Leaving Charlotte (Congress, Are You Listening?)

I left the meeting wishing I had arranged to fly out after the last session rather than before. I also left with a deepened respect for the remarkable work being done by imaging informaticists, and a sense of anticipation about what is to come. Let’s face it: it takes more than software and hardware to ensure digital communications. It takes experienced, innovative IT people who can adapt these tools to individual workflows. And then keep adapting. And adapting. And adapting some more. The job is never done.

Imagine what could happen if Congress deputized these people and this industry with the promise of some stimulus funding.

—C. Proval

The Marseillaise, Southern Style

Way down South below the meeting rooms, a mood of revolt percolated across the exhibit floor. Maybe it was the two sets of stairs required to make the descent into the exhibits or maybe people just didn’t have any money to spend, but the level of commercial activity in the booths was nothing to write home about. Attendance did appear sparser than in the recent past, but the real surprise would have been if hadn’t been. SIIM is not immune to the worst economic downturn since the Great Depression.

Vendors, however, were looking for an advocate to emerge from organized radiology to articulate what needs to be said: radiology informatics is a very real piece of the electronic medical record, and if practices and hospitals can demonstrate meaningful use, then they should qualify for funds. SIIM, an organization for education and research, appears unwilling to be that advocate. Question: will radiology’s advocacy organization, the ACR, take a position? Or will it keep a low profile on the issue and reserve its political capital to fight DRA II? And RAP II?

—C. Proval

The United States of SIIM

Throughout the meeting, there was evidence of the tremendous diversity that SIIM has come to represent. In attendance, were PACS administrators, hospital IT people and information management people, private practice radiologists, academic radiologists, practice IT managers and CIOs, and radiology administrators. And probably even more.

During the image sharing session, Cyrus Samari, Sorna Corp, wanted to know why people were still producing non-DICOM CDs. A woman in the audience explained that this was all that her modalities produced. Question marks appeared on the brows of many in the room: Was she using technology from the Paleozoic era? Was she making it herself from an erector set? Sensing the curiosity, she confessed that she was a veterinarian with an organization that owned 700 hospitals.

CDs: Friend or Foe?

In a Saturday afternoon session on cross-enterprise image sharing and accessibility, most people seemed to be of presenter Bradley Erickson MD’s mind: “I’m happy to give them, but I am not happy to receive them.”

Erickson said 85% of all materials coming in from outside the Mayo Clinic are on CD, and an informal poll of the audience confirmed that many radiology departments across the US are awash in CDs. While the digital revolution appears to have been a success, this heir apparent to film for providing patients their studies has created a new set of issues with which to contend.

Consider these figures from the Mayo Clinic:

2% are for the wrong patient
1% has more than one patient on it
3% are unreadable
1% contain correct patient but different forms of name or ID
4% contain non-DICOM data

What is your workflow for accepting CDs produced at other institutions from patients?

“Do it well or it will come back to burn you in many ways,” Erickson advised. “Almost two patients each day are showing up with the wrong CD.”

Worth Repeating

Heard on and off the podium:

On repeat exams: “There needs to be…a penalty to duplicate expensive imaging. [We must] do the right study the first time.”
—William Keyes, MD, Inland Imaging, Spokane Washington

On the need for distinguishing the archive from the software that manages the archive: “We talk about the image archive and the management as one thing. IHE has failed on that, separating the management part from the archive. That’s something that IHE hasn’t addressed.”
—David A. Clunie

On importance of IT to the private practice: “Our president said if he had to choose between IT and a CT scanner he would put it into IT…There is a need for OIC (outpatient imaging centers) to be ready for what is coming and at Jefferson we believe that will happen through IT.”
—Arne Meis BS, Jefferson Radiology.

On the real world (after Lawrence Tarbox, PhD, itemized the list of high technology reserved exclusively for research at Washington University School of Medicine) “I can’t get a PC.”
—Unknown private practice radiologist

On system users: “If you could just remove all of the end users from all of the applications of the database, the system would work perfectly.”

—Charles Socia

Open Source: Free, But Not Always Easy

There are two reasons to seek out open source software, said Jim Whitfill, MD, CIO at Scottsdale Medical Imaging Ltd: access to code and the fun fact that it’s free. This makes the tools particularly attractive to practices operating in the outpatient environment.

Whitfill moderated a session on PACS workflow and IT infrastructure in the imaging center environment, during which the presenters offered much evidence of the innovation and surprising achievements of small groups of imaging informatics professionals in the employ of private practices.

“We often have limited capital with R & D budgets, so if we want to play around, open source is a great way to investigate new technologies with a low cost,” he said. “As CIO, one of the things I like to do is see what’s going on in other industries, and see if they can work for us.”

Whitfill graciously shared his open source tool box with attendees with the caveat that although some have best in class functionality, you need a high functioning IT department to work with the tools.

“It’s not a free ride,” he warned. “Support makes CIOs nervous.”

Who Owns Imaging? (A Play in Five Parts)

This is not a trivial question. As digital imaging has matured, the stakeholders have multiplied, and a number of models have emerged.

But consider this: ultimately, whoever owns digital imaging is responsible for uptime. The better question might be: Who wants to own digital imaging?

“If we really recognize that digital-based image management is important, then it has to run 24/7,” said Paul Chang, MD, University of Chicago. “Who is responsible for providing the service, for the workflow, and for answering the phone at 3 in the morning?

The panelists took absolute positions (for dramatic purposes) on a handful of different models. Dramatis personae were: Manuel Brown, MD, Henry Ford Hospital, argued for radiology control; Benoit Desjardin, MD, PhD, University of Pennsylvania, argued that each clinical domain should control its own images; Steven Horii, MD, University of Pennsylvania, argued that IT should run imaging; Chang made a case for enterprise IT; and Matt Long, Philips Medical Systems, offered the vendor perspective on the optimal ownership model.

Northern Exposures

Over a sandwich on the exhibit hall floor and a white chocolate chip cookie the size of my head, I had an interesting conversation about national health IT initiatives with a radiologist attending from Hamilton in Ontario, Canada, David A. Koff, MD. What is interesting are the parallels between the Canadian and the US efforts to built a functional national EMR. The level of financing and its source are very much the same. Canada is spending about $2 billion on its effort, the Canada Health Infoway, and the US, with about 10 times the population, has allocated close to $20 billion in the stimulus package. Both efforts are government financed.

The big difference is that Canada has expressly reserved about $400 million, almost a quarter of the total, to build a nationwide Digital Image Repository that will hold images and reports. Part of that funding will also go towards financing up to 50% of a PACS purchase for a hospital that requires one. The DIR will be composed of 18 or 19 storage vaults and will contain images and reports for the life of the patient. Most provinces have anointed a preferred PACS vendor.

“It is either the most stupid or the most brilliant idea I’ve ever heard,” Koff commented. “I’m not sure which.”

Several more questions occur.

Why has Canada reserved almost a quarter of its EMR budget to finance imaging informatics when the US stimulus bill did not even mention radiology by name?

Here’s another:

—C. Proval

The Data Migration Blues

12:30 AM Pity the poor imaging informaticist who has a data migration in their future. That potentially includes everyone who owns a PACS.

“PACS has a 5 to 7 year life cycle,” explained Richard H. Wiggins III, MD, University of Utah Health Sciences Center. Wiggins sat on an afternoon panel, PACS/RIS Replacement Debate, with William Gregg Jr, MS, LSU Health Sciences Center; Richard “Skip” Kennedy, MSc, Kaiser Permanente Medical Group; and David Wild, Fujifilm Medical Systems. Charles Socia, RT, Empiric Systems/Fujifilm, moderated.

Forewarned is forearmed, so Socia laid out the ugly truth with a discourse on the nature of data structure and the specificity of HL7 message types. For instance, a DFT (data financial transfer) message can be hundreds of characters long, and there is an ADT (admission discharge transfer) message for every type of patient transaction. Needless to say, the opportunities for error are many in a field where data integrity is crucial for everything from taking care of patients to getting paid.

Stimulus Opps More Ephemeral Than Monetary

7 PM: A morning session on Economic Stimulus Package Funding Opportunities may have disappointed those looking for hard and fast guidance on how to pay for imaging informatics with some of the $19.2 billion allocated for EMRs. No fault, of course, of presenters Bradley J. Erickson, MD, PhD, Mayo Clinic, Rochester, David S. Mendelson, MD the Mount Sinai Medical Center, and Eliot Siegel, MD, University of Maryland and the VA Maryland Health Care System. The details are still vague.

But the session began to build a scaffold around how radiology may fit into the bigger picture. Meaningful use is a key qualifier to receive stimulus funds, but like a 1950s TV, the picture will take a long time to emerge: the deadline for the definition is December 2009. Now is the time to take that leap of faith, and brainstorm a better, more interoperable future through imaging informatics.