|John P. Glaser, PhD|
John P. Glaser, PhD, is vice president and CIO, Partners HealthCare System Inc, Boston; founding chair of the College of Healthcare Information Management Executives; and past president of the Healthcare Information and Management Systems Society.
Deb Krau is vice president, information services, and CIO, Main Line Health, Bryn Mawr, Pa.
Don Ragan, PhD, is senior vice president and CIO, Detroit Medical Center.
Patricia Castel Skarulis is vice president and CIO, Rush-Presbyterian-St Luke’s Medical Center, Chicago.
Q: Does your health care institution have a picture archiving and communications system (PACS)?
Glaser: Brigham and Women’s Hospital, Boston, and Massachusetts General Hospital, Boston, both have PACS. Early work on these systems began over a decade ago. Through the years, the PACS have advanced with the technology. The implementation of current PACS versions began 6 years ago, and both organizations are now filmless in radiology.
Krau: We are in the selection phase for an enterprise PACS to meet the needs of cardiology and radiology. We do have a system for one of our hospital cardiac catheterization procedures that has been implemented for about 3 years. A miniPACS is also in place for ultrasound at another hospital, but it lost its support at the end of 2001.
Ragan: Our PACS was implemented starting in 2000.
Skarulis: Rush-Presbyterian-St Luke’s Medical Center, Chicago, is all digital in radiology, with the exception of mammograms. We are using a PACS that was implemented in 2001.
Q: What is your archiving strategy?
|Don Ragen, PhD|
Krau: The enterprise digital imaging vision of Main Line Health, Bryn Mawr, Pa, transcends departmental barriers, and the information system technology must support enterprise digital imaging. The initial focus of the effort is on radiology and cardiology imaging. Main Line Health expects to include other medical and nonmedical imaging in this architecture in the future. The Main Line Health enterprise digital imaging vision includes, at a minimum (but is not limited to), the acquisition, integration, storage, distribution, access, and display of all and any digital (and analog converted to digital) medical and nonmedical images generated and read at any location throughout Main Line Health. Main Line Health has developed guiding principles for its digital imaging vision. These guiding principles will be used to shape the direction of the Main Line Health digital imaging transformation initiative. The guiding principles will also be used to benchmark digital imaging/PACS vendors’ understanding of the Main Line Health vision and their ability to assist Main Line Health in achieving this digital imaging vision in the future.
|Patricia Castel Skarulis|
The Main Line Health digital imaging guiding principles are:
? any diagnostician can view, work with, and be provided the appropriate corresponding tool kit for the image type and preselected work list for any image, any specialty, and any patient on a single diagnostic workstation;
? any clinician can view and work with any image from any specialty for any patient on a web workstation with all the capabilities of a clinical workstation;
? Main Line Health clinicians will read text results through the lifetime clinical record, will have an indicator to show that an image exists, will be able to view the image through the lifetime clinical record, and will work with the tool kit appropriate for the image through the web server;
? the Main Line Health enterprise digital imaging vision will be accomplished with as much commonality in technical architecture as possible to incorporate every specialty through adherence to, in compliance with, and in conformance with industry standards; and
? the Main Line Health enterprise digital imaging vision will be accomplished with the minimum number of systems and system components that need to be administered.
Ragan: We have 90 days of online storage, with nearline storage to digital audiotape; we are using more online storage now, since storage costs are down.
Skarulis: Our archiving strategy was part of our original design. We have a jukebox in? proximity to the radiology department and an identical jukebox in the central data center (located in a different building on campus). Each cabinet has somewhere between 20 and 40 terabytes of storage. We also create a backup tape for off-site storage/archiving.
Q: As departments outside radiology develop the need for digital archiving of images, what are your goals for the integration of this information?
Ragan: Our short-term and long-term goal is to have all data on one archive that is centered on the radiology information system (RIS)/hospital information system (HIS).
Skarulis: From the corporate perspective, as CIO, I think it is very important that we think in terms of corporate PACS rather than individual departmental PACS. Right now, our cardiology department is in discussions with radiology about sharing space on the jukebox archive in the data center. Radiology, however, is understandably cautious about taking on another department while they are still working on their own implementation. Cardiology is also exploring the use of the automated cartridge tape library that we use in the central data center for other types of archiving.
Glaser: Our short-term goals involve extending the PACS infrastructure and expertise from the two academic medical centers to other organizations within Partners HealthCare System Inc, Boston. The Brigham and Women’s Hospital PACS has been extended into the Dana-Farber Cancer Institute, Boston, and is in the process of being extended into the Faulkner Hospital (a Partners community hospital), Jamaica Plain, Mass. Planning is under way to extend the Massachusetts General Hospital PACS infrastructure into the Newton-Wellesley Hospital (a Partners community hospital), Newton, Mass, and the North Shore Medical Center (a group of four Partners hospitals in communities north of Boston). In the short term, PACS will be extended into cardiology. Plans for pathology and ophthalmology have not been developed.
Krau: The first phase of our enterprise PACS implementation will include cardiac catheterization, radiological ultrasound, and other modalities that are already Digital Imaging and Communications in Medicine (DICOM) digital. Thus, from the beginning, we will have both cardiology and radiology studies in our PACS environment. Pathology has been involved peripherally in our selection process, but is also interested in participating after we have more of our cardiology and radiology studies online.
Q: What are the primary obstacles to enterprise-wide integration of digital information?
Skarulis: Everyone concurs on the need for fully integrated clinical information. We are using one product for the enterprise master person index and the clinical data repository. We are in the process of adding more and more interfaces from existing systems. The incentive is to have all the information about the patient available to the physician/clinician and to develop alerting systems that tie in with provider order entry. We are already seeing economic and patient care benefits from some of our alerts.
Glaser: Enterprise-wide integration has to reflect the overall degree of integration of the integrated delivery system. We are in the final stages of implementing common general-accounting and human-resources applications, since these functions have been consolidated across Partners. On the other hand, our integration plans do not require a common radiology, laboratory, or pharmacy system. The overall incentive is to match the integration demands of the organization. Lack of capital, political complexity, and the ill-defined nature of integrated operations can all form obstacles. The impact of integration on billing, scheduling, and patient care can vary. Integrated billing or scheduling may (or may not) be an improvement. Integrated care is enhanced by integrated clinical information systems, but these systems may not be worth the cost if the planned degree of care integration is modest.
Krau: I believe that there are vendors now capable of supporting enterprise integration of cardiac and radiology images, with plans for moving to additional modalities. Given that we do not currently have many PACS in place, we do not believe that there are any obstacles to moving to enterprise-wide clinical imaging. The incentives that would cause an organization to pursue enterprise PACS are lack of a substantial prior investment in PACS (with readiness to pursue PACS now) and obsolescence of an existing PACS that it is not economical to expand. The biggest impact of enterprise PACS, at this point, is related to patient care. With members of each discipline having images relevant to the diagnosis at their fingertips, the ability to bring more information to the diagnosis process is greatly enhanced.
Ragan: We are committed to enterprise-wide PACS and expect it to improve scheduling, lengths of stay, and patient care.
Q: What do you see as the PACS-related roles of information services and information technology departments?
Glaser: Information services departments need to negotiate with radiology departments to establish the best distribution of roles. In our case, the information services department provides network and workstation infrastructure, capital for PACS implementation and growth, and integration services to link PACS with other clinical systems (such as the computerized medical record). Radiology information technology staff provide the PACS-specific expertise needed for PACS development, implementation, and system management.
Krau: Enterprise imaging moves the image archives and associated networks from being a departmental system to being a part of the infrastructure. The image systems become another of the tool kits available to all areas. The information services department has a partnership role to play in evaluating the underlying technologies and adherence to standards for all vendors considered. In addition, it has the responsibility of ensuring that the networks are designed to handle the multiple image sizes associated with a enterprise PACS. The department should also play a role in equipment selection, now that the equipment required is more of a commodity. For ongoing maintenance, the department has the responsibility of keeping the network performing at a desirable level, backing up the relevant databases, and securing the environment as web servers are added.
Ragan: The information services department is leading the PACS imitative.
Skarulis: The information services department handled all of the networking for the PACS. In anticipation of having web-based access throughout the medical center, we began installing larger monitors and increasing the memory in the desktop computers in all medical center areas. We also handle all of the security for the entire network, including firewalls and authentication.
Q: What have been the greatest challenges encountered in integrating PACS with other information systems?
Krau: Our greatest integration challenges have been related to dictation. We also, initially, faced a challenge in the implementation of an enterprise master patient index in radiology, as our medical-record numbers are not unique across the enterprise. The medical-record numbers used at one hospital may also be used at another of our hospitals. The RIS vendor did provide the support for a multisite medical-record numbering scheme within the RIS.
Ragan: We have purchased a PACS that is integrated into our system-wide RIS.
Skarulis: We have had no problems integrating the RIS with the HIS. We send admission, discharge, and transfer information to the RIS from our PACS and the RIS sends preliminary and final reports to our data repository. We have been doing this successfully using Health Level 7 for a long time. We anticipate that, at some time in the future, our clinical data repository will keep a pointer to the PACS image, in addition to the report itself.
Q: What impact is web technology having on enterprise-wide information management?
Ragan: We are using a web viewer for image review by attending physicians.
Skarulis: The physicians love having access to the image via web (with proper security) in the hospital, at their offices, and at home. Even though the image is not of diagnostic quality (it uses 10:1 compression), it is useful for almost all their purposes. In those areas that require diagnostic-quality images, such as intensive care units, the emergency department, and the surgical suites, we use DICOM to send images to PACS workstations.
Glaser: Web technologies are becoming the basis for all applications and infrastructure; hence, the boundaries between web-based applications and normal or legacy applications have effectively disappeared. Web technologies are the focus of the majority of information-technology innovation, leading to constant improvements in the technologies. Web technologies have desirable properties such as a lower total cost of ownership and the ability to ease the challenge of extending the reach of applications over very large geographical areas.
Krau: We believe that the strength of the web products being developed will eliminate the need for the clinical workstations and facilitate the interpretation of studies, especially in off-hours situations. The linkage of the image and the clinical data repository test results will help to eliminate retrieving images where the text is sufficient for diagnosis.
Q: Has the Integrating the Healthcare Enterprise (IHE) initiative had a positive impact on connectivity?
Skarulis: I am sure that the initiative has had a positive effect on connectivity. It has certainly encouraged communications between the radiology community and the information systems community: an important first step.
Krau: The initiative has had a profound effect on role definition, as well as in creating an environment that is much less proprietary. For the future, IHE can address areas or situations where the work flow needs to have role definition in order to let the integration of multiple vendors proceed at a faster rate and to eliminate manual steps needed to keep multiple systems in sync for data.
Kris Kyes is technical editor of Decisions in Axis Imaging News.