A Paradigm Shift: Enterprise Imaging and Integrated Clinical Care

By Srinivasa Chaganti, Director of Enterprise Applications, DHR Health

The Integrated EMR and Diagnostic Imaging

In the last 25 years, medical imaging has successfully transitioned from bulky film and paper-based workflows to digital image archives. Organizations deployed RIS, PACS with advanced Visualization capabilities. They integrated them with Structured Reporting (SR) and Voice Recognition (VR) systems to create mature workflows built to be fast, efficient, and accurate.

The HITECH Act and ACA in 2009 and 2010, respectively, heralded the Meaningful Use era in clinical care and delivery. Incumbent to these regulations, Accountable Care demands of the ACA emphasize quality, outcome, and costs across the care continuum. At the same time, the HITECH act mandated urgent computerization of medical records and clinical documentation, focusing on the EHR being at the center of all clinical care initiatives.

Medical Imaging, too, has started to see a paradigm shift from volume-based operations to “value-based” care delivery. Healthcare facilities began implementing and installing EMR System software solutions, mandating CPOE workflows and CDSCDS systems. EMRs created an organic need for interoperability to enable a significantly more patient-centric view of clinical records across the care continuum.

With the right outlook, strong leadership, a well-thought-out roadmap, and effective governance, an organization can accommodate newer technological advances that will continue to successfully shape the future of medical care.

The Enterprise in Imaging: The Rise of the Vendor Neutral Archive (VNA)

Over time, the EMR has evolved from being simple billing-tracking systems to the multispecialty clinical documentation storehouse of patient data that it is today. The EMR has created an ecosystem that requires clinicians to access all kinds of clinical records, including medical and diagnostic imaging from other clinical realms. Departments like Cardiology, Pathology, Dermatology, Ophthalmology, Wound Care, and Gastroenterology, to name a few, are imaging workflow intensive. The need for documentation and imaging to integrate into the patient’s longitudinal record in the EHR presents an opportunity to garner efficiencies in managing silos of different imaging systems and enable actual patient-centric workflows instead of application or department-centric processes.

Enterprise Imaging is an organizational mindset needed to address the need to eliminate traditional imaging silos by aligning imaging technology and infrastructure essentials with universal image availability (without silos). Enterprise Imaging seeks a more consistent data storage, image access, and image lifecycle management (ILM) approach.

The evolution of the VNA market is proportional to the expansion of imaging needs across multiple departments in the enterprise. The VNA is a vital part of the Enterprise Imaging solution. It consolidates all imaging data from various modalities, departments, facilities, and vendors into a central clinical data storage infrastructure that serves as a unified longitudinal patient imaging information repository. VNAs must store and display any file format, images, multimedia content, DICOM or non-DICOM, and retrieve data in its native form. In addition, it is desirable that VNA also act as a workflow engine to create a worklist for a modality or image source and perform prefetching and notification functions as needed for optimum lifecycle and storage management.

Most organizations are experiencing a considerable challenge responding to the rising costs attributed to the storage and retention of images in their legacy storage arrays. It is not uncommon for imaging data to be the primary storage infrastructure consumer in organizations with a significant Imaging footprint. Innovations in medical imaging technology have improved clinical considerations by collecting more data while increasing the size of a study with a significant impact on storage capacity and image life cycle management. For instance, Digital Breast Tomosynthesis (DBT), as a supplement to traditional mammogram imaging, takes between 400% to 4900% more images than a digital mammogram. Organizations that do not strategize and plan for escalating costs of technology and innovation in an integrated enterprise will stare at heavy investments in infrastructure silos. Medical Imaging silos in a health system, when unplanned, is one such cost driver.

To make Medical Images accessible throughout a health system requires an enterprise viewing application and two other key components – an archive and a workflow application. In today’s healthcare ecosystem, the endpoint for an Imaging enabled organization, and health record is deploying a VNA. Based on size, complexity, and budgets, other organizations tend to prioritize aggregating imaging services in the organization and implement the VNA first.

Five critical considerations while transitioning to a VNA.

1. Develop Strategic Roadmap for Technology and Imaging:
   Organizational budgets and strategic road maps drive leaders to consider first implementing an enterprise viewing platform by replacing the viewing components of the PACS before scaling up to a VNA. Complete a thorough audit of the Imaging infrastructure by granularly examining modalities, studies, image sizes, and imaging life cycle considerations to develop a strategic road map that you can budget for
   
   
2. Establish Imaging Governance in the organization:
   Set up a committee including all Enterprise Imaging stakeholders and information technology leadership to develop and sign off on a strategy with a clearly defined scope. Make sure to include IT strategies that account for security, privacy, and compliance in addition to availability, quality, and architecture.
   
   
3. Develop an ILM strategy:
   ILM is a significant feature of a VNA application. An impactful ILM application will set up the VNA to automate the management of study deletion and retention parameters after considering all policies and legal ramifications.
   
   
4. Define your workflows:
   Recognize that many non-radiology and cardiology enterprise imaging workflows differ from a traditional “procedure-based workflow” in a radiology imaging setup. In most instances, these “encounter-based imaging workflows” have no order placed before image acquisition. These workflows are also called “Point of Care Imaging” (POC) and constitute a significant chunk of unregulated enterprise imaging.
   
   
5. Cloud Migration (Data Migration):
   VNA deployment usually requires migrating all legacy archived data into the VNA. The economics of data and storage based on usual enterprise factors of System availability, Information security, legacy data retrieval, and retention will dictate that you strongly evaluate a cloud storage strategy.

The transition from the current to the future state can be challenging. With the right outlook, strong leadership, a well-thought-out roadmap, and effective governance, an organization can accommodate newer technological advances that will continue to successfully shape the future of medical care.