By Brad Levin, MBA
General Manager North America, Visage Imaging
I was stunned. A few weeks ago I was told that a number of our most respected imaging informatics leaders had convened and many were convinced “Radiology has solved the problems of going digital.” You may think something different, but I immediately thought of Saturday Night Live ‐‐‐ you know, the segment on ‘Weekend Update' from years past with Seth Myers and Amy Poehler. In my head rang out, “Really? Really?”
While it is an absolute certainty that we in Imaging have successfully transitioned from film to digital, it has been my experience that there is a tremendous amount of work still to be done. Our problems are far from being solved, from the most advanced pillars of radiology in academia, to the imaging center down the street. We can certainly put on rose‐colored glasses, and pound our chests with pride about going digital, but that would require we ignore today’s problems. I’d argue we can ill afford this practice, as the problems are a drain on productivity, they negatively impact patient care, and they are in fact a cataract on our collective achievements.
What problems and opportunities am I speaking of? I’m not talking about today’s exciting developments in big data, speech understanding, clinical/business analytics, critical results management, dose reduction/management, and achieving meaningful use. I’m talking about the basics, and in many respects so did Chris Meenan and Dr. David Weiss in their recent “Top 10 (and more) Clinical Challenges” post following the recent Philadelphia Regional SIIM Meeting. Far too many health systems, community hospitals, imaging centers, radiology groups, and teleradiology organizations are struggling with their aging imaging infrastructure. In our era of the App Store, smartphones, and powerful tablets, the vast majority of radiologists and imaging professionals go to work each day and log onto PACS systems that were designed a decade ago or more. Those PACS are stuck at a reduced functional level, and subsequently, many groups are struggling to satisfy minimal expectations in their markets, let alone be leaders.
But rather than talk in generalization, these are some of the real‐world problems I’ve observed working with countless imaging organizations over just the past 12 months.
Hanging protocols. Nearly every PACS has them, but how many work as expected? A huge number of systems I’ve encountered have flat‐out given up on their hanging protocols, including many that have made six‐figure investments in this area.
Timely access to priors. Going digital has created vast amounts of studies, and as systems have come together in a heterogeneous fashion, access to prior studies across these multiple platforms is frequently an impossibility. For example, one of the most prestigious systems located in New England has PACS everywhere in their system, but timely access to priors is not possible.
Many organizations are still routing the same DICOM studies to multiple destinations because they don’t know ‘who’ is going to interpret the studies. It takes so long to move the DICOM, they can’t afford not to have the images at the right location.
I’ve also run into systems that have multiple hospitals using the same vendor PACS, and yet they still do not have access to priors due to a variety of technical barriers. Additionally, I was surprised to learn just this week that a large, multi‐site/multi‐state imaging center chain in the Mid‐Atlantic just recently began auto‐routing priors, which for years had been querying and distributing priors manually. That very same chain shockingly does not use a worklist to manage interpretations across their team of more than a dozen radiologists.
Viewer overload. A multiplicity of viewers exist at most systems, especially those that have grown over the years. Viewers for the radiologists, for the clinicians, for access from the EMR, for access from CD/DVDs, for QA stations, etc. That’s 5 viewers. Multiply that by a few hospitals that have merged together over the years and that’s a major issue. A prominent health system in the NY‐metro area with over a dozen hospitals is losing referrals because once patients get into the system, referring physicians don’t know which viewer to use to access their patients’ images.
Viewer capability. Imagine it’s 2005, and you just received a shiny new laptop. The years go by and you continue to use the same laptop, getting periodic updates, but nothing major. Fast forward to 2013, and you’re using the same laptop, which is of course waaaay behind the times. Now instead of “laptop”, imagine substituting “PACS workstation” into this discussion. Radiologists and referring physicians are using viewers that were designed years ago to take on today’s challenges. I was at my orthopedist with my daughter a few years back and despite repeated tries, and reboots, he could not bring up my daughter’s study (with priors) on the review station. He had to read it directly from the CR, and I never saw the images. How many of you have had the same unfortunate experience?
Additionally, I met recently with a large independent radiology group in the Mid‐Atlantic that told me their web viewer is costing them referrals to other competing groups. A few short years ago, that same viewer helped to significantly build their referral base simply by word‐of‐mouth praise. Indeed, times have changed.
Won’t work. Does this sound familiar? “A prominent referring physician’s office just upgraded all of their PCs. They finally got rid of their old clunker systems, and they are now running the latest Windows 8 systems. They are literally on cloud nine, and we just told them our image viewer does not support the latest release from Microsoft.” You can also substitute, “We just upgraded our offices with new Apple iMacs.” This is bad customer service 101.
The reality is the vast majority of PACS in use today are woefully lagging behind their support of the latest operating systems, web browsers and platform support (e.g., Mac). It’s no wonder many referring physicians are frustrated with Imaging.
Advanced visualization. In 2011, KLAS reported that Radiology had not found an effective way to work 3D imaging into the workflow of the radiology department. I see this everywhere ‐ Technologists are performing reconstructions at the modality console, which take a considerable amount of time, and are sent to PACS as static secondary captures, with the hope they are what the radiologist requested/needed. If not, they need to be redone, taking time, impacting care. Some radiologists consider this practice the ‘technologist’s job’, but that’s largely because most legacy systems can’t display reconstructions on‐the‐fly, within hanging protocols. Some PACS today don’t even support hanging protocols and the techs do that work too, setting up every study for the radiologist. But I think mostly everyone has gotten past thinking that hanging studies via PACS is a technologist’s job.
Additionally, it is common to see studies such as PET/CT and CTA only available at isolated workstations. If the radiologist is not at that specific station, they do not have access to the images. Far too frequently radiologists are forced to move to the images. That’s an archaic practice in today’s high‐tech, mobile world.
Speed of access. As mentioned, the majority of today’s diagnostic workstations and clinical viewers were originally designed a decade ago or more. When those old viewers were forced to support multi ‐slice CT in the mid‐2000s, it took several years for viewer performance improvements to catch up. But the growth in multi‐slice studies has continued in terms of study size and number of slices. One prestigious system out West has a current benchmark that their viewer(s) need to be able to support rapid local and remote access to current + (multiple) prior studies totaling 8,000 slices. If viewers don’t support 2‐3 second access, they are no longer being considered.
A colleague of mine met last year with a prestigious stroke center located in the Midwest, responsible for stroke coordination across several large urban and community hospitals. Despite having PACS at each of the individual locations in the network, they could not reliably and timely gain access to CT studies w/priors before care decisions needed to be made. Their shocking and frequent solution ‐‐ Apple FaceTime using iPhones, viewing studies directly from the modality console. This reminds me of the stories I heard in the early days of PACS, the so called ‘camera‐on‐a‐stick’ days. We have to do better.
Remote/At home access. The PACS revolution eliminated film, but an embarrassingly large number of institutions to this day do not provide radiologists the same level of access at home as they provide at the hospital or imaging center that they work at during the day. The legacy technology either is too expensive to support from home, or does not provide adequate speed/quality of access over consumer networks using VPN. As many institutions strive to take‐back‐the‐night, this problem needs to be solved.
Mobile access and image exchange. Despite the availability of mobility and image exchange solutions over the past several years, the use of these solutions is far too low in actual practice. My guess is hundreds of facilities are using mobility and image exchange solutions, when they should be in use at thousands of facilities.
Unsustainable workflow. I’ve seen each of these reading workflows at multiple settings, from coast to coast ‐‐‐ Swivel‐chair workflow: A radiology group reads for multiple entities, each with their own RIS and PACS. Today’s typically used solution is to have a dedicated workstation for each entity and literally have the radiologist move in the swivel‐chair, from one station to the next, to read the day’s studies; 3D Lab Swivel‐chair workflow: Similarly, 3D labs usually have different workstations set to achieve different clinical tasks. The 3D techs need to move from station to station to complete their reconstructions, again in the swivelchair; Double-decker workflow: I’ve observed many breast imaging experts reading off of numerous displays, in confined spaces, frequently requiring several workstations on the desktop and several workstations wall mounted at eye level. Literally a setup of workstation overload, to perform multi‐modality analyses, instead of reading off a single viewer. Far too many of these groups have, or are contemplating, yet another workstation to read digital breast tomosynthesis studies.
In conclusion, we’ve got a good news ‐ bad news‐ good news story here. The good news is yes, Imaging has gone digital. Contrary to some, the bad news is today’s implementations of yesterday’s technology have plenty of problems still to be solved.
But the good news is that all of the problems I outlined, all of them, can be solved with technology that is available today. Really? Yes, really. Perhaps a great place to start would be to see what best practices and technologies are available at the SIIM 2013 Annual Meeting this June (Dallas, TX). See you there.