Image enabling your EMR – Starting small and

Image enabling your EMR –
Starting small and evolving
into an Enterprise Imaging
System.
Mark Ang
Program Director, Ancillary Diagnostics
Integrated Health information Systems
Agenda
2
•
Introduction
•
Enterprise Imaging Definition and Framework
•
Enterprise Imaging Architecture
•
Enterprise Imaging Technology
•
Enterprise Imaging Governance, Change Management and
Support Structure
•
Starting small.
Introduction
Purpose of Presentation
• Image enabling your EMR - Not new for radiology / cardiology
but relatively new for other kinds of images.
• The purpose of this presentation:
- Share our experience on Enterprise Imaging with
Radiology images.
- Share our thoughts on the kind of challenges you will face
when you embark on Enterprise Imaging for other kinds of
images.
Enterprise Imaging – Definition
•
Image creation,
storage,
management / workflow, and
consumption beyond radiology,
cardiology, any-ology.
•
Viewable anywhere, anytime,
by
anybody
across
the
continuum of care in healthcare
systems
Enterprise Imaging Framework – Based on VNA
Enterprise Imaging – Framework
•
Each any-ology department
has
their
own
imaging
workflow.
•
Storing and managing the anyology images on a VNA.
•
Viewing images using common
viewer.
•
Secured access through EMR
system across the continuum
of care in healthcare systems.
Enterprise Imaging Framework – Based on VNA
Enterprise Imaging Architecture
Pros
Decentralized or
Federated
Centralized or
Spoke and Hub
Pros
-
Fast performance.
-
Lower cost.
-
Less disruptive when
changing spoke.
-
Image - source of truth.
-
Consolidated Patient
studies.
Cons
-
Higher cost.
-
Data sync issues.
vs
Cons
-
Slower performance.
-
More disruptive when
changing spoke.
-
Patient studies are
more fragmented.
Requirements : (1) Scalable, (2) Good system performance (3) Cost effective (4) Easy to maintain
Enterprise Imaging Architecture – Early Days
• SingHealth / EHA first Radiology Imaging(PACS)
architecture was Federated.
• 3 hospitals stored all images on site and directly
query / retrieve.
• Why Federated?
- Product design philosophy, lower cost, data
was from source of truth.
Hospital 1
Hospital 2
Hospital 3
• Worked reasonably well with sufficient bandwidth –
only 3 hospitals. Patient’s total studies are
distributed.
NHG – National Healthcare Group (Tan Tock Seng Hospital, NHG Diagnostics, Institute of Mental Health, NHG Polyclinics),
NUH (National University Hospital)
JHS (Alexandra Hospital, Ng Teng Fong General Hospital)
AHS (Khoo Teck Puat Hospital)
SingHealth / EH Alliance – (Singapore General Hospital ,KK Women’s and Children’s Hospital ,Singapore National Eye Centre, National Heart Centre, National Cancer Centre, SingHealth
Polyclinics), EH Alliance – Changi General Hospital
Enterprise Imaging Architecture – Current
Hospital 1
Hospital 2
• NNJA first Radiology Imaging architecture was
Centralized.
Cluster PACS
• Hospitals sent local images to off site Centralized
Cluster PACS .
• Cluster PACS used for image sharing with and
across Cluster. Used as DR.
• When SingHealth / EHA replaced their PACS,
architecture was the same as NNJA.
• Centralized is popular architecture.
Hospital 3
Hospital 4
Enterprise Imaging Architecture – Cross Clusters
• Architecture for cross cluster is Federated.
• Users use their own PACS viewer to retrieve the images for cross cluster.
Cluster 1
PACS
Cluster 2
PACS
• Works well?
- Yes - Federated model is manageable because there are only two sites.
• Downside?
- Study information (meta data) stored in separate PACS.
- Slower performance than centralized model.
Enterprise Imaging Architecture – What’s mine?
•
Depends on the requirements e.g Is new archive necessary?
•
Hybrid model - strength of Centralized + Federated model.
•
One example:
- Centralized meta data.
- Federated pixel data.
•
Advantages:
- All studies information(metadata) available at one source
regardless of where the studies were done.
- Pixel data is from source of truth.
- Cheaper than centralized.
Centralized
Meta Data
Enterprise Imaging Architecture – other key considerations
1. How many VNAs? Impact analysis.
– Ride on the current Radiology VNA?
– May complicate Radiology DR function?
– Cost sharing (not architectural / technical
issue).
2.
Storing of DICOM and non DICOM objects?
– Dicomize everything? or
– Use XDS (Cross enterprise Document
Sharing) for non dicom objects?
Goal State
Enterprise Imaging Architecture – other key considerations
3. Policy on viewers
– Ideally ONE viewer to support.
– Zero Foot Print viewer preferred.
– Policy on advanced viewer for
some depts.
4. Guiding principle for departmental
imaging system with respect to VNA.
– Short term storage at department
level and long term on the VNA?
– Migrate all data to VNA?
Goal State
Enterprise Imaging Architecture
•
Approved EA, policies and guiding
principles shall become the blue
print.
•
Governance structures and
gatekeeping to ensure imaging
systems implemented comply with
the blue print.
Goal State
Technology
• Vendor Neutral Archive
- Is VNA the way to go?
• Viewer
- Why use ZFP?
• Security
Leveraging on EMR security matrix?
Technology – Vendor Neutral Archive
• Started as response to the cost and complexity of PACS-to-PACS migrations.
• Neutrality 1 - Change hardware storage without changes to PACS applications.
• Neutrality 2 - Change PACS applications without changes to hardware storage.
• Should VNA be used??
– VNA trend.
– Success stories.
Source: InMedica , a division of IMS Research – Competitive Dynamics in the North American Market
Technology – Vendor Neutral Archive
• Core capabilities surround vendor independence
and the adoption of industry standards.
• Stores image in non proprietary format
• Interface with all major PACS via DICOM
• Supports DICOM and non DICOM objects
• Supports HL/7 interface standards
• Supports bidirectional tag mapping/morphing
• Offers or supports universal viewer
• Supports non proprietary image compression
• Neutral to underlining storage fabric
• Supports massive scaling
• Supports XDS (Cross Enterprise Document Sharing) for document
sharing
Source – Gartner report 30 April 2014
Technology – Vendor Neutral Archive
• Can VNA be proprietary?
– Some VNAs may store in proprietary
compression and format.
– If “some what” proprietary format, ensure can
convert to non proprietary format easily.
– Proof of Concept (POC)
• Hardware storage neutrality test
• Application neutrality test
Technology – Zero Foot Print Viewer
• Characteristics of Zero Foot Print viewer.
-
View natively in any type of web browser regardless
of the device and OS.
-
does not store anything on the end user's machine.
-
Zero Maintenance: Zero download - avoids
increasingly difficult installation of client software.
-
Zero Time to Load: loads content on-demand.
-
Less functions than fat / smart client.
ZFP Viewer – Earlier version


•
•
•
supports single or 1x2
layout
Basic Image manipulation
tools only
No preset
No Angle/cobb Angle/RoI
No 3D/MIP/MPR/VolR etc
ZFP viewer- Newer version


• Provision of advanced viewers.




Enhanced layout: Up to 2x2
More Image manipulation
tools
Angle/Cobb Angle/RoI
3D capabilities
MPR/MIP/VolR
Comparison tools
Bookmarks
Search page enhancements
Technology – Leveraging on the EMR Security Matrix
• Same id and password.
• Management of access is centralized and consistent.
• Proven complex security matrix is difficult to replicate.
- Role based.
- VIP patient access.
- Limited to view only your institutions patient,
locations.
• Easier to implement security changes.
• EMR has proven resiliency.
Governance and Change Management
• The complex EI Environment is
like a eco system.
• Many components, many moving
parts, in EI eco system.
• Each component performs an
important function.
• If one of the components
malfunctions, it can affect the
health of the EI eco system.
Multi-Department
Support
Broad Device Type
Support
Flexible Workflow
Options
Broad Data Type
Support
• Ophthalmology
• Emergency
Department
• Nursing
• Burn Unit
• Surgery
• Pathology
• Gastroenterology
• Urology
• Otolaryngology
• Dermatology
• Speech Pathology
• Neurology…
• Pre-ordered, Just-intime Ordered, Orderless Workflows
• Data Entry by Worklist,
Demographic Query,
Barcode, Pick List and
Manual Entry
• Device, EMR, or
Scheduler Integrated
• Device Trigger or Foot
Pedal Capture
• Digital Cameras
• Video Cameras
• Ophthalmic
Cameras
• Surgical Scopes
• Endoscopes
• Fluoroscopes
• Microscopes
• Doppler
• Film/Image
Scanners
• CD/DVD Import
• Synthetic Images
(Print-to-IDC)
• Static Image /
Bitmaps
• Video, Video w/
Audio
• Multi-frame Cine
• Audio, Waveform
(ECG)
• PDF
Governance and Change Management
• Spikes in disk consumption - unplanned new
modalities.
• Image queue pile up – due to invalid data from new
system / changes to existing system.
• Governance and processes are needed for:
- Compliance with the architecture and guiding
principles.
- Approval of projects (including new imaging
acquisition) and changes to the system.
•
“Human side” of Change Management – Introduction
of changed workflow at imaging source end.
Who governs?
What processes?
Governance and Change Management
•
•
A new committee (Enterprise Imaging
Committee).
-
Provide overall direction and leadership.
-
Endorse the EA, strategy and get buy-in
for Enterprise Imaging.
-
Endorse policies, procedures and enforce
compliance, set transfer pricing keys.
-
Approve projects, oversee performance,
manage changes and ensure
sustainability and growth.
-
Issues resolution.
IT, MI, Imaging Dept reps, Clinicians, Nursing
Informatics and Bio Medical Engineers.
Who should be in
this committee?
Ongoing System Support
• Different from the typical IT or project support
because of the diversity and specialization.
• Support needs to come from different Imaging
departments, IT and BME.
• Clear roles and responsibilities need to be well
defined so that the different support departments
can co-exist harmoniously.
- Problem escalation process
- Level 1, 2 and 3
Are you ready? Start small first
• Easier to demonstrate success
-
identify low hanging fruits.
-
less complex, easier to get started.
• Fine tuning opportunities for
-
the governance structure, policies, process
and ownership, charging model, optimal
support model.
• Try out the technology on a small scale.
-
Allow time for maturity of technology.
• Make adjustments to your overall strategy,
implementation approach and plans.
Conclusion
• Architecture
– Centralised or Decentralised or Hybrid
– Policies, guiding principles and blue print
• Technology
– VNA is the way to go
– ZFP viewers, advanced viewers
– Why go through the EMR
• Governance and Change Management
– New imaging committee
– Need to govern and manage the Enterprise Imaging Eco-system
• Start small, leverage on you EMR security
25

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