Insight is a Fortune 500-ranked global provider of hardware, software, cloud and service solutions for business, government, healthcare and educational institutions. Insight provides clients with guidance and expertise in selecting, implementing and managing complex technology solutions to drive outcomes. Chief Information Officer Mike Guggemos is a recognized leader in IT and has been featured in the Wall Street Journal’s CIO Journal blog, Forbes, and other publications. He spoke at a recent information technology event about survival tips for IT administrators navigating the evolution from information technology to intelligent technology. PARCA eNews spoke with Mr. Guggemos about how those changes in information technology impact PACS administrators.
Q. What is intelligent technology?
There are a multitude of things that wrap into intelligent technology. A smartphone is an example, even the moniker in front of phone implies intelligence, and broadly any type of device that works on the "fringe" that people use outside of core systems. The reason why I use that particular phraseology when talking about these devices, or interaction points, is because they have changed so dramatically that they are mostly intuitive. And from the PACS perspective, I was an Army medic in the 80’s and 90’s and what they are doing today is dramatically advanced compared to then. The same fundamental processes are used, but now we are sending electronic files versus physical ones. They're going to processing, to patient care, to remote offices… They go to all these different areas and it spans multiple disciplines.
Well this is the other part of intelligent technology, and this is on the inside of the systems, so out on the fringe you (PACS administrators) have things that in some cases are controlled by their organizations and in some cases they are not. So anything that is cloud-based, run by a third party or in a co-op, they don't control. Somebody else fundamentally controls the technology, they may have input into it, but the cycle time of change is drastically reduced for those systems; things happen faster.
As you come into the PACS server environment, two major factors are impacting the need for additional capacity and stronger core infrastructure: the number of films being collected and the digitization/move to better quality images - i.e. more pixels. Every change at the fringe has an impact on the core servers that they are running and operating − the servers, networking, storage, etc.
I'll give an example. I'll try not to use specifics, but there is a very large oncology center in the US where the resolution they are using on their scans is something that was unheard of just three years ago. The change is as significant as the shift from analog to HD to 4k in television. What really changes is the pixilation – i.e., the amount of information that is broadcast and the density that can be displayed. It isn't being driven from the core system; it is being driven from “fringe” devices the physicians and others are using, such as iPads and iPhones or Windows Surface devices.
As screen resolutions improve, normal resolution films become grainy and distorted. How do you fix that? Well, suddenly you have to go back into the camera aspect, or how those films are being saved and transmitted. Having denser films means you need more network, because they consume more storage space, and in some cases can be up to four times as much data.
Those are the things that are really hitting those administrators hard, and they have to be paying close attention to things that they normally wouldn't. So it is about getting the films and having them routed and storing them, and the other piece, that is just now emerging, is more on the end-user devices within their environment and how cameras and screen resolutions are changing, and are they able to keep up with the infrastructure needed to get the data to those intelligent devices as quickly as possible.
This is where internal infrastructure now has to be intelligent as well. Infrastructures now have to respond dynamically to “fringe” devices; this is the reverse of how most architectures were designed and how organizations operated.
Yes, that is absolutely part of the issue. I'll try to synthesize this down. PACS administrators had almost total control 5-6 years ago and definitely 10 years ago. Now, there is so much that is out of their control. As a result of this shift, one complaint might be: “I can't read this film or it doesn't display properly, or it is in bits and pieces.” But those bits and pieces are outside the core system that the administrators run. So the things that are impacting their world are things they don't have control over, almost without exception. There are a few institutions where they control the whole ecosystem, but the majority don't.
Q. Is that the chaos PACS administrators need to look out for? Is there a management possibility or is it all out of their control and they just have to work with that?
No, I think there is much more within their control than it sounds, but it is not a management issue, and this is true across all areas, not just in the medical space. People make a mistake by trying to own all of the devices. For example, a practice group purchases a new ultrasound device. What say do the PACS administrators have in that purchase today? Probably not much. However, the new one (ultrasound) has a higher resolution screen than the one prior to it, and that is outside their control, so trying to manage that type of chaos today is illogical. However, getting more closely embedded, spending more time with those functions (providers), or other organizations that are bringing this equipment in, so you can know about it in advance and thus proactively coordinate within the PACS environment, is actually very doable and it is important as they move forward.
Q. You’re saying the key to avoiding the chaos is integrating more closely with cardiology and other disciplines besides radiology?
Yes, exactly. Coordinating with the other organizations that consume their work; it may sound simple, but it is a change for most.
Q. The next issue you talk about is watching out for the missing guardrails, what does that mean and how does that apply to PACS?
Let’s take an overly simplistic look at archiving - the PACS servers, networking, storage, specialized applications, etc. - the normal core environments. PACS administrators need to define what those things are at the core of their operations for receiving, storing, and transmitting images back and forth and then not negotiate on them. This is more difficult than it sounds. This is probably one of the harder areas, especially as an organization brings in new equipment and evolves with new models. If an organization decides to do bedside readings or make information more readily available via some sort of portal, do they involve the PACS team? A portal is created for patients to be able to view films or transport them to other physicians. If such work is not pre-coordinated with the PACS administrators, odds are the portal will fail.
A portal is on the fringe but accesses the core. This access space is where things come into and even interrogate core architectures for data. To protect the core, PACS administrators need to truly own and define their systems in the same way a regular IT organization does ERPs (Enterprise Resource Planning). Need to provide access, but needs to be controlled as well. Call it API (Application Program Interface) access if you like, but the intent is that by predefining how to access, people can skip multiple parts of approval processes yet still meet all security and operational requirements; publicly defining what to do, and how to do it, as well as performing spot audits, provides guardrails.
Q. It sounds like whether PACS administrators want to or not, the technology and evolution towards patient-centered care and the use of the technology to support patient-centered care is requiring them to work not just with radiology, you have to begin working with all the other image producing organizations. Is merging of these inevitable?
I think your statement is correct. They have to start working beyond just radiology. You go back 10 years, and radiology controlled all this stuff, how it was viewed, etc. that is not the case today. Going into the future it depends on the organization. For most hospitals, I would presume that being integrated into normalized IT is the route that will emerge. The reason for that is that it (PACS function) is now just specialized software. All the hardware you are using, servers, storage and networking, there is nothing proprietary about what the medical organizations are using any more. At the application layer, it is a bit different, but that's why I reference it in relation to the ERPs, such as the SAPS, Oracles, Dynamics they need to be more application centric, which means they have to be more focused on how people use what they provide versus just making sure everything runs.
Q. The last point you made about the elephant in the room sounds very pertinent to PACS. The need to be able to say no. That seems to be something PACS administrators often face.
Absolutely. I'm going to try to paint a verbal visual and tie this together. It is almost like a universe model. At the center, particularly for PACS administrators, it is their images, their films. Images are the sun, and there is a special set of applications that are utilized to provide their light out to all these orbiting planets. And PACS admins own that deliverable. They also own the infrastructure and other things that sit underneath it. And depending on what planet is orbiting closest, they need to make sure they are providing the right types of information to them as quickly as possible, and the right means of access.
As you get further and further out, there are different organizations that need to have access, but may not need to have the same type of short-term changes, or inclusion of different pieces of technology the same way as those that orbit the closest to them, and the ones that orbit the closest to them are generally going to be the radiology department, folks that are interacting with patients, and interacting with patients means sitting at their bedside, or setting up portals or accessing these types of information.
So there are a whole series of planets that go out. The ones that are very close should have some type of APIs in place or some type of rules where they can access the data directly without having to go through many formal processes. The further out you go from that area, the more formalized those processes should be because the interactions are rare and the changes are probably impactful. The PACS administrators have to be able to say no that this request cannot be done because it can impact that nearest – and most important - orbiting planet.
Q. How do PACS administrators get help in doing this? I'm assuming this is where Insight comes into play.
Insight can definitely come into play, but there are probably two areas that are paramount. The first is the architecture of the infrastructure. And again it is pretty much a given in the industry that end-user devices are smart; they're intelligent. The infrastructures have to become more intelligent as well, and they are. That is where you get the converged and hyper converged environments, and they are architected to allow different things to connect through to them as well as to grow and expand out, or even in some cases shrink as per need. That is all the core architecture at work. Insight is very strong in these areas. For us, it is about having coordinated center, server, storage and networking built to meet application needs.
But the other part, which is huge, is approaching it from the perspective of how you view your home versus your office. Many organizations are very process bound, and they have to be because of regulations and who can access what, where, when and how, etc. I would strongly encourage folks to not view the office as the office that they've worked in, but to view it as they would view their home.
For example, if you have an opportunity to have brand new LCD flat screen TVs throughout your home that are 4k, the highest resolution possible, and they can do it at the same cost as they have it today, presuming it is on a lease, would they do it? The answer is probably yes, even if they have to upgrade their data connections whether it be satellite or cable or whatever, they would probably pay the upgrade to get that capability to have that content delivered, they'd probably upgrade their program subscriptions, and at the same time, look for other things in the house to get rid of to offset the cost. It seems very logical but most organizations don't do it well because they have very deep process documentation and entrenched operational habits.
Most PACS administrators and the organizations associated with them are measured on operational efficiency and forecast-ability, which means operational groups and finance groups are measuring how they perform day-to-day and whether their costs go up or down; making changes impacts their cost basis and operating models thus people avoid them. Looking at one’s office the same way one would look at their home changes perspective. Many organizations simply don't make changes because they introduce slight risk to forecasts and models, even though if it were their home they would.
Q. Is there anything else you would like to emphasize?
For PACS administrators, and in general, the world has changed dramatically over the last 5 or 6 years. Cloud options are proliferating, technology leases are adaptable, combining with IT organizations - or at least improving the relationships with IT organizations – is becoming required, and truly understanding how and why organizations consume their information is critically important. PACS administrators are in an exciting transition; they are becoming medical care partners vs. providing content for those who provide the care.
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