RSNA 2016

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In what I believe is my 15th consecutive RSNA, I have a full schedule of business meetings, committee and board meetings, with some time for connecting with friends. In addition to the typical, semi-organized chaos, I am giving two talks.

Hope to see you all in Chicago.

RCC24 – Starting a Health IT Consulting Company

Room: S501ABC
Mon 28-Nov-2016, 2:30 pm to 4:00 pm CT

RC654 – Using IHE Profiles to Plan for Medical Imaging

Room: S504AB
Thu 1-Dec-2016, 8:30 am to 10:00 am CT
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IHE Integration Profile Development – Vote Now (Voting Closed)

Update: Voting is now closed. Integration Profiles selected by the IHE committees for development in the 2016/2017 development cycle:

  1. Enterprise Scanner Protocol Management
  2. Critical Finding Follow-up and Communication
  3. Standardized Operational Log of Events

What healthcare use cases do you want addressed? What are the biggest interoperability issues facing our community today?

Provide your input to the IHE integration development process by completing the survey. Simply rank the six proposed profiles. It take 10 seconds.

Dealing with Multiple Terminology Domains in a Consolidated Enterprise

As the number of the PACS consolidation projects grow, I think it is important to explore some of the informatics concepts that need to be addressed to maximize the value of a consolidated PACS’ clinical functionality.

As mentioned in my recent MIIT talk, there are operational, financial and clinical goals that drive PACS consolidation projects. One of those reasons is to enable multi-facility diagnostic reading workflow: acquire anywhere and read anywhere in the enterprise.

One of the key informatics prerequisites of a successful PACS consolidation project is dealing with Patient Identities in a Consolidated Enterprise to establish patients’ longitudinal imaging record. Once that fundamental challenge is addressed, dealing with the normalization or mapping of the exam terminologies used by different RIS systems across the consolidated enterprise is the next critical informatics area to tackle. Often, PACS consolidation projects do not include the unification of the facility RIS, which forces the PACS to deal with multiple terminology domains.

In this series of the blog posts, I will examine this challenge in detail and describe the imaging informatics industry’s current capabilities to deal with it.

The Challenge

First of all, let’s define the problem and why it is important.

The anatomical and procedural information for a radiology exam is used by the PACS to primarily: 1) determine relevancy across patients’ historic studies; and 2) establish the correct display protocol for the PACS Workstation. As different ordering systems (EMR/RIS) may use different values to describe the same ordered procedure, the consolidated PACS will have to use a value normalization or mapping method to properly process the information.

The following diagram conceptually illustrates the difference between normalization and mapping methods.

terminology

Mapping

This approach relies on keeping many-to-many translation tables where each term has a corresponding defined value under each terminology domain. This approach is feasible only with a very small number of values and terminology domains.

Normalization

This methodology creates a “canonical” representation of each term and establishes a one-to-one relationship between each value in each terminology domain and the corresponding value under the “canonical” representation. This approach can accommodate a very large number of values and terminologies, as the translation from one terminology to another is always done through the canonical value.

In the next post, I will describe the imaging informatics use-cases that have to deal with this challenge.

SIIM 2016: Where’s Don

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SIIM 2016 is almost here. If you are attending this year’s Annual Meeting, you may find these sessions that I am chairing of interest.

Developing an Imaging Record Quality Policy
Thursday, June 30 | 1:15 pm – 2:45 pm
Portland Ballroom 256

Strategies and Tactics for Capturing and Sharing Images
Friday, July 1 | 8:00 am – 9:30 am
Portland Ballroom 256

Strategies for Dealing with Patient Identities in a Consolidated Enterprise
Friday, July 1 | 1:15 pm – 2:45 pm
Portland Ballroom 256

Basically, just park yourself in Portland Ballroom 256 and I will come to you.

I will also be participating in the:

Hackathon Project Showcase (#SIIMHacks)
Friday, July 1 | 9:45 am – 10:45 am | Portland Ballroom 254

I look forward to catching up with some old friends and making some new ones over some craft beer!

Medical Imaging Informatics and Teleradiology (MIIT) 2016 Conference

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Genady Knizhnik (@genady_knizhnik) and I (@donkdennison) will be speaking at the 11th annual MIIT conference on Friday June 17th, 2016 in Hamilton, ON, Canada (Liuna Station, 360 James Street).

I am moderating a panel discussion in a session titled “Longitudinal Patient Imaging Record in a DIR” and presenting a talk on “Breast Tomosynthesis: Impact on IT Systems”.

Genady is presenting on “PACS Consolidation and Imaging Record Quality Policies”.

More information, including the complete program, is available here.

Register to attend here.

VNA and Enterprise Viewer Projects’ ROI

When I discuss industry trends with colleagues and clients, I find that we periodically touch on the topic of defining and realizing VNA and Enterprise Viewer (EV) projects’ return on investment (ROI). Our industry has made several attempts to develop an ROI calculator, which would typically encompass:

  • the benefits of consolidating IT infrastructure;
  • avoiding the cost of repeat exams due to the availability of a longitudinal patient imaging record;
  • and efficiency gains stemming from the optimized distribution and visualization of medical images.

Often these calculations are tied to a specific project and not easily reused.

During our involvement in various VNA and EV projects, we observed an interesting pattern that can bring an additional perspective on the ROI discussion.

By the end of 2010, the vast majority of U.S. hospitals had installed a PACS solution. The bulk of the deployments took place during the 2005-2010 period, and many of those are still in place, bolstered by many upgrades and technology-refresh cycles since their initial installations. During that period, both the hardware and storage components of a PACS solution were often procured directly from the PACS vendors. This procurement approach allowed the vendors to enjoy significant Service and Maintenance Agreement (SMA) revenues that would cover not only their solution components but also any included third-party hardware and storage.

Since that procurement wave, many things have changed:

  • PACS market maturity resulted in a commoditization of some of its functional areas
  • Hardware and storage costs have significantly dropped
  • Server virtualization became the preferred deployment methodology
  • Procurement of the infrastructure components has been steadily shifting from the Radiology department to the Enterprise/Corporate IT team

Also, PACS market saturation depreciated PACS vendors’ software license sales, resulting in SMA revenues becoming the key contributor to their top line.

All of these changes often created a tension between a hospital’s staff and its PACS vendor because the perceived value of the services delivered under the SMA contracts do not seem to warrant the high dollar cost. Besides tough negotiation tactics, a hospital has few practical tools at its disposal to change this dynamic. This is where well-thought-out VNA and EV projects may become extremely important in changing the negotiation power balance.

The technical and operational benefits of having a VNA take over a PACS Archive, EMR integration and sometimes even workflow components by the VNA and EV solutions are well documented and often result in the hospital’s reduced dependency on the existing PACS vendor.

Consequently, a hospital that implements VNA and EV solutions will be well-suited to renegotiate existing PACS SMA contracts to adequately reflect the provided service. The reduced SMA value can partially offset the cost of VNA and EV projects, thus contributing positively to the ROI calculation. Having said that, without a compelling event, such as an RFP to replace the existing PACS, the incumbent vendor will have little incentive to concede in the SMA renegotiations.

In order to successfully realize the above potential savings, it is important to understand what core functional areas of a PACS can be replaced by a VNA or an EV solution. Consider the following diagram:

ROI-1

Impact on Workflow or External Systems Replacement Complexity Industry Ability to Replace
Long-term Archiving and ILM This functionality is typically not exposed to external systems and has relatively simple orchestration workflows Low: Besides the need to keep the VNA copy of the study in sync with the one cached by the PACS, the archival and retrieval functionality is relatively straight-forward Current state-of-the-art VNA solutions offer proven methodologies to take over this functional area from the PACS
Routing, Pre-fetching and Relevancy This functional area may play an important role in orchestrating a departmental or an enterprise workflow Moderate: Relevancy detection can potentially increase the relative complexity of study routing and pre-fetching, which are typically quite straightforward due to their transactional nature The majority of the leading VNA solutions can adequately deliver this functionality, but their rule-definition flexibility coupled with their ability to express sophisticated relevancy rules (especially across multiple terminology domains), may vary
Acquisition and Quality Control (QC) Workflow Orchestration This functionality has a major impact on the acquisition and reading workflow with a large number of 3rd party systems integrations High: The large number of acquisition modalities will often have different associated configurations. Additionally, in large enterprises QC workflows could be very complex involving both automatic and manual activities. The effort to recreate all QC workflows, which were accumulated over the course of many years could be quite significant The VNA systems’ ability to provide this functionality represents one of the major product differentiation areas among current vendors
Image Distribution and EMR Integration An ability to provide access to images outside of the Radiology department is a critical component of a provider’s single patient record objective Low: The need to provide access to images within multiple applications (e.g. EMR, portal) or stand-alone impose some security and integration challenges. Besides the privacy and security considerations, the rest of the deployment and integration activities are relatively straight forward. Current state-of-the-art EV solutions offer proven methodologies to take over this functional area from PACS

Although this post is primarily focused on SMA-related costs, the reduction of the PACS functional scope will also decrease the corresponding Professional Services expenses.

Working on an Enterprise Imaging project? Leave us a comment with your thoughts, or contact us.

Article: The biggest problem in health care today

This article, inflammatory headline aside, is spot on.

In what other industry are consumers provided less information about the cost of a product or service until after purchase?

Price transparency is the first step in allowing consumers to choose. And choice means market forces drive down costs and force providers to focus on efficiency (or go broke trying).

For more reading on healthcare financials, including Radiology reimbursement, read my past blog posts here, here, here, and here.