What is your Enterprise Imaging Strategy: Bottom up or Top-down?

Enterprise imaging is the latest trend; however, a well working solution can be challenging to implement. The most common challenge is the differences in the various workflows. To implement an enterprise solution, three methods can be used:

1. A "top-down" approach - This model implements a vendor-neutral archive (VNA) for radiology, cardiology, and several other departments, all pretty much at the same time. The problem is that every department has a different workflow. Some use the DICOM Modality Worklist, some use a HL7 feed, some don’t use any prior order or worklist mechanism causing the images to be reconciled with the patient information after the fact. As a matter of fact, if you look at all of the different possible combinations, there are more than 100 different scenarios as described here. Using the top-down approach will set you up for chaos if there are no well-defined workflow options and you let every department decide on their “favorite” workflow.
2. A "bottom-up" approach - This model, which was used for example at Stanford University Healthcare, implements a VNA beginning with one department, and then adds other departments using the same workflow. This solution results in an initial struggle to adapt everyone to the same workflow but as soon as people start to see the results, everyone will get excited and be ready to tackle the next one. As of today, Stanford has several departments on-line, but everyone uses the same workflow. Interestingly enough, radiology was not the first department they started with. Also note that this is a multi-year process, which will take longer than the top-down approach.
3. A hybrid approach - This method, which was adopted for example at the Mayo Clinic, is a combination of both approaches as it might not be feasible to have everyone using exactly the same workflow. In this particular institution they have identified five distinct workflows and all of the new departments pick from these five options. These options include the traditional order-based workflow, in their case driven by their EMR, the non-order-based workflow using Patient ID look-up for demographics and creating an EMR order after the fact, DICOM wrapping of JPEG’s and a couple of variants.

Therefore, to implement enterprise imaging, don’t go for the top-down approach as it can be chaotic, as each department uses a different workflow, but rather, develop a handful of workflows (preferably 3 but no more than 5) and steer the departments to these options. The options will be different for most institutions as each one has a different IT infrastructure and different access to patient order and encounter information. Before starting your implementation, develop these workflow options and spend time testing them to see how they work, and if they do, stick with these, even though it will require that users to change their behavior. As soon as they see the benefits, it will be successful.

For a video version of this presentation, including some thoughts on recent developments in PACS technology, see the live interview here.

Volunteering in Africa

Black Lion hospital CT/MR pavilion

I stepped out of the hotel lobby in Addis Ababa, Ethiopia, to a tropical downpour. No way would I have been able to walk to the hospital without being totally soaked, including my backpack with my laptop. The doorman saw my desperate look and told me to wait, as he was talking with a gentleman in a nice car waiting in front of the hotel. He then told me to step in and that he would take care of it. I told the driver that I was on my way to teach in the local hospital and we had a nice conversation while he made sure I arrived dry and safely. When I wanted to pay him, he refused, saying, “Thank you for what you do for my country.”

This is the kind of experience you can expect when working in a developing country as a volunteer. Not only do you make a big difference by spending your time and sharing expertise, but it is also very rewarding, and excellent “feel-good” therapy. The people you interact with greatly appreciate your contribution; not only the professionals that directly benefit from the shared knowledge, but many others that you encounter on the street or at your hotel.

In this particular trip, I was doing a RAD-AID sponsored IT assessment of the PACS system at the Black Lion Hospital in Addis Ababa. We were trying to solve a number of issues including: image quality issues with MRI images coming up unreadable at the PACS, figuring out how to connect their home-grown EMR to get a worklist going at the modalities, installing a teaching file solution, and trying to address several other small issues that they were encountering. In the week prior to that I taught a PACS bootcamp to 13 PACS administrators in Dar El Salaam, Tanzania, which was very well received. I like nothing better than the “Aha, is that how it works?” glint in the eyes of these professionals.

Teaching PACS bootcamp in Dar El Salaam

People sometimes ask me how it is to teach or work with healthcare professionals in developing countries, and I tell them that it is not any different than teaching in the US or any other country. There are smart and eager-to-learn people everywhere. The problem in developing countries is that there is very poor or no support from the vendors that provide the equipment as they don’t spend time and effort to create a support structure with well trained engineers. Therefore, the hospital staff often has to figure out the issues by themselves, which is why training by organizations such as RAD-AID and the SIIM Global ambassador program is so important and makes such a big difference.

I would encourage each and every SIIM member to consider volunteering. I know it might be somewhat out of your comfort zone, but I can guarantee you that not only will it make a major difference on the receiving side, it will be equally rewarding for you as a person as you will grow and gain new experiences. I myself am definitely hooked and can’t wait for my next assignment. I’ll do this as long as I am able, and I’m thankful for SIMM to support such a great cause.