) 
Achieving enterprise centralization, standardization and interoperability for any/all clinically-relevant image data content throughout the enterprise has recently garnered support through industry acceptance and adoption of the vendor neutral archive (VNA) methodology. Although beyond the scope of this review, VNA can be described as: 
“An intelligent imaging software and systems solution designed to achieve neutralization of any/all clinically-relevant image data formats and/or metadata profiles into a seamless, interoperable image data management environment permitting receipt, and/or exchange of, image data content within a longitude patient image record across, and external to, the Enterprise, regardless of entity-specific systems or application architecture. Data retention, life-cycle management and image distribution models are an assumed part of a VNA environment, yet it’s the image data neutralization processes that are the cornerstone of any credible VNA.”  
Governance - (Enterprise Image Data & Systems Management Standards across all Disparate Clinical Imaging Service Models) 
Enterprise imaging clearly depicts a sophisticated, diverse set of imaging services models, functioning through a complex web of systems integration, image data normalization, and neutralization of image metadata, for any/all clinically-relevant image data. Such sophistication and diversity requires oversight and ownership at the enterprise executive level.  
The key objective is to leverage best-practice standards and expertise from imaging leaders and constituents, throughout the enterprise. Effective ownership will require empowered EI Leadership, tenured in the world of imaging, imaging IT and clinical transformations with an ability to drive collaborative consensus between site, vendor and corporate leadership for any/all strategic imaging initiatives. Governance would ultimately be driven by a set of technical and functional standards, securing and sustaining normalization and neutralization processes across the enterprise for all clinical imaging disciplines.  
Diminishing reimbursement, pressure to reduce cost of business, healthcare reform, and retaining imaging SMEs are well-known challenges facing today’s healthcare executive. The complexity and diversity of today’s clinical imaging services, as described above, is yet another roadblock. All clinical imaging Ologies, and their image data management environments will continue to be challenged with how best to manage image acquisition, quality, display, data integrity, archive, and distribution management in a manner consistent with best-practices and fiscal responsibilities, internal to each site, and now to the enterprise as a whole. At the same time, they’ll have to deliver relevant and appropriate access to the clinician and customer, including patients and payers.  
An EI program provides a solution that includes clinical and non-clinical imaging acquisition, archive and management systems solutions, consistent with sound imaging management principles and best practices. EI program would ensure image data content integrity and effective image content distribution throughout the enterprise, including image content exchange models sufficient for internal and external healthcare affiliates. Execution and governance of EI program would align with sound fiscal accountabilities for asset and resource management, while ensuring compliance with regulatory, client, vendor and market competitive mandates. An EI program’s vision should meet, or exceed, physician practice and workflow demands across the enterprise for any/all clinically-relevant image data.  
The good news is the technology, tools and expertise to design, implement, and govern such a program does exist. Here are the next steps that should be taken: 
Find out where an EI strategy fit among other mission-critical clinical support systems. 

Commit to a”concept-to-closure” strategy, assessment, vendor evaluation, implementation, support, and governance planning process.  

Seek and secure consultation with an entity or resource that can guide you through the journey, someone that has actually lived it and not simply talking-the-talk 

100,000 Foot Concept View

Don Pittman is an imaging expert with four decades of clinical imaging, imaging IT, vendor and consulting experiences and contributions. Trained as a Radiologic Technologist & Imaging Specialist, educated in Health Services Administration and Certified in Project Management, he has traveled the ever-evolving and transforming journey of clinical imaging services from analog-to-digital and now from entity-to-enterprise. He is committed to, and passionate about, serving and mentoring today’s imaging and imaging IT professionals with the goal to reinstate the imaging professional back into a strategic leadership role alongside other mission-critical clinical service leaders.

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