Q. You’ve got more than 40 years in healthcare IT and medical imaging. Can you tell us a bit about your path that has led to your current role as a consultant?
I started working in a hospital in the 70s, a 500-bed hospital in Belgium. I was the first medical engineer coming into the hospital, so I started the Biomedical Department. I collaborated closely with equipment vendors, but when the hospital got busier, they realized that they needed to reduce turnaround and response time for repairs and maintenance.
I started to work with the vendors and introduced the concept of using a maintenance contract with vendors as opposed to working on a time and material basis and to train the biomed department as super-users of medical devices so they can provide expert support for the hospitals’ healthcare workers.
That reduced user errors, which by itself reduced significantly equipment downtime since very few repairs were needed because people were using the equipment in the right way.
That resulted in a huge savings with maintenance contract costs going down by a factor of 30 percent because the hospital could prove to the vendor of the maintenance contract that they didn't have to dispatch staff to the hospital as often as they normally would have because a 90% decrease of equipment problems due to correct use and ample user training.
A couple of years after that the hospital asked me to start the digital transformation of the hospital's admission and registration process. This was in the 1970s so very early on. The computers we had were PDP-8 and PDP-11 from DEC (Digital Equipment Corporation). I started with automating the hospital’s laboratory and then automating the patient reception and registration.
I was working with a great biomed team in the hospital when Philips came to me and hired me away. I started at Philips working with their teams in rolling out digital subtraction angiography, which was kind of the early digital imaging modality besides CT. After that, I started to work in product development for MRI where I created the advanced visualization workstation of the Gyroscan MRI replacing the previous VAX computer with a SUN workstation with Digital Processing Units (DSP).
Very few people had DSP, but an important subcontractor was familiar with it. Advantages of DSP over the then popular array processors (AP) was that DSP didn’t need to store the code in the chip’s hardware as APs required. You don't have to burn all the code in the DSP so you can change the software on the fly. Our team embraced this DSP project and 2 years later, the team launched the Gyroview 2000 HR, which was an advanced visualization system specifically for MRI. This team a was close-knit community, and it was a honor to be part of this team.
I was then very much involved with early implementations of the standard product interconnect SPI Some people called it, the Siemens-Philips interface. It was like an early version of DICOM, but it was still based on the seven layers of the ISO model and made available by the end of the 80s. The result was that we had a system that was kind of a predecessor to DICOM and allowed MRI users of MRI systems made by Siemens and Philips to share images.
Now in 1990 there was a company called AGFA who came to me and they said, “we believe, that over time, digital imaging will replace film and we want you to lead that evolution.”
I hired a digital imaging team in the USA when the demands for digital was rising, and that team was great. I made sure that the team was screened off from all kinds of management bureaucracy so they could work and do what they thought was the best. And in 1994 we came out with the first IMPAX system, the AGFA PACS, and it was one of the first PACSs that was based on non-proprietary hardware. It was all running on SUN Microsystem boxes, which were one of the first common off-the-shelf hardware (COTS). Just add the licensed software and voila, you had a PACS. It was not quite that simple but pretty close. AGFA had a fantastic market share, and actually, the product survived until like the mid-2010’s.
In 1998, I went to work for Siemens Medical Systems USA, Inc., I started as their PACS division manager, and after a short time moved on to other opportunities in the company. I worked in market research and then went into regulatory and standardization work assignments required for various organizations.
Then Siemens also opened the door for me to NEMA, the National Electrical Manufacturers Association where I became chair of the Imaging Informatics Division and remained chair for 10 years. In the meantime, at Siemens, I was combining all the above with working on strategic relationships, with Siemens end-users, consultants and regulatory bodies.
And after 20 years, at 70, I decided to retire. I want to get in my hobbies. After three or four months, I got bored.
Q. You had to get a bit busy?
It was not good sitting in a chair watching TV and commenting on everything my wife did and what I heard on radio or TV.., so my wife told me to get busy and I started my consulting company.
Q. How long have you been doing this consulting then?
Since the end of 2018.
Q. Talk about your approach to working with a client. How do you like to work with them? What do you look for in terms of the relationship with an organization?
Actually, I have very few clients, most of my clients are temporary clients, like a healthcare organization that has certain question regarding what they should purchase. I never tell them that, what I do is give my clients an overview of what is available in the market, who is offering what with what conditions and with what technology, and where is this technology going in the next three years A crystal ball doesn't work beyond three years, especially in IT. So that's one thing that I do, but that's occasional. These are like one or two or three-day engagements
Then I have other engagements such as “a consultant for consultants”.
These large consulting organizations have great resources in project management, they have great legal counsel, and they know healthcare. However, when it comes to enterprise imaging or PACS or advanced visualization, they often don't have the in-depth knowledge in-house and so they outsource to me.
And that's basically what I'm doing. Occasionally I have an OEM that asks me, what do you think about the necessity to include this kind of capability, or this kind of feature in our PACS or in our advanced visualization system? I also follow the blogs but that I don't charge for that. I really love it when I can teach people something, and while teaching I often I learn more from the conversation than I can teach. Also, I keep up with online information portals and with print journals to stay current with the evolution in imaging informatics.
Lots of things going on these days. We see expansion in office-based labs, we see an expansion of the independent diagnostic testing facilities, which is a growing trend. Patients don’t like to go in hospitals when they can find the same tests in smaller facilities.
When the hospital moves the patients to ambulatory locations, the patients are less afraid to come into a small facility than to go into the hospital with the risk of infection, and the cost is lower, instead of being a thousand dollars, maybe they pay $700. If you do not have the best health insurance, that's important because it limits your out-of-pocket cost.
At the same time, the hospital is lowering costs because the maintenance of the equipment and the staffing for that equipment is lower. They contract with an independent diagnostic testing facility, which remains independent, although being part of the IDN infrastructure. That's going to change our whole paradigm in the next few years. It will be slow but it's going to happen because it is the only way to provide sustainable healthcare.
Q. What is that paradigm shift? What, what do you see there?
Well, I see that hospitals will continue to expand, but it will be an expansion that doesn't require investing in new skills and new technologies that will be an expansion that enables a third-party service, but with service line providers to do what a hospital needs. Think about big organizations that are outsourcing their radiology service line. Of course they still need their lab services, and of course they still need a CT scanner in the hospital but a lot of testing will be farmed out to independent diagnostic test facilities, and to ambulatory surgery centers. Why go the hospital for a procedure that can be performed as an outpatient without having the risk of contracting a hospital infection.
Q. Backing up a little bit you mentioned you advise clients on purchase decisions, when you're advising about which vendors and equipment, what are some of the things that organizations may get wrong when they're shopping for a PACS or enterprise imaging system?
You have to make sure that they understand a PACS or whatever enterprise imaging system they are considering is not going to be like the PACS that they used to purchase in the past, where it was a departmental system. Today it needs to be closely integrated with the EMR. And not only the EMR, but if you have a document management system, it needs to be integrated with the document management system as well. And that integration is something that is easily drawn on a whiteboard, right? One block for EHR, and another block that it's the Enterprise Imaging, or PACS system, and you write on one side of the block IF (interface), then you draw a line to the PACS and you draw a little square that interface and now you're done.
In reality it is a little more complicated, all care providers have one source of truth, the EMR.
They don't have time during their busy day to run to yet another workstation to open the document in the documentation system or the EMR, or the imaging system, they can't do that. They want to see it on the same screen or the same screens that they use for the EMR. If you implement an interface system that is based on a point-to-point connection, then you build in your first mistake.
You have to be flexible in what you can access and how you can access data. There are mechanisms like APIs, an application program interface and standards organizations are working on standardizing APIs for interfacing with an EMR. You have another standard called FHIR (Fast Healthcare Information Resources) and that’s the way to go.
Another thing you have to think about is what am I going to do with all that hardware three years from now when I have to store all these images with gigabytes of information. What am I'm going to do with all that storage infrastructure in five years, it will be obsolete. What I'm going to do then, decommission it and pay a lot of money to buy another system? The question to ask: have you considered the cloud? That's the whole goal of a consultant, helping a client make an informed decision, but ultimately, it's the client’s decision, it's not a consultant’s decision.
Q. I read a 2019 paper that you were the lead author on about building and implementing an Enterprise Imaging System. It was a white paper for the HIMSS and SIIMs. Since then, there's been a pandemic, and I was wondering if you were to update that paper, have you seen any changes in the way organizations are configuring their medical imaging systems in the wake of the pandemic?
Last year we did not see much at all, when it comes to enterprise imaging because everybody was very preoccupied with COVID-19, they didn't know what would happen the year after and they still don't know. I've seen renewed uptick in, and it may be a good idea to revisit the paper and see what we've learned in the meantime and see what should be updated.
The same thing applies to white papers I wrote on cybersecurity for HRA (human reliability assessment). We wrote it just at the beginning of ransomware attacks so that probably will need an update. But anyway, last year we didn't see much happening at all because of COVID-19 with tragic developments and resources were all focused on that.
This year however, I already see changes. I see that hospitals are looking more into enterprise imaging, especially the large ones because they realize that in order to get to the triple aim, (improving the healthcare experience, improving the health of populations, and reducing per capita costs) they will need enterprise imaging.
How can you decrease costs, by eliminating silos, right? Enterprise imaging will get rid of the silos. How can you improve patient care? How can you improve quality of care? One way is if you have more information at your fingertips, you probably can make better decisions. How can you improve customer satisfaction? If you can communicate with your patients with increased confidence that there is nothing else that they should be worried about or that they may need to come in for therapy or intervention, if you communicate with your patients based on facts and science, they probably will be very satisfied. They become more satisfied if they can have the procedure performed in an ambulatory surgery center or if you can do the test, in an IDTF (independent diagnostic testing facility) then they will also be very satisfied. Now to do that you have to make sure that all these departments can collaborate, and enterprise imaging is going to be a big piece of making that collaboration possible.
You know things are always about people, processes, and technologies but if you want to enable the triple aim, you will need enterprise imaging strategies. Now, how do you get there? The first thing to do is governance, bring the stakeholders together and make sure that they have governance. Otherwise, you will see what's happening today with IDNs, where they have 20 hospitals and 12 different PACS systems that don't communicate. So governance will be absolutely required.
Q. One of the good things to come out of the pandemic is the rise of telehealth. I saw statistics from MAYO Clinic that showed pre-pandemic telehealth visits made up about 6% of their clinical encounters. And then during the pandemic telehealth visits comprised 50% of clinic visits. And now as the pandemic eases, they're probably doing 25% of their healthcare visits by Telehealth, which is an amazing increase in the use of telehealth. How is telehealth affecting enterprise imaging?
Well, I think that as I said already that you have, what is called the new requirements for the triple aim. Telehealth helps with improving patient experience, and to improve quality of care the provider will also have to see an image and possibly share that image with his or her patients, which is going to promote the concept of image sharing.
Now that doesn’t necessarily mean that image sharing will happen between different IDNs, but it's not because it's impossible or difficult it is because hospitals don’t want to share patients with other IDNs. But within the IDN they will share and you know if they have the resources in the clouds, that's the best place to share and you have a web-enabled user interface that works through your mobile device and the radiologist or the clinician that is conducting the Telehealth visit is sitting in his or her office, while the patient is sitting in their home. It will be necessary to access all images and all information and all of the EMR from there.
The patient can even take pictures and send them back like for a dermatology care or for wound care. You will be able to compare over a period of time how the wound is healing without the patient, having to come into the hospital or clinic. If it gets worse, you can call the patient into the ambulatory surgery center or into the hospital if needed.
Q. I guess the last question is what are the main benefits an organization can expect from hiring a consultant? What should they expect? What should they not expect?
What I often see is that an external consultant goes hand-in-hand together with governance. If you have your internal consultants there always will be a bias, there will be certain preference of one of the board members, there will be certain personal things such as they may like that lady or hate that lady but these human factors are definitely present.
When the consultant comes in, you know, I think it is amazing. Everybody has a tendency to listen because they know they're paying good money for the consultant. And so they want to get the maximum value. And instead of arguing, they will listen to the consultant.
Therefore, I always advise my customers to make sure that your consultant is not paid by an OEM or by a vendor. The consultant should be independent, that’s the point.
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