Integration: Next stop for enterprise imaging

Louis Lannum, director
enterprise imaging, Cleveland Clinic

Among the next biggest challenges facing imaging IT professionals is to integrate imaging across the enterprise into EMR systems, which is why PARCA launched its Certified Healthcare Enterprise Architect, or CHEA certification last year. The Cleveland Clinic successfully completed its enterprise imaging system, called MyPractice nearly two years ago. To find out how they did it, PARCA talked with The Cleveland Clinic’s Louis Lannum and Kimberley Garriott. Mr. Lannum heads the enterprise imaging team that systematically integrated nearly any image, regardless of its capture modality, into a Clinical Imaging Library and integrated it into the patient EMR. Ms. Garriott joined Cleveland Clinic’s MyPractice Imaging team in 2011 as program manager for design and implementation of the enterprise imaging strategy. Both will be speaking at SIIMS 2014,

Kimberley Garriott, program
manager, enterprise imaging,
Cleveland Clinic

May 15-17 in Long Beach, and the American Health Information Management Association (AHIMA) Convention in San Diego in September. The Cleveland Clinic now offers their expertise in a consulting service for other health systems through MyPractice Imaging Solutions.

Q. How did the Cleveland Clinic’s enterprise imaging program get started?

A. Lou – Radiology purchased a system to replace their legacy PACS and also bought a VNA as part of that strategy. Our ITD, Information Technology Division, took advantage of that VNA and created an enterprise program where we went out and developed workflows and image management strategies for other imaging departments.
All images are normalized with EMR data and are stored in a centralized repository that we call the Clinical Imaging Library, and all of those images are available today through integration with EPIC. We are currently ingesting imaging from 14 different service lines, in addition to radiology, including gastroenterology, ophthalmology, women’s health, point-of-care ultrasound, wound care and surgical cases in the OR. So we’ve taken imaging out of the radiology focus and made it an enterprise focus over the last year-and-a-half. Last year, outside of radiology and cardiology, we ingested close to 180,000 imaging studies from other service lines into the Clinical Imaging Library.

Q What is the overall strategy?

A. Lou –At the end of the day it was not about a storage strategy. When most radiology departments purchase a VNA it is usually about an extension of a storage strategy, but here it is all about integration to the EMR. It’s about breaking down all the independent imaging silos, and providing an imaging platform that is tightly integrated with the EMR so that every image captured has one source of integration with the EMR. From the Cleveland Clinic’s point of view it wasn’t an image storage strategy, it was part of the EMR strategy.

Q. Is that the strategy that most institutions with multiple imaging service lines are looking to adopt?

A. Kimberley – What Lou and I are seeing in the industry is that there is a big a focus on the VNA piece without serious consideration to other key components. We believe that it is necessary to improve clinical workflow around the image acquisition, management, and visualization; which is a much broader focus than just how images are stored. There are many metadata standardization considerations that need to go into this, as well as the workflow to acquire the images, that is how you are going design a workflow that is conducive to the physician’s environment without being disruptive to their existing processes.

A. Lou – What Kimberley is alluding to is that nothing goes into the image library that doesn’t match an EMR scheduled event or EMR patient event. It is not a storage platform. If a department calls up and says, “We’ve got all these images and need to store them somewhere,” we don’t ingest them into the library unless they are normalized to a patient event.

Q. How did you get buy-in across the enterprise to integrate all of the imaging into the EMR?

A.  Lou – We created an imaging council at the CIO level, members included the CIO, CMIO, the chairman of radiology, and a number of other department representatives, as well as, administrators. That council makes enterprise-wide imaging decisions across the entire scope of the organization. For example, if a department wants to buy an imaging system, we don’t tell them what system to buy, but they come to the council and present what they are doing and we vet that system to ensure that that it can satisfy both the department needs and the enterprise needs. This governance body meets every month with an agenda that includes looking at imaging system related purchases that the institutes and departments want to execute. The whole key to our program is to take imaging out of the departments and make it a strategic asset rather than a department asset and solely a department asset.

Q. Are the providers across the enterprise seeing the advantage of this kind of collaboration?

A. Kimberley – Absolutely, actually it was surprising when we started this initiative and began talking to our physicians.  We thought that the physicians would be hesitant , given that the workflow considerations may add steps to their existing processes, but they were anxious to learn how their images would be integrated into the library with only minor concerns about the changes to their workflow. Integration of images to clinical imaging library, not only enhances caregiver coordination throughout the care continuum, but creates an opportunity for the physicians to bill for their point-of-care ultrasound studies -- a type of imaging that is widespread across many organizations. Most physicians don’t have anywhere to store these images, and imaging retention is being required by CMS for billing reimbursement of the procedure on a professional fee level. So that is a big motivator that helped push it over the edge as being something the providers see a lot of value in, but of course the greater value is the quality of care they will be able to provide their patients because they will have all information available at their fingertips.

Q. What are the keys to integrating all these different imaging systems?

A. Lou – One of the biggest keys is managing workflow in each department. Managing the workflow inside the department so that it is easy for them to capture both the image and metadata needed to match, or normalize against, the EMR, and then adopting an indexing scheme on the backside so that everything that goes into that library is viewable inside the EMR. So it is about managing the metadata.

A. Kimberley – One thing I’d like to add is that our program includes point-of-care imaging, which we consider ultrasound, c-arm, digital photography, and scope imaging --anything out there that the physician is using at the point of care without radiology assistance. We consider point-of-care imaging as one major bucket. A second bucket of imaging is integrating third-party image management systems, such as a system like Provation, which is used for GI studies, colonoscopy and endoscopy, or a third-party ophthalmology image management system. An important component of this integration is standardizing the way those third party applications provide common HL7 and DICOM information to our clinical image library solution so that all of the required data is received. All of our vendors agree to the standards we set forth and this ensures that all of the data received into the imaging library has consistent metadata surrounding it and that enables us to better support the system and maintain it, but more importantly be able to pull back important information, like business and clinical analytics because we know the information needed for those reports will be available in the system.

Q. Did it take quite a bit of time to get the vendors to agree to the specifications you set forth?

A. Kimberley – I think we had the benefit of the strength of the Cleveland Clinic brand behind the conversation. With that said, the vendors were surprisingly willing to understand the vision we have for creating this type of standardization. I would say that the average length of time for them to be able to comply was less than six months. As a result, many vendors in the industry are prepared for efficient DICOM and HL7 integration. 

Q. Do you find that after integration, providers achieved increased efficiencies in their workflow?

A. Lou– In some cases yes, in some cases the workflow can be a bit more disruptive, but at then end of the day, providers find they can go to any one of our 35,000 clinical workstations and see that image no matter where they are at in the enterprise. But there is a balance between the disruption of the workflow and the availability of that image across the enterprise, and most would rather have that availability.

Q. Any unexpected obstacles?

A. Lou – That’s an interesting question. I don’t think there was anything we hit that we couldn’t eventually develop a solution for. We produced a document that we call the Enterprise Design Document, which outlines what the integration should look like so that we were all starting from the same playbook. I think in the beginning that was the hardest thing to do, to agree internally what that document would say and what the requirements would be. Once we had that document agreed upon, and we understood the direction we wanted to go in, I don’t think there was any wall we couldn’t climb.

A. Kimberley – There was the challenge of being among the first to walk down the path, to walk with the vendors, but there was nothing that wasn’t surmountable.

 Q. What are some of the biggest wins resulting from integration?

A. Lou – One of the things we’re seeing in surgery, for example, is that when the surgeon comes out of the OR the captured images are immediately available in the EMR for use in discussions with the family. The result is that the patient and family interaction with the doctor is much better because there is a visual component to that discussion. Secondly, the interaction between physicians across the enterprise is also much better. The ED doctor on one side of town can have a much better discussion with the physician on the other side of town as they both look at the same image. So collaboration between physicians is much better.

A. Kimberley – One example (of a win) is when a patient presents in the ED with abdominal pain. The ED doctor uses ultrasound, at the point of care, and identifies an appendix condition; he/she then determines that the patient needs to go to the OR for an appendectomy or similar procedure. In the past the surgeon would need to do the ultrasound again, or send the patient to radiology for a CT study to see or confirm the ED findings. But now there is a trend in some organizations, where the ED physicians have been doing this over time and, that the surgeon no longer feels the need to have another verification step, so they don’t need to perform the ultrasound themselves when the patient arrives, and that speeds the time-to-care for the patient, and I think that is one of the biggest patient quality impacts, the patient time-to-care. Whether the surgeon is able to look at the images while the patient is being transported to the OR, or in the case of say, a patient with a suspected thyroid condition. In the past, the endocrinologist would have to feel the patient’s throat, feel that the thyroid node is enlarged and refer the patient to radiology for an ultrasound, and two weeks later the patient has a follow-up appointment with the endocrinologist and  has to take more time off from work to come in and discuss the exam. Now the doctor can do the imaging in the office and be able to determine if the patient needs a thyroid biopsy before leaving the office, so we’re saving time in the process of rendering care and getting diagnostic answers much more quickly.

Q. Tell me about the consulting services your group offers to other hospitals?

A. Lou – The consulting services, are an executive consulting service. Our portfolio for services includes a site assessment, basically walking into a hospital and documenting all the points of imaging outside of radiology. At the end of the assessment we produce a blueprint of exactly what their image acquisition capabilities and related workflows are at that point in time.

A. Kimberley – Most organizations have no idea what imaging is taking place, there is so much digital photography and point-of-care ultrasound out there that they are at a loss to understand what is being performed and what the workflows are around that.

A. Lou – The second thing we offer in our portfolio is an actual design of an imaging strategy. Now that you know where your imaging is being acquired, how do you develop a strategy for building a library, and integrating all of those images into the EMR. We also coach organizations on how to establish an effective governance model and get them to a level of designing an imaging program that is appropriate for their hospital. And finally we offer project management and can manage their systems and service contracts at the end of the integration projects if desired.

A. Kimberley – We’ll help an organization design a strategy that is right for their enterprise and help them to find the right solution or solutions. That may include the  development of a RFP and going through the evaluation process with them, whatever it takes to design and execute the right solution for the client, from a strategy consulting perspective, is where we focus.

A. Lou – That is our portfolio business. One of the differentiators our group has is that we are the same group that built the imaging strategies for the Cleveland Clinic and implemented that strategy and continue to maintain it.  

Q. How do you keep up with the technology and the processes of integration?

A. Kimberley – We are both prolific readers, we attend conferences, and we sit in the center of one of the largest incubators in the country so we are the bleeding edge of technology. I think attending conferences, learning what other organizations are doing, working with vendors to find out what they see as the emerging market trends and what they think are the solutions and then working with peer organizations sharing information are the top ways I approach staying abreast of the current changes.

A. Lou – One of the things I’m really very interested in is a career path in enterprise imaging. When you talk about enterprise imaging, the CIO will typically send a person down to radiology because they are seen as imaging experts for the whole organization. But radiologists are radiology focused. In the IT space you’ve got very good network and hardware engineers, but no one with real practical imaging experience. What I’d like to see is a way for people in the radiology administration to get the education that they need to step into an enterprise role and become active in developing enterprise imaging strategy.

Q. One of the certifications PARCA offers is the Certified Healthcare Enterprise Architect (CHEA), so you think that is something organizations will be looking for in the future?

A. Lou – I absolutely agree. It is not easy for someone who has spent his or her career entirely in the radiology department to step into the enterprise. It is a different model and a different set of skills. I’d like to have a forum where we are teaching those skills and they can acquire those skills so they can jump into that enterprise slot.