Chances are good that information technology science is not the forte of most radiologists, and that radiology informatics is, in fact, something of an enigma. It need not, indeed, it must not be, say a great cadre of experts, because informatics has become one of today’s keys to success for radiology departments at institutions large and small.
A reason why informatics may seem mystifying is the fact that there are as many ways to define it as enterprises engaged in it, according to David B. Dillehunt, chief information officer of Cape Fear Valley Health System in Fayetteville, NC. “The concept of informatics takes in a lot of area,” he says. “To me, it includes the standard radiology information system, integration with the hospital information system, interface to a dictation system, integration with a picture archiving and communications system [PACS] or a clinical information management system [CIMS], the interfacing to and from all the various source radiological devices, like computed tomography, magnetic resonance imaging, ultrasound, and other modalities, and also to the other systems like digital radiography. To me, simply stated, informatics involves the enabling, through the use of technology, of significant, positive changes in business processes and strategies-in this case, in the area of radiology.”
Gary Wendt, MD, MPA, MBA, director of information systems for the Department of Radiology at the University of Wisconsin in Madison, holds a similar view. “Informatics does mean many different things to many different people,” he says. “For example, to an educator in an educational setting, radiology informatics will be more focused on the instruction of medical students and residents, physicians, and patients, as well as continuing-education credits. On the other hand, in a clinical environment, radiology informatics will be more focused on improved and universalized patient data access. Then, too, informatics can also represent a cross between clinical and educational when capabilities such as data mining and outcomes analysis are emphasized. Or it can be a vehicle for permitting applications such as teleradiology so that radiologists can perform reads when away from the hospital and small community hospitals that cannot afford subspecialists in every field of radiology can consult with those particular types of subspecialists at institutions elsewhere in the country or around the world.”
At the University of Wisconsin, informatics is employed in most of the aforementioned capacities, but also as a clinical decision-support tool for referring physicians. In that capacity, informatics helps nonradiologists decide which tests they should or should not order for each type of clinical problem.
“The clinical decision-support role of informatics will become more crucial as managed care becomes more dominant and demanding,” says Wendt, who is also an assistant professor at the University of Wisconsin. “If you operate in a managed care environment where you must make certain every health care dollar being spent represents the greatest value possible, then clinical decision-support systems become indispensable.”
Regardless of what informatics is, what it should never be, in Wendt’s opinion, is something that contemplates only the impact it will have on radiology activities within the radiology department. Rather, he says, informatics must? seek to have impact on the overall care provided to each patient wherever that patient might be at any given moment in the hospital or health-delivery system.
CONNECTIVITY, ACCESS, AND SECURITY
Radiology informatics-in order to function properly and fulfill its potential-requires that all of the information capture, processing, and retrieval components throughout the department, hospital, and health care delivery system (if applicable) and, increasingly, outside the enterprise be able to talk to and understand one another. This capability is known as connectivity.
“Information and clinical images cannot be effectively and efficiently distributed where there is limited or no connectivity,” Dillehunt says. “Historically, connectivity was seldom an issue as long as the emphasis on information gathering and retrieval was radiology-centric. But since the emphasis is now enterprise-wide, connectivity is a major concern.”
This is especially so in an enterprise that is growing by means of acquiring business units rather than building them from the ground floor up. Often, these acquired units come with information systems of a make different from that of the enterprise core. The more units acquired, the greater the potential multiplicity of unlike information systems. And the more unlike information systems there are in the enterprise, the greater the prospect that direct electronic data exchanges will be difficult, if not impossible, experts say.
Thus, connectivity is essential, but not merely from the standpoint of allowing data to flow across the enterprise or beyond. Connectivity is crucial to ensuring the reliability of the data being exchanged. In the absence of true connectivity, data that somehow is able to make its way from one user site to the next may very well arrive in a corrupted form, according to Jim Campbell, technical director of the Visual Integration Research Center at Duke University Health System in Durham, NC.
“With systems talking fluently to one another, you have the basis for guaranteeing that the patient’s medical record from Hospital A is exactly the same at Hospital B on Hospital B’s different information system,” Campbell says. “The physician may need to see his patient at both those hospitals, so he is going to expect that the patient’s medical record does not lose anything in the translation from one system to the next. The doctor wants to be able to review the record at either facility and have total confidence that he is looking at the record that actually belongs to this patient, that the blood type is right and so forth. If the doctor believes the record may be unreliable, then he is going to shun the system.”
Related to and dependent upon connectivity is the ability of users to readily access images and text from the system. For nurses and other clinical support personnel, access need occur only at the site where care is delivered. For administrators and clerical support staff, it need occur only in their offices or cubicles. However, for physicians, access will need to be possible not only from the care delivery site and their offices, but also from home, in the car, in an office on the campus of another institution, or at a hotel in a faraway city.
The issue of accessibility introduces a further challenge: ensuring the security of the data and preventing it from falling into the hands of individuals inside and outside the enterprise who have no legitimate need to utilize it.
There are various ways by which the reliability of data can be ensured. One that Campbell favors is called context management. This approach, as he describes it, permits multiple applications to coordinate around a single topic, like the patient’s identity, so the clinician can trust that all the applications are showing information about the same patient. Software specifically designed to perform context management is required to implement this type of security measure.
Encryption offers the preferred means of ensuring data security. This technique transforms comprehensible text into incomprehensible code that can be made recognizable again only if the recipient of that encrypted data is in possession of an electronic decoding key. Industry experts note that in recent years encryption technology has improved to the point that now only the most determined and sophisticated hackers can succeed at piercing this type of safeguard.
THE CHALLENGE OF HIPAA
The security of data will become a much bigger issue in coming months when the federal government gets around to completing and unveiling a full set of regulations pertaining to provider compliance with last year’s Health Insurance Portability and Accountability Act (HIPAA), a law intended to protect patients against losing their medical coverage when they change jobs.
“Even without the full regulations being made known, we already understand that HIPAA will necessitate the free flow of electronic patient information among providers and insurance companies,” Campbell says. “But, at the same time, we are expecting that patients are going to want assurance that the personal health information they disclose to their physicians or that what their physician learns through the processes of examination and treatment is going to remain confidential. If patients feel that is not the case, then they will lose trust in their doctors. When that happens, not only will people not get the care they need, but the data that are collected will be useless for outcomes measures because people are not going to risk telling anything to their doctors.
“So, what we are going to have here is a need for accessible information in direct conflict with a need for confidentiality.”
Wendt says regulators will have to strike a balance between those conflicting interests. In all likelihood, the balance they seek may prove satisfactory to neither the proponents of accessible information nor the defenders of patient privacy no matter how carefully the line is drawn.
“My fear is that the regulations will favor the privacy argument to the extent that health care itself will be compromised,” Wendt worries. “Information will be limited so severely that hospitals will decide it would be the least costly thing to just unplug, disconnect, and make access to information unavailable. The HIPAA regulations likely will require that hospitals be able to initiate full audit trails of information access and utilization. The cost of being able to run audit trails outside the environment of your own hospital or health system is going to be very expensive, especially if you have to ensure the security of devices that are outside your own four walls.
“The complexities of complying with the HIPAA regulations may be such that it will make the effort to get ready for the Y2K bug seem simple by comparison.”
HARDWARE AND SOFTWARE
The success of any radiology informatics initiative depends, of course, on the computer platform at its foundation. More and more these days, that platform entails a Windows-based, personal computer (PC) environment. Customarily therein, individual PC workstations are networked through a communications scheme that employs devices known as hubs and routers and fiber-optic transmission lines (or some variation such as T-1 telephone lines, cable-modem lines, or digital subscriber lines), which, in turn, are tied into larger computers-or servers-packing sufficient processor power and performance to run memory-hungry software applications such as PACS and CIMS.
“You have a lot of varying types of hardware, software, and network communications devices from which to choose, but the implementation of these can be made easy or difficult depending on the vendor,” Dillehunt cautions. “You want a system that blends and harmonizes all these components right from the beginning-not via a lot of technological improvisation. If you acquire informatics technology that has to be worked through by the vendor in order for it to do what you want or expect it to do, then you are doing what is known as acquiring technological baggage. That is something to avoid.”
The Importance of Standards
In order to end up with an informatics implementation that has connectivity and can, by extension, be accessible, Campbell recommends acquiring computers, workstations, input modalities, and output devices that feature open architecture, or open-system technology.
“Open-system technology means that hardware and software from different vendors have been built around standardized sets of specifications,” he says. “The HL-7 standards organization has defined widely used standards to exchange health care data between applications and to coordinate health care applications at the user-interface level.”
Open-system technology, it so happens, is a good defense against the problem of technology obsolescence, which plagues computers seemingly within a matter of months after they are unpacked from their shipping cartons and put into service, given the incredibly fast rate at which technology is improving, experts say.
“I think the safest way to deal with the obsolescence challenge is to choose a technological platform that is generally accepted as an information industry standard,” Dillehunt asserts. “By doing that, even if the technological requirements change to a point where you need bigger, faster systems, the industry standard equipment you started with can usually be used in another area of the enterprise, thereby maximizing your investment in the hardware itself. As for the software, you have to choose a vendor who you believe will continue to enhance and develop the technology, using nonproprietary platforms again, and include those upgrades as part of the normal business arrangement.”
Software, meanwhile, does not become obsolete as quickly as does hardware. For that reason, Wendt recommends software be purchased separately from the hardware.
“It is much easier to replace outdated hardware than it is to replace software in some applications, such as PACS,” Wendt says. “As informatics increasingly becomes PC-based, I can schedule replacement of older hardware more frequently and cycle those older pieces out into the department in areas where the demands for processing speed and power are not so great. The software I simply load onto the new computers.”
This strategy, consequently, allows Wendt to squeeze the most use from a PC before it is at last ready to be discarded. “The bottom line is that vendors should at least consider offering a software-only solution,” he says. “Then, if they add hardware, it will be much easier to decide if you want the vendor to support hardware or if you want to take it on internally.”
ON THE INTERNET
An informatics strategy currently being embraced calls for deploying programs on the Internet.
“The Internet is a logical place to supply the solutions for informatics,” Campbell says. “The Internet is a classic example of an open system. All of the Web servers on it talk to one another, because they all use the same engineering specifications.”
Wendt agrees: “It is relatively cheap and cost-effective to use the Internet to put up secured, virtual private networks and use encrypted data to give those community hospitals access to the expertise in subspecialties from elsewhere around the country or around the world. In addition, you can use secure Web servers to make images and reports available to referring physicians more quickly than with film.”
Informatics models that utilize the Internet can do so through a relationship with an application service provider (ASP). The ASP is an external, usually unrelated entity that has already gone to the expense and trouble of installing sophisticated Internet hardware and software and is in a position to rent inexpensive access to it. Some ASPs are technology vendors who make this approach available as a customer service. Other ASPs are entrepreneurial start-ups formed expressly to make money this way.
“It is unknown whether this will ultimately prove to be a viable model in health care,” Campbell says. “But there certainly is a lot of economic incentive to utilize it. Hospitals typically do not want to invest in the operational support required for information technology, and the smaller community hospitals certainly do not want to pay for a huge data center. The ASP model allows those smaller hospitals to realize the benefits of a huge data center without the expense of creating one. Open standards are going to be incredibly important to fold ASP offerings in with existing systems. That is why HL-7’s CCOW [Clinical Context Object Workgroup] standard has put so much focus on Web technology.”
Whether or not the Internet is tapped for this purpose, informatics itself presents an abundance of expenses for hardware, software, communications devices, technical support, maintenance, upgrades, and user training. Thus, it is imperative that radiology department chiefs and senior administrators develop sound economic justification for their informatics initiatives, experts urge.
“It took us several years of analysis before we came to realize what it was we were truly trying to accomplish with our informatics efforts,” Dillehunt says. “We wanted to impact the way that physicians interact with our health system. We wanted to capture the referring physicians’ business by making it so much more convenient for them to work with us, to the point that doing business across town would just not be worth the effort. We wanted to reduce length of stay and thereby the cost of treating those patients. And it was on the basis of all this that we were able to develop a convincing justification for the allocation of capital for the acquisition of everything we needed to make our informatics initiatives a success.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.
