Post-SIIM 2013 Annual Meeting Reflections

Another great SIIM annual meeting is behind us and it was great, as always. I am going to post some thoughts and reflections this week.

Today, I have been thinking about analytics and, in particular, the use of a workflow engine and a standardized set of terms and definitions (such as what is being defined in SWIM) to ensure analysis of workflow events (type, timing, relationships, patterns, etc.) consistently across systems.

There were several great talks by Dr. Brad Erickson and Chris Meenan and others on the topic and these were followed by a large turnout of engaged attendees for a SWIM demo (see pic below).

...SWIM lessons
…SWIM lessons

My thoughts…

  • The use of a mature, off-the-shelf (open source or commercial) workflow engine has been considered by PACS and RIS vendors, with some attempting to use them in their product. It has not been widely adopted for two main reasons (I believe)…
  1. Most PACS from large vendors were bought, not built by them—the risk of replacing the built in logic with an external engine without introducing functional regression is high (read as: it would be expensive);
  2. Unless the workflow engine spans several systems, it would not have the full benefit (see more on this below).
  • The workflow examples cited often started with the arrival of the image objects from the modality (initial event that starts the workflow channel). Ideally, the workflow engine extends to before the order is placed, managing the order placement, decision support to ensure the right procedure is ordered, scheduling, protocoloing, and acquisition, along with the reading and post-processing steps. It should also span to the results distribution and archiving, managing the timing and destinations of the report and the lifecycle of the historic imaging data.
  • One of the limitations of using a parallel image management pipeline (e.g. sending images through a system before arriving in PACS) in order to detect the event that triggers the workflow can introduce some points of failure. Consider if the system integrated with the workflow engine goes down and images don’t get to the PACS—this outage would limit the value of the integrated image management and workflow engine system. A possible solution is to extend PACS and other systems, such as the RIS, EMR, CDS, VNA, Enterprise Viewer, document management system, etc. to expose the event information. This would allow the workflow engine to apply the desired workflow rules and orchestrate the data flow and work steps without being a potential bottleneck.

More thoughts from SIIM later. Stay tuned.

Article – Readers Write: 256 Shades of Grey(scale): The Dirty Little Secrets of Radiology and PACS

Contrary to what the title suggests, this article debates whether radiology has succeeded in solving the problem of going digital (by using PACS).

I believe that PACS solved the initial problem that it was intended to solve: get rid of film. Whether it provided more value than that had a lot to do with the design of the PACS, and who was managing it.

But, the value of PACS has a lot more to do with how it is deployed, configured and managed. If a PACS owner fails to use informatics and operational best practices, they and their users will suffer. If they fail to invest in and manage the infrastructure—such as the networks, servers, and storage—they will suffer.

I have seen too many PACS operators with too heavy of a dependence on their PACS vendor. Radiology and IT too often lack staff that understand informatics, integration best practices (e.g. as defined by IHE), or how their system operates. I have seen two hospitals with the same software application doing very similar exam volumes, and one experienced high levels of user satisfaction and operational excellence, while the other had chronic issues.

I would argue that in today’s mature PACS market, it is not what you buy, but how you use it. Provider staff need skills and knowledge about best practices. They need to know more about PACS in general, and be less constrained to knowing only what their PACS vendor tells them. And one of the best places to develop these skills and broad knowledge is SIIM.

I’ll be at the SIIM meeting—stop and say ‘hi’ if you see me.

Article – Enterprise Imaging: Beyond Cloud-based Image Sharing

Read this, seriously.

Some thoughts…

  • I agree with most of what the article covers. I believe that Radiologists will be more consultant than owner of the Enterprise Imaging (EI) platform.
  • One topic that is not covered is the informatics around the metadata to collect at the time of capture. DICOM and IHE provide guidance as to what metadata we want to capture and include when doing a CT exam, but what needs to be captured when a clinical images are captured and stored is far less defined (though this will evolve as EI is adopted). Hopefully, we can start defining this by using some standard lexicons and codes (like SNOMED CT), as these are more mature now than when we started defining metadata values for traditional radiology modalities.
  • There needs to be close attention paid to the indexing of metadata in the EMR and the EI platform; more than is traditionally done when doing a basic EMR and PACS viewer integration. If an HIE is in place or planned, this also needs to be considered. Not all systems will be capable of managing all the desired metadata (including unique identifiers).
  • The EI platform should be considered a component of the EMR and managed as such–don’t put EI in your radiology PACS; just don’t.
  • We need to develop EI professionals through education and shared experiences, if we want to succeed. I may be biased, but I believe that SIIM is one of the organizations well-positioned to provide this. Check out my two-part blog post (part 1, part 2) on the SIIM web site.

PACS Challenges – A Perspective from the SIIM Regional Meeting

SIIM Reg Meeting Mar-2013 - PACS Challenges

“PACS” is used well beyond radiology; how can they still own it? It is being decomposed into discrete services, but it still has to come together and be fast and reliable (software is only valuable if it is available and responsive when needed).

Integrating patient records (different patient ID domains, order schema, different procedure codes, etc.) is critical to a patient’s imaging record interoperability, whether it is to consolidate records to a shared system (e.g. imaging studies in a VNA), or at access time (on demand cross indexing when viewing studies from different patient ID domains).

For all the pages of must have features that fill a PACS RFP, most people I talk to would trade most of them for a fast PACS that never crashes.

SIIM Regional Meeting in Philly

I am attending the SIIM regional meeting in Philadelphia. Keeping the sword sharp by listening to experts talk about challenges in radiology and informatics. Good turnout. Great to see some friends.

Noted some increasingly commonly reported trends…

  • Funds for PACS expansion, upgrades, and replacements are threatened by the focus on EMR adoption.
  • Enterprise imaging is becoming a focus for informatics professionals; a VNA is the most common place sought to store these images.
  • In addition to the VNA taking the “A” out of PACS, it seems most people are looking to PACS add-ons (“PACS Apps?”) to solve problems over looking for a solution engineered into their PACS. I wonder if this is because of the focus that a smaller vendor can apply to the problem space, or that PACS vendor resources are consumed with managing the installed base, or that they are strategically reducing R&D investment as the PACS market become saturated and radiology revenues decline.

SIIM Blog: Part 2 – Organizing Concepts to Focus Learning Efforts

Part 2 of 2 of a SIIM blog post. Enjoy.

I have been discussing what it would take to create a “check list” of sorts (a scorecard?) to assess ones facility’s capabilities and strategies along the proposed themes listed. Would be fun to work on, but would need lots of help from people with bigger brains than mine. Stay tuned for a bonus Part 3, maybe? 🙂

P.S. Part 1 is here.