The majority of the US hospitals are looking for a VNA or Vendor Neutral Archive to facilitate future PACS upgrades and/or changes in PACS vendors and also to allow different specialties to make use of this enterprise-wide asset to archive and manage their images. An additional advantage of the VNA is that it also becomes an access point for inter- and intra-enterprise image access by non-radiology physicians.
The VNA, combined with the recent wide-spread implementation of EMR’s facilitated by the ARRA Meaningful Use incentives now can provide easy access to imaging archives via the EMR portals with a simple click of the mouse. Most radiology results used to be available only through transcribed reports, except for “heavy” imaging users such as surgery or orthopedics, but now the floodgates are open and images are available at basically every PC. The scale of this image availability can be mind boggling, take for example the Mayo health system in Rochester MN, which has close to 50,000 PC’s that have this capability.
The days that physicians had to come to the radiology department to look at images are long gone, although image access was available through web-based protocols at clinical workstations, by tying image archives into EMR’s, image access has become ubiquitous. What is the impact for radiologists? They are no longer gatekeepers of the information, and their role needs to change if they want to keep their added value. Here are some of the recommendations on how to deal with the advent of enterprise imaging and my suggestions for turning it into an opportunity:
1. Have input on the workflow.
Make sure the radiology voice is heard and participates in planning meetings as it is critical to design the workflow upfront. Here are a few potential bottlenecks that can cause issues:
Determine when images are becoming available to the enterprise. It might be wise to make images available to physicians only after the report is generated, assuming it does not involve emergency cases.
Some large hospitals have a dedicated 3-D lab for the CT and MRI reconstructed views. Creating these additional images might also be a condition to have the images in a holding pattern until all data is ready to be reviewed.
How to handle image updates, deletions, and modifications must be taken into account. Imagine that all changes are made by a technologist, or in the case of a complicated fix by a PACS administrator at the departmental PACS, these must be communicated to the VNA. There could be a race condition where some of the image fixes arrive at the VNA prior to the images, and to avoid any conflicts, you might need middleware to buffer those changes until the images arrive.
Make sure that the EMR viewer supports displaying the key images identified by a radiologist; you don’t want your surgeon to have to scroll through a 3000-slice whole body CT. Instead open up only the images that are relevant to the finding, for example, a lesion to be excised in the lung. In addition, make sure that Presentation States are supported as well to show annotations, window and level settings and zoom/pan changes by the radiologist.
2. Consult with the specialties about the review and processing features of the EMR viewer.
Each specialty has its own workflow, especially if they are “encounter based” and not used to scheduling formal orders such as is the case for most radiology departments, so that merging the patient demographics to the images could be challenging. Remember that radiology has probably at least a decade of experience with managing and viewing images, which can be invaluable to the deployment of image viewing across an enterprise. There are many lessons learned that can benefit the decision- makers who are looking to make an investment in the enterprise imaging system. This does not apply only to the radiologist but also to the PACS administrator who will have a lot of experience keeping the system up and running and taking care of the image and information integrity.
3. Change the role from gatekeeper to consultant.
Be proactive to make sure that the physician knows that he or she can access your expertise and ask questions about any findings. For many findings there is a grey area in between benign and malignant or is it really a fracture or a sprain, and having a conversation about these findings can be invaluable for the physician and ultimately the patient.
4. Embrace the opportunity of additional access.
Enterprise imaging does not only provide access for many more specialties than radiology and cardiology, but the reverse is true as well. A radiologist looking at a head CT can also view the images from the CBCT done by dentistry, looking at potential head wounds and/or other image documentation done when the person was admitted to the ER, correlating ophthalmology images with brain function that control vision, and surgery notes if there was any brain surgery done. There is much to gain, especially if the PACS is driven by the EMR providing access to notes, labs, allergies, patient family history, and much more.
Enterprise imaging also assumes access from outside your enterprise through standard communication protocols for image and information exchange such as XDS and access to a registry to find out if and where prior exams would be accessible. This is also a major advantage as the headache of importing and exporting CD’s with prior studies will replaced with easy on-line access.
In conclusion, enterprise imaging is an opportunity instead of a threat. It belongs in the “O-quadrant” of your SWOT analysis. According to Harold Welch, the vice president of technical solutions at Novarad, patients and physicians will begin to demand that medical institutions have this more progressive level of technology. Don’t feel threatened by this; embrace the opportunity for change. Radiologist, being THE imaging experts can make an impact on having input on the decision-making process for the next generation imaging and informatics solutions.
The author, Herman Oosterwijk, president of OTech Inc., is a healthcare imaging and IT trainer/consultant for Novarad, and other companies, specializing in PACS, DICOM and HL7.