Wednesday, June 1, 2011

Tips from a Road Warrior (12): Check Your Connections

The majority of my travel stories deal with my travels to India, as this country, despite its high tech image, still has so many infrastructure problems and issues that I typically characterize it as operating in "controlled chaos." Yes there is public transportation and there are taxis, and they have airports but they seem to be built for a fraction of the people that use it today. For example, there is typically only a single door to enter the airport, causing a queue out of the terminal stretching literally around the block. Unless you know a back-door, or wave a few hundred rupees, there is no way you will make it to the front without at least a one- or two-hour wait. As an illustration, I had to connect from Bangalore back to Dallas through New Delhi. Unfortunately, that means changing from the local to the international airport. Upon arriving at the local airport, there are no signs directing where to go or what to do, and after asking several people for a clue, they pointed me to an obscure ticket counter to purchase a bus ticket. The next bus was going to leave in an hour and looking outside to the queue already lined up, there was no way that we were going to fit into that bus. Talking with a fellow American in the same predicament, we decided to take a cab, which is an adventure by itself, especially when each of us had two suitcases to get into these tiny cars. Upon arriving at the international terminal, we decided to bribe our way through by giving an important looking person with an airport badge a good tip, and we made it just in time. 

Lesson learned is that any connection depends on the parties involved. Connecting from Tokyo Narita to Haneda or London Heathrow to Gatwick is a breeze, not in India. The same can be said about connecting devices, whether it is to a RIS or to a PACS or even a workstation. Just as traveling with the same airline, purchasing a modality from the same vendor as your RIS or PACS does not guarantee that it will be simple, straightforward, and without any connection issues. Remember most large companies have separate development centers for their different products. The RIS might be developed in the US on the East Coast, the modality in France, and the PACS by a division at the West Coast. Their DICOM conformance statements do not always follow the same template and do not have the same level of detail, and each seems to have their own conventions and ideas about configuration and installation. As a matter of fact, I would argue that some of the mid-sized PACS companies, who do not sell any of the modalities, are more open and easier to connect as they have every incentive to make this as painless as possible. 

It is important to do your homework and test the interfaces extensively prior to connecting devices. This not only applies to the interface of a modality with the RIS and PACS, but also to the reporting system, web-based viewers, MPR and future EHR applications as well. Most of the calls for assistance are not related to the basic connections anymore but for example, information missing in the report template for cardiology ultrasound exams. In this case, the reporting system does not quite interpret the information from the structured report template generated by the ultrasound. There are also issues with archiving and displaying the new modality objects such as being generated by the latest generation MR and CT as well as 3-D breast imaging devices. 

As images are going to be distributed more widely through electronic health records and possibly in personal health records as well, the connectivity issues are only going to grow, if for no other reason than rising volumes. Image distribution used to be rather well controlled within one or more departments, it is already widespread, so you can imagine what it will be like when patient images are accessible by any physician who is authorized by a patient: the sky is the limit. 

In conclusion, anytime there is a connection or interface, one should be aware of potential issues and prepare accordingly. This can be done by studying the interface specifications, and testing sample images and transactions in advance. Don't assume that it is easier if you use the same vendor on each side, just as using the same airline doesn’t guarantee easy connecting flights. 

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