The annual gathering of healthcare imaging and IT
professionals, i.e. SIIM 2019 in Denver kicked off with a moving story by the keynote
from a patient, Allison Massari, who survived a life-threatening accident that
burned over 50 percent of her body. Her story of the impact healthcare
providers had on her recovery set the stage for hundreds of healthcare imaging
practitioners, consultants and vendors to exchange their experiences and gave
added meaning their professions before talk turned to their products and
services, and education of their peers on what is new and what is coming. The
meeting had good “vibes” as people were eager to learn and there was excitement
about new developments.
Here are my impressions:
1.
AI is over its initial hype: the initial
fear factor that came with the hype of first AI applications that made radiologists
anxious about the potential impact on their jobs has faded and it is
becoming obvious that there is still a
lot of work to do and a long way to go.
Most AI companies don’t even have
FDA approval for their products yet, even though the FDA is stepping up to the
plate and is giving special considerations to the fact that many of these
products are based on deep learning, whereby the behavior of the software might
change over time.
This infographic
provides a nice breakdown of FDA approvals over the past several years showing
the percentage of radiology algorithms that were approved. AI is finding its
way in some of the PACS applications starting with workflow enhancements, there
are dose reduction applications for CT screening and some “low hanging fruit” surrounding
detection of common diseases.
2.
Enterprise imaging is still very challenging:
As Jim Whitfill, the current SIIM chair mentioned during his update, enterprise
imaging is what most likely saved SIIM from its demise after the 2008 downturn
in membership and conference attendance, as IIP professionals were starting to
think about how to do enterprise imaging and subsequently publishing about it
in the Journal of Digital Imaging.
The VNA or Vendor Neutral Archive
became the vehicle to implement enterprise imaging solutions, however, the non-order
(aka encounter-based) workflow for those non-radiology or cardiology
departments is poorly defined and there are many different options. See my
related post
in which I identified more than 100 possible implementations. Talking at SIIM
with several implementors, I identified three different strategies:
·
The "top-down" approach - This
model implements a vendor-neutral archive (VNA) for radiology and/or cardiology
first, and then starts to expand it with other departments, however, there is
no single, uniform workflow for those departments resulting in many different
options.
·
The "bottom-up" approach - This
model, which was used at Stanford University implements a VNA beginning with
one department and then adding in other departments using the same workflow
(which is DICOM worklist based). After adding many other specialties, they are only
now starting to add radiology and eventually cardiology.
·
The
“hybrid” approach - This method, which was adopted at the Mayo Clinic, is a
combination of both approaches, instead of having many different workflows or
only one single workflow, they settled for only a handful, in this case five
major workflows for the different departments. You can see details of this
discussion at this short video clip.
3.
Teleradiology workflow is very challenging: there are only a few PACS vendors that do
teleradiology well, as a matter of fact, many teleradiology vendors build their
own system as the requirements are so different:
a.
The turn-around time requirement is very
challenging - a typical turn-around time has to be 5-10 minutes for trauma
cases. This means that the workflow is super-optimized.
b.
AI can make a major impact - Hanging protocols
are very hard to define as the source for these studies vary widely, some of
the studies group all images in a single series, some in multiple series, and
the series descriptions are not uniform, therefore, a simple algorithm
determining which is the PA and which is the lateral chest and ordering them
consistently saves a few mouse clicks which is time. Prioritizing studies based
on certain critical findings is important as well. AI definitely assists in the
efficiency and automating of repeated tasks.
c.
There is a lack of patient contextual data - There
are many challenges to get the prior images for a particular study (see a
renewed activity described below) as the use of CD’s for image exchange does
not seem to be going away soon. But this workflow is well defined by IHE XDS-I
and other profiles, and in many countries other than the US there are
successful image exchange implementations based on standards. However, instead
of a radiologist logging into an EMR and looking at the images while having the
other patient context at their fingertips, a teleradiologist logs into a PACS
seeing the image, wanting to have that patient context from potentially many
different EMR’s. It is a “reverse” workflow, instead of being EMR-driven
pulling multiple imaging studies, it is PACS driven wanting to pull multiple
EMR documents. This is a new challenge which is not quite addressed yet;
ideally one could maybe pull CDA’s from these EMR’s but those were really
defined for a different purpose.
d.
The workflow is reversed - the traditional
Order-Study-Report workflow looks different for a teleradiology application as
in many cases the order comes after the fact, so it would be Study-Report-Order
(including “reason for study”)-Report update. Interestingly enough, when
talking with teleradiologists, they only have to adjust their report based on
the “reason for study” in a few cases. Regardless, this workflow needs to be
addressed by their PACS.
e.
Many studies, if not all, are “Unverified”- This
is particularly true for battlefield and disaster applications. There is often
no patient name (“civilian 1”), and definitely no patient ID, and it is not
uncommon to have partial studies. A PACS that depends on the traditional
order-based workflow will perform very poorly.
4.
CD’s are here to stay (for a while): I do
have personal experiences (as many do) with image exchanges for me and my
family as witnessed by the stack of CD’s I carry to doctors and specialists.
Actually, as some of them lack CD readers on their laptops or have their
computers locked down by their security departments, I carry a laptop with me
with the images preloaded and ready to be viewed. My experience with my
veterinarian is completely different. When I asked for a copy of the MRI of our
dog on a CD from our neuro-veterinarian, I was told that it is “old-fashioned”
but that they would be more than willing to send me a link to view the images
in a viewer, or, alternatively allow the images to be downloaded as a zip file
for me and my regular veterinarian to review, which I did. How is it that our
veterinarians have this all figured out and our physicians don’t? I can come up
with many reasons, but one of them was identified by a special ACR/RSNA
committee which met during SIIM and that is the lack of a standard governance
agreement. Instead of having to get BA’s from all your partners covering the
HIPAA requirements, they recommend a standard document as part of the Carequality consortium, in the form of an
implementation guide, which is available as a draft for public comment. In the
CareQuality framework, 36 million documents are exchanged each month using 16
networks based on IHE XCA standards. If we can exchange documents, there is no
reason to not exchange images.
5.
Cybersecurity is a hot topic: there is
not a day or week that goes by without a report of yet another ransomware
attack or security breach exposing literally millions of patient records. There
have been reports of CT scans modified to create significant findings using the
DICOM header preamble on CD’s to embed viruses on old devices that still run
old OS that are not being patched anymore (note that Windows 7 support stops in
January 2020).
Key safeguards include upgrading old
OS’s, if that is not possible, then isolate them from your network as well as
disable the USB’s (which is a problem by itself as several modalities depend on
the USB to connect ultrasound, dental, or other wands and detectors), secure
networks, and educate your employees on the danger of social engineering is
critical. At one facility, the open rate of spam emails dropped from 80% to
less than 20% after the IT department started to send out “bogus” spam emails
to alert their employees to the danger of social engineering. Another great
example of this phenomena was that of a (infected) USB drive that is dropped in
the employee parking lot of a hospital with its logo on it so that an
unsuspecting employee with good intentions will insert it in a hospital network
computer resulting in great harm.
6.
New standards are available to provide
greater interoperability: DICOM, FHIR and IHE have made several new
additions which are covered my SIIM report part 2.
Overall, yet another good year for SIIM and its members. The
major differences between SIIM and other mega-meetings such as RSNA is the fact
that you can cover the exhibitions without having to walk (and often run) many
miles in between different booths, you have much better access to many of the
faculty and peers, and last but not least, there are an abundance of hands-on
workshops to experiment with new tools and standards.
For example, at the XPert IIP workshop, attendees could learn
troubleshooting DICOM headers using DVTK and the DICOM protocol using Wireshark
sniffer using pre-loaded laptops provided as part of the training. Sessions
covering DICOMWeb and FHIR hands-on experience as well as the IIP sandbox
covering Mirth interface engine programming were also very popular. One of the themes this year was empowerment, what better way
to empower users than by providing them with the skills and tools to do their
job better and more effectively.
Next year will be in Austin, which is closer
to the OTech home base (Dallas, TX), I am looking forward to another great meeting next
year!
