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.

Enterprise Imaging Industry State-of-the-Art

Based on discussions with colleagues and our clients, Enterprise Imaging is becoming an integral part of U.S. Hospital IT Consolidated Clinical Record strategies.

HIMSS-SIIM Enterprise Imaging Workgroup‘s current working definition of Enterprise Imaging is as following:

  • Diagnostic Imaging – Encompassing traditional diagnostic imaging disciplines such as Radiology and Cardiology
  • Procedural Imaging – Including images that are acquired for diagnosis or clinical documentation purposes (such as visible light photos, point-of-care ultrasound)
  • Evidence Imaging – Including images and/or videos that are acquired for clinical documentation purposes (for example, scope videos, computer aided detection)
  • Image-based Clinical Reports – Documentation that includes or entirely consists of images (for example, Pulmonary Functional Test (PFT) report, multi-media pathology report)

Despite the attention from vendors, industry focus, and provider demand, this market space is still in its early stages of development. There are two main reasons: 1) the scope of the problem domain is still being defined; and 2) the vendor community is still working out the best practices and optimal technical approaches.

Moreover, the number of the departments that generate Enterprise Imaging content and that have their own departmental workflows is quite large.

This results in significant confusion on the provider side who are left to navigate a myriad of perspectives expressed by the imaging informatics industry. There are on-going initiatives that are currently working on demystifying the field of Enterprise Imaging. For example, the recent SIIM Webinar delivered by Dr. Towbin from Cincinnati Children’s, provides a very thorough analysis of the problem domain.

In conversations with vendors and providers, we have compiled several observations that might benefit the imaging informatics community.

The Right Approach

In the SIIM 2015 Opening General Session presentation, Don Dennison presented the following slide titled “Enterprise Image Management: Making the Right Choice”

EI

With the various systems in place to manage patient record data, there is often debate as to which enterprise system is best suited to offer Enterprise Imaging services.

At the moment, there is no obvious answer to the question presented by the slide. Besides the technical capabilities of the systems, the provider’s internal IT capabilities, capacity and policies can significantly influence the decision. At some organizations, where the Imaging Informatics Team plays a prominent IT role, the choice could be the VNA, while at others, where the Enterprise IT team takes the lead, the EMR or ECM is often chosen.

The Right Functionality

During RSNA 2015, we conducted a study to identify the state-of-the-art of Enterprise Imaging technology, including methods of acquisition, management, and distribution of non-DICOM images. The following table summarizes our findings.

 

Image / Video Acquisition
Ability to capture from mobile devices The majority of current vendors opted for native applications to provide better user experience and tighter security controls. Still, image capture is the prevailing capability, with video acquisition capabilities lagging behind. Some vendors offer integration with leading EMRs’ mobile applications.
Ability to capture from visible light cameras The ability to manually (i.e. file browse, drag & drop, etc.) upload both videos and images is a commodity. Automatic ingestion, on other hand, varies significantly from vendor to vendor. Most vendors offer proprietary integration frameworks, but their comprehensiveness and real-life integration experience is very different from one to another.
Ability to capture from different scopes Most of the vendors leverage third party hardware devices to integrate with digital or analog video sources real-time.
Acquisition Workflow
Order-based Workflow DICOM Modality Worklist (DMWL) SCU support, as well as the ability to generate or receive order information, are available in most vendor’s applications.
Context-based launch of the capture application is also a well understood and supported functionality.
Many of the vendors mimic an order-based workflow (i.e. create the Accession Number) for the acquisitions that are not scheduled. The main challenge with this approach is to determine the correct method to feed the created information back to the EMR (e.g. often called an “unsolicited result”, which may not be supported at the site).
Encounter-based Workflow Some vendors, originating from the Diagnostic Imaging space, struggle with native Encounter-based workflow support.
On many occasions, departmental visit/encounter information, supplied in HL7 messages from the EMR, is sufficient to build specific acquisition worklists for different service lines.
Scenarios where information services are not available Most of the vendors offer the ability to manually create patient and procedure information. The difference lies in whether all or just a sub-set of capturing methods (e.g. mobile vs. desktop) support that functionality.
Patient identity management Standards-based methods to discover or receive patient information is widely supported, while the support for proprietary methods to connect to patient information sources varies from vendor to vendor.
Ability to Edit Images/Videos
Editing Tools Most of the vendors rely on an installed Windows OS client application to edit (e.g. crop) acquired images or videos as part of the manual upload process (e.g. drag & drop). Selected vendors also allow static image editing only (i.e. no video) during the mobile capture.
Images An ability to associate different types of metadata (including notes) is supported by the majority of the vendors. Also, basic manipulation of the acquired images such as image deletion, markups and annotation, which are stored as overlay objects associated with the acquired images is common.
Only selected vendors are capable of calibrating images on-the-fly by using recognizable objects of known size embedded in the image.
Videos A flexible and comprehensive ability to associate different types of metadata (including notes and keywords) is supported by the majority of the vendors.
Most of the vendors have very limited (if at all) video editing and capturing capabilities and rely on third party providers.
Viewer
Current state The solutions typically consist of the following viewers:

  • Mobile capture
  • Desktop image/video upload
  • Desktop image/video editor
  • Zero-footprint (ZFP) EMR viewer with very limited, if at all, editing capabilities
Privacy and Security
Current state Most of the vendors offer a range of methods to ensure PHI protection such as:

  • Information deletion/encryption from the device
  • Strong Authentication and Authorization methods
  • Auditing
Reporting
Current state The most prevalent approach is to rely on an external system, such as the EMR or specialty-specific reporting application, to create and manage reports.
Record Management
Current state Most of the vendors opt for managing image and videos in their native format, while converting the content on-the-fly for standards-based communication with external systems.

Conclusion

It seems that Enterprise Imaging is going to rapidly evolve and we are eager to see how our clients, and providers in general, will benefit from these changes.

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

Why should you work here? No EMR!

This article has some great observations and sound bites, including the mention of a hospital promoting the lack of an EMR in their employee recruiting ad as a reason to work there.

Health IT is often touted by IT professionals (myself included) as necessary for the digitization, consolidation, aggregation, integration, access, and exchange of a patient’s information.

The article describes how the introduction of an anti-social third party—a computer with an EMR on it—affects the physician-patient relationship.

It also talks about the current state-of-the-art for user experience design within EMR systems.

In an example of a near fatal medical error involving an EMR, it mentions a phenomena often known as “alert fatigue”, whereby a system provides so many alerts, they become ignored (or disabled). IT professionals may have experienced this in poorly configured system monitoring solutions.

See this article for an more in depth explanation of the problem that caused the medical error.

In talking with organizations that are in the throws of EMR adoption, they are focused on data migration, interface development, pre-canned training, roll outs, organization redesign, and cost management. There is little time for reflection on user satisfaction or efficiency. Vendors trying to sell their solutions into one of these organizations often find it difficult, as resources are scarce and the motivation to add yet another system to manage/interface is low. Budget holders are reluctant to spend money on solutions if their pending EMR promises to have similar capabilities (even if this claim is yet unproven).

When I encounter an organization that is well past their EMR implementation, they are typically looking for ways to optimize their use of the EMR. This may involve configuration changes to the EMR or changes to their workflow, but often involves the use of add-on solutions to fill gaps, or “hacks” to provide alternatives to the user interfaces provided by the EMR to their users.

The above observation on how organizations differ based on where they are in their EMR adoption, makes me think about this excerpt from the article…

“In the 1990s, Erik Brynjolfsson, a management professor at M.I.T., described “the productivity paradox” of information technology, the lag between the adoption of technology and the realization of productivity gains. Unleashing the power of computerization depends on two keys, like a safe-deposit box: the technology itself, but also changes in the work force and culture.”

I think that where Brynjolfsson is recommending  that both “keys” are considered and used in parallel—at least where EMRs are concerned—we are more often than not using them serially. First, get the EMR in as quickly as possible (to save costs and hopefully to reap the rewards promised sooner), and only after we better understand what we actually bought and have, start to figure out how to do it right.

There may be no better way, given that healthcare institutions can’t just stop and “reboot” themselves with a system and staff that is optimized. But, one can imagine that living and working in that period following an EMR implementation, and before the age of enlightened optimization, can be painful and frustrating (and even dangerous, as the article shows).

So, maybe promoting the lack of an EMR may attract those people tired or afraid of the post-EMR, pre-optimization period, as there they can be happy. For a while.

Article – CDC on EHR errors: Enough’s enough

In this article, the CDC has issued a warning on the issues of user interface design when presenting patient information in EHRs.

As the examples in the article illustrate, having information in digital form is not enough. It needs to be presented in an effective way to ensure comprehension. After the current wave of information digitization and consolidation (moving information from disparate, departmental clinical information systems into a single large enterprise system), the next wave of effort needs to be on privacy/security, accessibility/reliability, and usability, or the incredibly high potential gains will not be realized.

Users need to trust the system, it needs to be there when they need it (wherever that is), and they have to want to use it.

P.S. Here is an infographic on EHR adoption.

The Gamification of Radiology

Check out this article on gamification and clinicians.

In Radiology practices, obvious applications of gamification is using the inherent social pressure of it to improve report turnaround/signing times and peer review quota compliance. Or, even clinician satisfaction of the report.

It could also be used to provide reward/advantage to technologists that provide superior service to patients and acquire good quality imaging exams.

Participating in continuing education opportunities—say, like by attending the SIIM Annual Meeting—could also earn “points” toward rewards.

To work, it needs to be based on meaningful activities, include an aspect of social pressure and provide rewards that matter to the participants.

JDI Article Published – REST Enabling the Report Template Library

I contributed to an article recently published in the Journal of Digital Imaging. The primary author is Brad Genereaux (@IntegratorBrad). His blog is here.

This article examines the use of a REST API to discover, retrieve and use structured radiology report templates from an on-line report repository.

Check it out and let me know what you think.

JDI Article Published – Where to build It

Another article I submitted to the Journal of Digital Imaging has been published electronically.

This article compares the pros and cons of building a healthcare IT application in an Established Vendor, a Start-up or a Hospital Lab environment, examining aspects such as access to design input and validation to commercialization and transition to support.

Check it out and let me know what you think.