Join us Online (and get your CE credits) for the First Virtual MIIT Meeting on Fri May 15!

Now Online!

Why MIIT Went Virtual

As someone that has mostly worked from home for over seven years, I understand the value of digital communication and collaboration. In healthcare, we have had many digital tools for more virtual experiences, but have been slow to adopt them. The COVID-19 pandemic has caught many organizations with paper-based and analog processes flat footed.

Education is no different than healthcare and other organizations that have heavily depended on in-person settings. While there is no doubt an in-person conference is more personal and provides social networking opportunities, content can easily be delivered online (the slides and audio are all digital, right?).

This year’s Medical Imaging Informatics and Teleradiology (MIIT) meeting was scheduled to take place in-person in Hamilton, Ontario, just like it has for well over a dozen years. Given the current situation we are all facing, my Co-Chair Dr. David Koff (@koff14) and I were faced with a choice: cancel or try to continue with an online version. As we believe strongly in the importance of imaging informatics education, and the value in this year’s excellent program, we chose the latter.

The first virtual MIIT will take place on Friday May 15, 2020. We have lowered attendee and sponsor rates in consideration of the lower costs of operating a virtual meeting.

Program

We have a great program this year with Dr. Tessa Cook from UPenn, Dr. Vamsi Narra from BJC, Dr. Cree Gaskin from UVa, Les Folio from the NIH, Dr. Adam Prater from Emory, Michael Toland from UMMS, Ted Scott from HHSC, along with Kevin O’Donnell providing an update on the DICOM standard at MIIT 2020 and MIIT’s own Britt Tomlin providing an update on Alberta’s province-wide Connect Care CIS program.

Review the full program here.

Costs

At only CAD$80 per person (which, at the current exchange rate, is only US$57 for our American friends), and with accreditation for CE credits, it is very high value. There are no travel costs and imaging informatics professionals can join from anywhere in the world.

Register using the “Register Now” button at miit.ca.

Sponsorship

Sponsorship of MIIT is still available, starting as CAD$1,000 (~US$715 with today’s exchange rate). Higher tier sponsors are given high visibility with attendees and the opportunity to give a brief talk during the lunch hour.

Be sure to stay top-of-mind among imaging IT decision makers and influencers (from anywhere now) to make up for lost contact at cancelled meetings, conferences, and trade shows!

More information is available here.

More Information

If you have any questions, email us at info@miit.ca.

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.

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.

SIIM 2017

The Society for Imaging Informatics in Medicine (SIIM) annual meeting will be held on Thu June 1 to Sat June 3, 2017 in Pittsburgh. It has a great program, and by all early accounts, will be one of the best attended in years. See the complete program here. Register to attend here.

Genady and I will be participating.

don-headshot-round

Don K Dennison

Weighing the Options: Enterprise PACS vs. VNA for Enterprise-wide Archiving

Thursday, June 1 | 3:00 pm – 3:30 pm
Science & Innovation Pavilion | Exhibit Hall Theater
#AskIndustry Session

Sharing an imaging archive is generally a good thing, but should you implement one archive and connect multiple PACS and other imaging IT systems to it, or should you build an Enterprise PACS and consolidate your various PACS into it? We will get the perspective of vendor staff that are faced with these types of questions from their customers.

TCB: TCO to the CIO for the CIIP

Friday, June 2 | 8:00 am – 9:30 am
Room 301-302
Whiteboard

The ability of a CIIP to accurately model the Total Cost of Ownership (TCO) for imaging IT application investments and operating costs are critical to getting the support of the CIO, and to getting necessary funding.

In this interactive whiteboard session, “Taking Care of Business: Total Cost of Ownership to the Chief Information Officer for the Certified Imaging Informatics Professional”, attendees will be walked through two scenarios — Multiple PACS Replacement and Consolidation and Cost Model for Shared Enterprise Imaging Platform — by faculty experienced in financial analysis and cost model development.

Combining whiteboard discussion and review of some predefined spreadsheets that provide important calculations for each scenario, this session is intended to be highly interactive with Q&A throughout. The spreadsheets used in the session will be made available to members on the SIIM website following the annual meeting.

genady-headshot-round

Genady Knizhnik

Economics of Imaging Informatics

Friday, June 2 | 4:15 pm – 5:15 pm
Pittsburgh Ballroom B
Core Topic Session

Imaging informatics teams routinely embark on new projects and have to support their operations, which depend on the right budget. Budget preparation and justification skills, as well as understanding of the right size and structure of the operational team, are important for securing required financial support. Attendees will examine the fundamentals of preparing well-defined budget requests that CIOs are looking for, as well as how to structure and staff the optimal imaging informatics team.

Medical Imaging Informatics and Teleradiology (MIIT) 2017

The 12th Annual Medical Imaging Informatics and Teleradiology (MIIT) meeting will be held on Friday April 28, 2017 at Liuna Station in Hamilton, Ontario, Canada. This year’s theme is Enterprising Imaging and AI: Welcome to the Future and the program features many fascinating talks by thought leaders, including Drs. Eliot Siegel and Chris Roth.

MIIT 2017 has an all new interactive website and meeting app for increased attendee participation.

Genady and I will each be giving a talk.

Enterprise vs. Diagnostic: Image Viewers Converging?

don-headshot-round

Don K Dennison

As web technologies evolve, the gap between Enterprise Viewers used primarily for accessing images as part of a patient’s electronic medical record and PACS Viewers used for primary diagnostic review is rapidly closing. But how close are they, really? This talk will explore the feasibility of Radiologists using a web viewer instead of a PACS for reading.

Managing Imaging in an EMR Centric Era
genady-headshot-round

Genady Knizhnik

As health systems converge on a common electronic medical record (EMR) system and longitudinal patient record, new requirements and expectations are placed on imaging records and the systems than manage them. This talk will explore the impact that the implementation of a modern EMR has on patient and procedure information within PACS, VNA, and other imaging IT systems.

Program and Registration

See the complete program here. Register to attend here.

Meeting Sponsorship Opportunities

Interested in sponsoring MIIT 2017? Read about the available sponsor packages here, or register as a sponsor here.

Dealing with Multiple Terminology Domains in a Consolidated Enterprise – Part 2

In my previous post, Dealing with Multiple Terminology Domains in a Consolidated Enterprise, I introduced a typical challenge that many imaging projects face today.

In this post, I will describe three common use cases where the problem of multiple terminology domains manifests.

Single PACS, Multiple RIS

Often, rapidly growing health systems aim to consolidate imaging informatics solutions across their facilities. Replacement of multiple PACS with one such system, while keeping separate RIS systems in place is not uncommon. The reason behind this dichotomy is that a RIS is much more ingrained into the local Radiology department’s operational and clinical workflows than a PACS, making its replacement complex and impactful on many stakeholders.

The following diagram illustrates this scenario.

term-pacs

In such a deployment, the consolidated PACS is responsible for dealing with multiple ordering systems that use individual procedure terminologies. It also maintains patients’ longitudinal imaging record, which will include different values in the DICOM headers to describe the same procedure types.

Multiple RIS/PACS, Shared VNA

Health systems that seek to benefit from IT infrastructure consolidation, as well as a single Imaging Record Management, Archive, Access, and Sharing application, often opt to procure and deploy a shared VNA system across their facilities. By keeping their RIS/PACS systems in place they can rapidly deliver clinical and operational benefits with minimal disruption to the existing workflows. This approach allows individual facilities to stay fairly independent in their imaging informatics system and process decision making.

The following diagram illustrates this scenario.

term-vna

In this deployment, the shared VNA typically maps or normalizes procedure terminologies in the DICOM header of the studies that are served to the individual PACS systems as part of the relevant prior pre-/push-fetch workflows.

Single PACS, Single RIS

An increasingly common scenario is when health systems include a RIS consolidation project within their EMR consolidation strategy, while PACS consolidation happens in parallel. This approach results in a single master set of orderable procedures that is used by all participating facilities. The challenge arises from the fact that historic imaging records maintain, in the DICOM data, procedure information using historic terminology values that predate consolidation and can include known values (from the latest RIS) or some potentially unknown value (previous RIS systems for the institutions that replaced their RIS system at least once and did not replace the values with one used by the new RIS).

The following diagram illustrates this scenario.

term-rispng

In these deployments, the consolidated PACS is responsible for dealing with new common and fragmented historic procedure terminologies.

In the next post, I will describe how PACS and VNA vendors deal with this challenge.

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

SIIM2016

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!

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.

Developing an Enterprise Imaging Strategy—What is the best approach?

In my last post, we explored the current state-of-the-art of the Enterprise Imaging (EI) industry. In this post, I will zoom in on storing and managing non-DICOM images and videos. This can be ambiguous and may confuse providers who are trying to procure an EI solution. It also results in different schools of thought among vendors.

Currently, EI content can be stored and managed in one of the following formats:

  • Original object (e.g. jpg) stored in a solution’s database and/or filesystem using the vendor’s API (Application Programming Interface)
  • Original object (e.g. jpg) stored using the IHE Cross-Enterprise Document Sharing (XDS) integration profile in a solution’s XDS Document Repository component
  • Original object (e.g. jpg) stored in a solution’s database and/or filesystem using HL7’s FHIR® Media Content specifications
  • DICOM object stored in a solution’s Image Manager/Archive component; for example, using the IHE Web Image Capture (WIC) integration profile
  • DICOM object stored in a solution’s Image Manager/Archive and XDS Document Repository components using the IHE Cross-Enterprise Document Sharing for Imaging (XDS-I) integration profile

The following diagram depicts the main steps that take place during information capture activity for each method.

storage methods

All of the above methods have corresponding pros and cons, which leads to the current divergence of opinions regarding the best option to use. Having said that, it is clear that, irrespective of the chosen method, there is a need to properly collect and manage patient, administrative and clinical context (aka metadata) for the acquired EI content.

Metadata

Each of the above methods offer different levels of metadata rigidity and extensibility which impact the interoperability:

  • DICOM, FHIR and XDS-I based methods offer a level of certainty for the vendors with respect to what information should be captured and how it should be encoded.
  • XDS takes an approach of developing specific content profiles that address specific types of content; for example, the IHE XDS-SD (Scanned Document) integration profile. At the moment, there is no content profile that is specific to the Enterprise Imaging domain. Additionally, XDS allows the original object to be wrapped in a CDA Document to capture additional metadata in case the specified XDS Document Entry attributes are not sufficient.

Is there one “right” answer?

There are two overarching clinical reasons to capture EI content:

  1. To enrich patients’ clinical record
  2. To provide reliable, authorized access to it across the enterprise (and beyond)

As the following diagram suggests, the way EI content is stored is less important then the flexibility of an EI solution’s “Capture” and “Discovery and Access” components, because it is hidden behind those interfaces.

EI Access

It seems that, currently, there is no single answer for the best EI content format given the informatics complexity of healthcare provider’s enterprises. In order to adapt and compete, vendors will be pressured to support multiple inbound and outbound methods (such as FHIR, DICOM, DICOMWeb, XDS, proprietary APIs, etc.) and only time will tell which approach will become a de-facto standard.

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