Enterprise Insight in Today’s Consolidated Enterprise

As health systems acquire or partner with previously independent facilities to form Consolidated Enterprises, and implement a Shared Electronic Medical Record (EMR) system, they often consolidate legacy diagnostic imaging IT systems to a shared solution. Facilities, data centers, identity management, networking equipment, interface engines, and other IT infrastructure and communications components are also often consolidated and managed centrally. Often, a program to capture and manage clinical imaging records follows.

Whether the health system deploys a Vendor Neutral Archive (VNA), an Enterprise PACS, or a combination of both, some investment is made to reduce the overall number of imaging IT systems installed and the number of interfaces to maintain. An enterprise-wide radiation dose monitoring solution may also be implemented.

While much has been written on strategies to achieve this type of shared, integrated, enterprise-wide imaging IT solution, there are several other opportunities for improvement beyond this vision.

In addition to imaging and information record management systems, enterprise-wide solutions for system monitoring, audit record management, and data analytics can also provide significant value.

Systems Monitoring

Organizations often have some form of enterprise-level host monitoring solution, which provides basic information on the operational status of the computers, operating systems and (sometimes) databases. However, even when the hosts are operating normally, there are many conditions that can cause a solution or workflow to be impeded.

In imaging, there are many transaction dependencies that, if they are not all working as expected, can cause workflow to be delayed or disabled. Often, troubleshooting these workflow issues can be a challenge, especially in a high-transaction enterprise.

Having a solution that monitors all the involved systems and the transactions between them can help detect, prevent, and correct workflow issues.

Audit Record Management

Many jurisdictions have laws and regulations that require a comprehensive audit trail to be made available on demand. Typically, this audit trail provides a time-stamped record of all accesses and changes to a patient’s record, including their medical images, indexed by the users and systems involved.

Generating this audit trail from the myriad of logs in each involved system, each with its own record format and schema, can be a costly manual effort.

The Audit Trail and Node Authentication integration profile (ATNA), part of Integrating the Healthcare Enterprise (IHE), provides a framework for publishing, storing, and indexing audit records from different systems. It defines triggering events, along with a record format, and communication protocol.

Enterprises are encouraged to look for systems that support the appropriate actors in the ATNA integration profiles during procurement of new IT systems and equipment. Implementing an Audit Record Repository with tools that make audit trail generation easy is also important.

Data Analytics

Capturing and analyzing operational data is key to identifying issues and trends. As each system generates logs in different formats and using different methods, it often takes significant effort to normalize data records to get reliable analytics reports.

Periodic (for example, daily, weekly, or monthly) reports, common in imaging departments for decades, are often not considered enough in today’s on-demand, real-time world. Interactive dashboards that allow stakeholders to examine the data through different “lenses”, by changing the query parameters, are increasingly being implemented.

Getting reliable analytics results using data from both information (for example, the EMR and RIS) and imaging (for example, modalities, PACS, VNA, and Viewers) systems often requires significant effort, tools to extract/transform/load (ETL) the data, and a deep understanding of the “meaning” of the data.

Enterprise Insight

Implementing solutions that continuously and efficiently manage the health of your systems, the records accessed, and operational metrics are important aspects in today’s Consolidated Enterprise. Evaluating any new system as to their ability to integrate with, and provide information to, these systems is recommended.

Imaging Exam Acquisition and Quality Control (QC) Workflow in Today’s Consolidated Enterprise – Part 2 of 2

In my previous post, I discussed common challenges associated with the imaging exam acquisition workflows performed by Technologists (Tech Workflow) that many healthcare provider organizations face today.

In this post, we will explore imaging record Quality Control (QC) workflow.

Background

A typical Consolidated Enterprise is a healthcare provider organization consisting of multiple hospitals/facilities that often share a single instance of EMR/RIS and Image Manager/Archive (IM/A) systems, such as PACS or VNA. The consolidation journey is complex and requires careful planning that relies on a comprehensive approach towards a solution and interoperability architectures.

An Imaging Informatics team supporting a Consolidated Enterprise typically consists of PACS Admin and Imaging Analyst roles supporting one or more member-facilities.

Imaging Record Quality Control (QC) Workflows

To ensure the quality (completeness, consistency, correctness) of imaging records, providers rely on automatic workflows (such as validation by the IM/A system of the received DICOM study information against the corresponding HL7 patient and order information) and manual workflows performed either by Technologists during the Tech Workflow or by Imaging Informatics team members post-exam acquisition. Automatic updates of Patient and Procedure information are achieved through HL7 integration between EMR/RIS and the IM/A.

Typical manual QC activities include the following:

  • Individual Image Corrections (for example, correction of a wrong laterality marker)
  • DICOM Header Updates (for example, an update of the Study Description DICOM attribute)
  • Patient Update (moving a complete DICOM study from one patient record to another)
  • Study Merge (moving some, or all, of the DICOM objects from the “merged from” study to the “merged to” study)
  • Study Split (moving some of the DICOM objects/series from the “split from” study to the “split to” study)
  • Study Object Deletion (deletion of one or more objects/series from a study)

QC Workflow Challenges

Access Control Policy

One of the key challenges related to ensuring the quality of imaging records across large health system enterprises is determining who is qualified and authorized to perform QC activities. A common approach is to provide data control and correction tools to staff from the site where the imaging exam was acquired, since they are either aware of the context of an error or can easily get it from the interaction with the local clinical staff, systems, or the patient themselves. With such an approach, local staff can access only data acquired at sites to which they are assigned to comply with patient privacy policies and prevent any accidental updates to another site’s records. The following diagram illustrates this approach.

QC-1

Systems Responsibilities

Another important area of consideration is to determine which enterprise system should be the “source of truth” for Imaging QC workflows when there are multiple Image Manager/Archives. Consider the following common Imaging IT architecture, where multiple facilities share both PACS and VNA applications. In this scenario, the PACS maintains a local DICOM image cache while the VNA provides the long-term image archive. Both systems provide QC tools that allow authorized users to update the structure or content of imaging records.

QC-2

Since DICOM studies stored in the PACS cache also exist in the VNA, any changes resulting from QC activity performed in one of these systems must be communicated to the other to ensure that both systems are in sync. This gets more complicated when many systems storing DICOM data are involved.

Integrating the Healthcare Enterprise (IHE) developed the “Imaging Object Change Management (IOCM)” integration profile, which provides technical details regarding how to best propagate imaging record changes among multiple systems.

To minimize the complexity associated with the synchronization of imaging record changes, it is usually a good idea to appoint one system to be the “source of truth”. Although bidirectional (from PACS to VNA or from VNA to PACS) updates are technically possible, the complexity of managing and troubleshooting such integration while ensuring good data quality practices can be significant.

The Takeaway

Often the QC Workflow is not discussed in depth during the procurement phase of a new PACS or VNA. The result: The ability of the Vendor of Choice’s (VOC) solution to provide robust, reliable, and user-friendly QC tools, while ensuring compliance with access control rules across multiple sites, is not fully assessed. Practice shows that vendors vary significantly in these functional areas and their capabilities should be closely evaluated as part of any procurement process.

Imaging Exam Acquisition and Quality Control (QC) Workflow in Today’s Consolidated Enterprise – Part 1 of 2

As existing healthcare provider organizations merge and affiliate to create Consolidated Enterprises, image acquisition workflows are often found to be different across the various facilities. Often, the different facilities that comprise the Consolidated Enterprise had different procedures and standard of practice for image acquisition and Quality Control (QC), along with different information and imaging systems.

Standardizing and harmonizing enterprise-wide policies, especially for imaging exam QC, can have significant benefits. A failure to standardize these workflows in a Consolidated Enterprise may result in inconsistent or inaccurate imaging records, which can lead to reading and viewing workflow challenges. These are compounded with a shared imaging system, such as an enterprise PACS or VNA, and can result in delays in care and patient safety risks.

There are generally two areas worth evaluating for optimization:

  • Technologist imaging exam acquisition workflow (Tech Workflow)
  • Imaging record Quality Control workflow (QC Workflow)

Here, we will explore Tech Workflow. QC Workflow will be covered in a subsequent post.

Throughout this discussion the term Radiology Information System (RIS) is used, which can be a standalone system or a module of an EMR.

Tech Workflow

The use of DICOM Modality Worklist (DMWL) for the management of image acquisition is well-understood and broadly adopted. However, the process of marking an exam as “complete” (or “closed”) following acquisition is less standardized and varies across different vendors and healthcare enterprises. The subsequent QC and diagnostic reading workflows rely on the “completion” of the exam before they can begin. For example, an exam that is never marked as “complete” may not appear on a Radiologist Reading Worklist, and an imaging exam that is marked as “complete” when it isn’t will be available for Radiologists to read with only a partial set of images.

Imaging Technologists typically interact with the following applications on a daily-basis.

Tech WF Screens

  • Modality Console – a comprehensive set of tools, attached to the modality, to perform image acquisition activities (such as DMWL queries, exam protocoling, post-processing, etc.).
  • Radiology Information System (RIS) – a specific view into the enterprise RIS application, allowing Technologists to look up patient/procedure information, a set of tools to document the acquisition and mark exam as “complete”, etc.
  • Image Manager/Archive (IM/A) QC – a comprehensive set of imaging exam Quality Control (QC) tools, provided by the Image Manager/Archive (IM/A), such as PACS or VNA, or a dedicated application, to make any necessary corrections to ensure the quality of acquired imaging exam records.

As stated above, there is significant variability among healthcare providers with respect to instituting Tech Workflow policies and procedures. The following diagram illustrates the steps involved in a common Tech Workflow.

Tech WF Flow

Notes:

  • In some cases, Technologists validate the quality of the image and confirm that the number of images in the IM/A is correct for multiple studies at a time instead of each one independently due to the high-volume of exams being acquired.
  • An ability to assess the quality of the imaging exam and correct it (if needed) in a quick and user-friendly manner is critical for an efficient exam completion workflow.

PACS-driven Reading Workflow

In this scenario, the PACS Client provides a Reading Worklist and it is typically responsible for launching (in-context, through a desktop integration) the Report Creator application. There are several methods used across provider organizations to communicate study complete status updates to the PACS.

Method Benefit Challenge
Time out – this is the most typical approach, which considers a study to be complete after a defined period of time has passed (for example, five minutes) since the receipt (by PACS) of the last DICOM object from the modality.
  • Easy to implement
If the time-out is too long, the creation of the corresponding Reading Worklist item will be delayed. Alternatively, a short time-out may result in a Radiologist reporting an incomplete study, which requires follow-up review and potentially an addendum to the report once the missing images are stored to PACS.
HL7 ORM – some organizations release HL7 ORM messages to the Report Creator only after the order status is updated (to study complete) in the RIS.
  • Easy to implement
  • Prevents reporting of incomplete exams (although relies on Technologists to validate the completeness of the study structure in the PACS)
There are scenarios where PACS has received DICOM studies, but their statuses in the RIS application has not yet been updated (for example, as can happen with mobile modalities). The Reading Worklist is unaware of the HL7 message flow between the RIS and the Report Creator and, therefore, allows the Radiologist to start reviewing cases. However, these cases have no corresponding procedure information in the Report Creator. When the Radiologists tries to launch the reporting application in the context of the current study, the Report Creator is unable to comply.
DICOM MPPS – Once an exam is complete, a DICOM MPPS N-Set message (issued by the modality) informs the PACS (and/or RIS) about the structure of the study and the fact that it is completed (along with other useful exam information).
  • Prevents reporting of incomplete exams
  • Automatic confirmation of the structure of the study

 

  • The adoption of DICOM Modality Performed Procedure Step (MPPS) is still limited in most enterprises, even though some modalities, RIS, and PACS support it.
  • Somewhat complex to implement (requires integration and testing between each modality and the MPPS server) coupled with a lack of understanding as to the benefits of this approach in many healthcare provider organizations.
  • Some modality vendors charge an additional fee for a license to enable MPPS integration.
  • Can be disconnected from the “completion” of the exam in RIS (i.e. can ensure the Report Creator’s readiness), provided only the PACS receives and processes the MPPS messages.
DICOM Storage Commitment – Once the exam is complete, a series of DICOM messages (N-Action, N-Event-Report) between modalities and PACS can determine whether a complete study was stored to PACS.
  • Prevents reporting of incomplete exams
  • Automatic confirmation of the structure of the study
  • Although most PACS and many modalities support this DICOM transaction, it is not widely implemented by healthcare providers.
  • Somewhat complex to implement (requires integration and testing between each modality and the PACS server) coupled with a lack of understanding as to the benefits of this approach in many healthcare provider organizations.
  • Can be disconnected from the “completion” of the exam in RIS (i.e. can ensure the Report Creator’s readiness).

RIS-driven Reading Workflow

In this scenario, the RIS provides the Reading Worklist and it is implicitly aware of the status of the exam (assuming the same system is used by Techs and Rads). It creates the worklist item that corresponds to the exam once it reaches the “complete” status. As the Reading Worklist launches both the Report Creator and the Diagnostic Viewer (PACS Client) applications, it does not face the informatics challenges inherent to the PACS-driven Reading Workflow described above.

Enterprise-wide Reading Workflow (Dedicated, Standalone Application)

Some organizations use an enterprise-wide Reading Worklist that is a separate application from the PACS and RIS to orchestrate enterprise-wide diagnostic reading (and other imaging related) tasks across all their Radiologists using fine-grained task-allocation rules. Similar to the RIS-driven Reading Workflow, the worklist launches both the Report Creator and the Diagnostic Viewer applications once a worklist item is selected.

To prevent the complexity of the PACS-driven Reading Workflow described above, some organizations choose to release an HL7 ORM message from the RIS application to the worklist only when the status of the corresponding exam in that system is updated. Alternatively, organizations that choose to send all ORM messages to the worklist application as soon as procedures are scheduled, need to deal with ensuring that the PACS has a complete study prior to allowing it to be reported.

So, what?

It is important for healthcare provider organizations to understand the relationship between the Tech Workflow and the Reading Worklist approach they adopt. If a RIS-driven approach is not chosen, then there should be a clear integration strategy in place to ensure that studies are not reported too soon or missed.

SIIM 2018 Annual Meeting: A Preview

SIIM18 graphic
Gaylord National Resort, National Harbor, MD

The SIIM 2018 Annual Meeting in Washington D.C. is just around the corner (May 31 to June 2). I look forward to seeing many friends, sharing ideas, and learning. I will be involved in number of sessions this year. Here is a preview.

Preparing for a Successful RFP and Contract with Vendors

Thursday, May 31 | 9:45 am – 10:45 am | Annapolis 1

In this roundtable session, participants will discuss how to best prepare for, develop, and issue an RFP, as well as how to analyze and grade the responses. We will also discuss how to best prepare for, and support, contract negotiations with a vendor.

Debate: Enterprise PACS vs. Vendor Neutral Archive (VNA): Choose Wisely

Friday, June 1 | 9:45 am – 10:45 am | Cherry Blossom Ballroom

Depending on your organization’s goals and scale of enterprise, the options available to you for an image archive can vary. In this debate-style session, we will explore the merits of using a Vendor Neutral Archive (VNA) vs. an archive provided as part of an Enterprise PACS. I am moderating the session.

Imaging IT Financials – Learn from the Masters

Saturday, June 2 | 12:45 pm – 2:45 pm | Baltimore 3/4/5

Participants that sign up for this learning lab (limited seats available) will work hands-on with experts to learn how to perform clear and compelling financial analysis. Two lab exercises—one focused on assessing cloud-based vs. on-premises image archive storage, and another on the IT investment required for rolling out the enterprise imaging solution to a newly acquired facility—will be worked on in teams. Each team will share their work with the other near the end of the session. Lab assistants will be on-hand to assist. Participants must bring a laptop or tablet with Microsoft Excel installed.

 

MIIT 2018 – May 4, 2018

In just less than a month from today on Friday May 4, 2018 (Star Wars day!), the annual MIIT (Medical Imaging Informatics and Teleradiology) conference will once again be held at the beautiful Liuna Station in Hamilton, Ontario, Canada.

This year’s theme is Connecting Imaging and Information in the Era of AI and the program features several distinguished speakers from Canada and the U.S.

Talks will cover EMR implementation, Radiology Outreach, the link between Quality and Informatics, Highly Automated Radiology (using AI), an update on IHE, and a comparison of PACS+VNA vs. Regional PACS. It will also have a panel on the impact of EMRs and AI on Radiology and a talk on AI by a speaker from IBM Watson Health.

Register Today!

MIIT Badge

RSNA 2017: PACS Reconstruction

RSNA 2017 Logo

“All the king’s horses and all the king’s men…”

Deconstructing a PACS into discrete, enterprise-scale components seems to be all the rage for many organizations. But, like many things in life, taking something apart is often far easier than putting the pieces back together (and getting something that works).

At this year’s RSNA meeting, I will chair a session on PACS Reconstruction (RCC24) on Mon 27-Nov-2017 from 2:30 to 4:00 pm CT that will focus on the challenges and opportunities of building an integrated enterprise-wide imaging solution for diagnostic review and clinical access.

Following my introduction of core concepts, we will hear from Charlene Tomaselli, Director of Medical Imaging IT at Johns Hopkins and Bob Coleman, Senior Director of Enterprise Imaging Informatics at MaineHealth on their progress and vision to providing an integrated imaging solution for their enterprises.

We will have a panel Q&A with the audience to share lessons learned and discuss how to best prepare for changes.

Enterprise PACS vs. Vendor Neutral Archive (VNA)

I recently contributed an article to HealthCareBusiness that explored the scenarios whereby the use of an Enterprise PACS—defined as a system serving multiple organizations and facilities across an enterprise—or the use of a VNA may be the right approach for an organization seeking to consolidate their image archive and provide a longitudinal patient imaging record. It also covers some scenarios where both may be required.

To some vendors, this can be an ideological debate. It can also lead to discussions about the definition of what is “vendor-neutral” or not.

What is important is understanding what problems you are trying to solve, what requirements exist for the overall solution, what benefits you expect (and a plan to measure them), and having a feasible plan to get there.