Surrounded by flying dice and one-armed bandits, the Healthcare Information and Management Systems Society (HIMSS) conference in Las Vegas did its best to establish a middle ground for discussions about enterprise imaging. Among the many difficulties that accompany the integration of medical images into patient medical records, workflow stood out.
For the past 30 years, managing workflow has been relatively easy for radiology, with its worklist of tasks driven by RIS and PACS. Orders from referring physicians begin the process, and images and patient data are neatly structured by the DICOM standard. But now, as PACS gives way to an image-enabled enterprise, workflow is, well, challenging.
But electronic medical record (EMR) and PACS vendors are rising to the occasion, developing integrated products that aim to deliver the best of both worlds: robust support for medical images, with workflow that matches the unique needs of nonradiology specialties producing images that need to be included in enterprise image management networks.
Rules of engagement
Disciplines outside of radiology are increasingly seeking to adopt digital image management, but they follow rules of engagement alien to radiology, which pioneered the concept. This can cause a disconnect for both sides.
A case in point is the dermatologist who shoots digital photos of a rash; the rash is later investigated with point-of-care ultrasound, after which it's biopsied and sample-sectioned into slices the thickness of a cell, stained, and digitally photographed. The capture of these various images reflects the workflow of dermatology, not radiology.
"How to capture the right data in ways that are not cumbersome to physicians can be difficult," said Kim Garriott, one of the organizers of a HIMSS 2016 session on the challenges facing enterprise imaging. "It has to be a natural part of the workflow."
Cerner, which globally has the largest share of the EMR market, envisions the electronic medical record as the force that will propel workflow across the enterprise and become the workflow engine for the patient care team.
Cerner's EMR software allows physicians to review a patient's medical record and prior diagnostic procedures, see multimedia images in a viewer, communicate with other doctors, and even send notes and comments about the patient or results of exams. But it has its limitations.
The University of Missouri (MU) Health Care system is partnering with Cerner -- and McKesson -- to create a hybrid system that administrators hope will integrate electronic medical records and medical images. McKesson is providing the PACS side of the equation, meeting the requirements for cardiology and radiology; Cerner is providing the EMR for handling data coming from other disciplines. The PACS will have a zero-footprint viewer, while the EMR will have a built-in viewer of its own.
"It will have the advantage that, on one platform, a clinician can look at a photomicrograph or an arthroscopy image and then look at the MRI of the knee," said Dr. Thomas Selva, chief medical information officer at MU Health Care. "We actually have radiologists now who are asking to see biopsy results and arthroscopy studies, because they are going to help them read the MRI better."
A test system integrating technologies from the two companies is now being installed, Selva said. Test servers are being built; data migration plans are being hatched. Cerner engineers are onsite working with MU Health Care staff, jointly coming up with ways to handle the problems of enterprise imaging, devising solutions that extend to medical facilities across the state of Missouri.
It's a different story at MetroHealth Medical Center, which is based in Cleveland and serves northeast Ohio. This institution, a real-life St. Elsewhere on steroids that's licensed to operate more than 700 beds and a couple dozen satellite offices, is transitioning to enterprise imaging. The process feels like it has been going on "forever," said Don Reichert, MetroHealth vice president and chief information officer. Yet it has only been underway for about 18 months.
It has involved multiple trials -- and errors -- in the process of solving various problems. Workflow has been a recurring issue.
Contributing to the uncertainty that enfolds all transitions to enterprise imaging is an ever-shifting technological foundation. When MU Health Care chose its McKesson-Cerner axis, Cerner's image-handling capability was immature, Selva said. That has since changed. But the change came too late to factor into the decision-making at MU Health Care.
"Cerner has a product and some human factors in radiology that are pretty impressive, but they weren't when we were [deciding on the] contracting," Selva said. "You have to go with what you think is the best at the time."
PACS vendors respond
Just as new image-enabling technologies are evolving at EMR vendors, PACS-based technologies for the enterprise are changing in response to better connectivity with the EMR and support for nonradiology workflow. On the exhibit floor of HIMSS 2016, vendors highlighted a range of workflow engines, many of which are rooted in PACS.
Four years ago, the Impax 6.5 software from Agfa HealthCare was installed at the Cleveland Clinic. Even back then this PACS software, which has since morphed into the company's Enterprise Imaging package, had lofty ambitions.
The company framed the system as driving enterprise-wide access to patient imaging information as well as satisfying departmental workflow needs. Impax encompassed not just radiology but also other image-producing departments at the Cleveland Clinic, such as ophthalmology and digestive disease.
Central to managing workflow at the time was the Impax RIS/PACS engine. Today, the evolved version of this engine is capable of managing the day-to-day tasks of a wide range of "-ologies," marshaling tasks across 39 departments and service lines at the institution, including point-of-care ultrasound, wound care, and dermatology, as well as radiology.
"It is driving the clinical processes -- and efficiency -- that people are looking for," said Lenny Reznik, director of enterprise imaging and information solutions at Agfa.
Reznik explained that the workflow engine is designed in a way to support and enable integrated care delivery.
"You can't dump a radiology information system into a dermatology department. The workflow is totally different," he said. "You can't take a RIS and put it into a point-of-care ultrasound system. The worklist is totally different."
Providing a single platform offers cost savings, clinical efficiency, and standardization, according to Reznik. Agfa's Enterprise Imaging platform, which was only officially launched in the weeks leading up to RSNA 2015, addresses all of the workflows and provides all of the tools needed to consolidate and distribute information across the enterprise, he said.
Subscribing to this one-platform approach is Carestream Health. Its Clinical Collaboration platform, like the Enterprise Imaging platform from Agfa, evolved from PACS and was built around a vendor-neutral archive with software that manages and shares images and other clinical data across multiple formats and domains. The system is designed to provide access to patient history, as well as to images, videos, and reports.
Carestream unveiled a key new element at HIMSS 2016: a mobile care module that allows digital photographs to be uploaded onto the platform from virtually anywhere, including doctors' offices, clinics, emergency rooms, or even accident sites.
Those images, according to Carestream executive Cristine Kao, may document patient wounds, for example, or skin conditions of the kind that might be found in a dermatology office. They reflect an ad hoc, encounter-based workflow.
"The EMR is ultimately at the core of this workflow," said Kao, the company's marketing and growth operations director. "Imaging has to be complementary to that workflow."
The Web-based module is portable, operating on a range of mobile devices, including the iPhone, iPad, or other tablets, as well as a desktop workstation. In addition to allowing the input of patient information, accompanying the capture of digital images, meta-data tagging is encouraged.
"Meta-data tags are critical," she said. "They tell why you took the photo."
Importantly, they are the handles with which digital photos are found and forwarded to physicians inside and outside the enterprise.
The offerings from relative newcomer Lexmark exemplify a best-of-breed approach whose various options have the advantage of a single workflow. Its workflow engine is designed to manage the unique processes outside radiology. Yet, like many others in enterprise imaging, it rose from the PACS-driven breeding ground of radiology, still bearing a name indicative of its origin.
Less than two years ago, Lexmark acquired PACSGear and its suite of offerings including PACS Scan, a software package designed to capture digital photos in the context of patient information. PACS Scan serves up these images to the EMR system, according to Sandra Lillie, Lexmark industry manager for enterprise imaging, yet leaves no trace of patient data on the mobile devices on which it operates.
PACS Scan is complemented by another technology from PACSGear, called MDR, which connects to devices that record video, such as endoscopes.
"It provides the opportunity for the clinician to capture what is most clinically relevant and to store it in the context of patient information," Lillie said.
Taken as a whole, the suite of offerings in PACSGear eliminates the myriad silos that today characterize much of medicine, she said, providing capture, archive, and access to patient data and images found in radiology, cardiology, gastroenterology, dermatology, orthopedics, and pathology.
Experience has shown that when image-enabling the enterprise, finding the right solution is not so much the challenge as finding ones that work. And what works depends largely on the circumstances of the enterprise being image-enabled.
