Thursday, March 29, 2012

Document Management and EMR

Paper will be with us for a while...
After a visit to a tradeshow such as HIMSS, it is always hard to get back to the real world where, instead of everything being available electronically, there are still a lot of faxes, paper EKG’s, consent forms, patient questionnaires, and old paper charts and loads and loads of other paper documents to deal with. Managing these documents in an electronic system such as an EMR is not a trivial matter. It requires a lot of work to scan them in and properly identify and index them. Traditional document management systems have been around for quite a while. I looked at some of the text books on this subject and some of them date back from the early 90’s when we were just beginning to think about EMR’s. At that time, an electronic patient record involved scanning every piece of paper into a document management system, which obviously was time consuming and does not provide any of the advantages that electronic information provides such as coding, decision support and the many other benefits of an EMR.
So, how do we deal with all these paper documents? As a matter of fact, scanners have become rather sophisticated. There are high volume production scanners on the market that can take in a stack of hundreds of documents and scan them at high speed, often scanning both sides, along with software that can automatically index the documents and recognize the patient record and type of document. The initial somewhat crude optical character recognition (OCR) has now advanced to what is called “zonal OCR” where one can instruct the software to look at a certain region, and can even be extended to ICR, which can also include handwriting. Most of this technology was not developed uniquely for medical applications. I am sure many of you are familiar with the recognition of handwriting that is widely being used to scan in checks at an ATM. Documents can be scanned directly into a database or management system such as Sharepoint, which can easily be interfaced with a EMR.
One of the challenges from an operational perspective is who is going to scan all of these documents in and make sure that they are properly indexed? There is an analogy with the transition from film to electronic imaging. In that case, the file room clerks were typically trained to scan films into the PACS system and ensure that they did end up in the right patient record. The same will have to be done with paper records, in this case, the front office or dedicated clerks will take care of this. As a matter of fact, one of the VA hospitals I visited had a whole department whose sole job is to scan all of the paper records and forms. They were one of the early hospitals to claim to be totally paperless. There is a challenge with training and educating these employees on the scanning technology and the basics of electronic records. To help improve quality and standardize document management practices, OTech has developed a certification program for Certified Healthcare Document Management Administrators (CHDMA) and a certification exam through a grant from Eastman Kodak Company. Document management will still be important as there will be paper around for the foreseeable future. It is important to have qualified, and if possible, certified personnel managing the processing of these documents.

Private HIE’s, dialing back the clock 15 years?

Courthouse, Denton TX a small town
of about 120,000 inhabitants,
which will most likely see 3 HIE's:
two private and one public
The definition of an HIE (health information exchange) is generally accepted as the electronic mobilization of healthcare information across organizations, within a region, community or hospital system. Unfortunately, there has been an important piece left out of this definition, i.e. to do it using open, well-defined and/or accepted exchange standards. There are more than 50 so-called “public” HIE’s funded by the American Recovery and Reinvestment Act (ARRA), which has handed out more than US $548 million as of January 2012, but there are about an equal number of private HIE’s appearing as well. A private HIE is typically set up by a single provider or provider chain that is creating a central repository and/or registry for patient documents and related information.
In my opinion, implementation of private HIEs defeats the purpose and does not meet the main objective of what we are trying to achieve in the US: the exchange of patient information to eliminate redundancy, improve efficiency and ultimately improve the quality of patient care. It is very similar to the scenario we have been going through with PACS installations over the past 15 years where we could not easily exchange images between two systems from different vendors. More and more institutions are migrating their information to a Vendor Neutral enterprise wide Archive (VNA) to disconnect the image management from proprietary vendor solutions. These systems are now able to exchange information because a true VNA is able to exchange the images and related information in a standard, vendor neutral manner.
Today, institutions are trying to interconnect their EMR’s and exchange information among them. If this is done through a private EMR, with an interface, which is customized to a particular EMR vendor and/or institution, we are in the same situation as we were using PACS systems 15 years ago. In other words, we just dialed the clock back 15 years. Note that it is not only important to standardize the interface protocol and transactions, such as used for querying for patient demographics and exchanging documents, it is even more important to standardize on the content, and its encoding. Otherwise, the receiving system is not able to interpret the information electronically and/or automatically update its EMR with the imported input.
As a case in point, I am involved with a small clinic in my hometown, Denton TX. It treats patients who could have been seen at either of the two hospitals in town, who are competing and have their own HIEs. Therefore, to exchange the information we would have to connect to both private HIEs, in addition to the public HIE through which we might need to access any information from local specialists. This does not seem to make sense to me. When our own Chief Technology Officer, Farzad Mostashari was asked the question during his HIMSS 2012 keynote speech about this issue, he answered that we chose “capitalism” and therefore we apparently have to deal with it. Well, sometimes we need to sacrifice a bit of our capitalistic ideology to achieve a healthcare system that is competitive with other western countries, which are able to treat their patients much more effectively and safely at less cost. If we fail to get our healthcare costs under control, we will find ourselves at a significant cost disadvantage in competing with other industrialized countries.
What will happen to the HIE connectivity of our clinic in our little community in Texas? Time will tell; I will keep y’all posted.

Friday, March 9, 2012

Tips from a road warrior (21): You have to deal with the car you are given.

I have probably taken hundreds of cab rides in many different cities all over the world. Most of them were rather uneventful, however, some of them I will never forget. For example, the ride from Boston’s Logan airport in a cab that was tailgating (as they usually do) while the road surface was very slick, and, when the driver had to brake, he slid into the car in front of us. I saw it coming and threw myself with my back against the front bench seat so I was not hurt.
One ride in New York City was also scary as the cab’s front door flew open every time the driver took a sharp curve while empty soda cans would roll out from the floor. Then there was the one when we were packed into a VW bug with four people in Mexico City (don’t believe the circus trick about packing many people into a VW as there is no way you can fit more than four). And then there are many times I was ripped off or overcharged, which is an issue in Middle Eastern and Asian countries. In any case, when stepping out of an airport terminal to take a taxi, one is totally at the mercy of who happens to be at the front of the cab line. You have to deal with the cards (or car) you are dealt.
Similarly, you can be taken for a ride by a vendor you have barely met when your institution is selecting a healthcare IT system. There are multiple drivers, technologists, physicians and others, who all steer in different directions while you are in the back seat. One suggestion is to move up to the front seat and actively get involved with the direction and speed that your system is moving. In many cases you might want to deliberately slow it down.
A good example of slowing down is when installing new releases, upgrades, or connecting new modalities. One of my rules is to never install a new release that is called “x dot zero”, for example, 5.0 or 6.0. Always wait until it reaches x.1 or, even better, x.2. One PACS administrator in my hometown is even more conservative. He waits until the vendor no longer supports the current release before he upgrades his system. His institution might miss out on some of the latest bells and whistles, but his system is rock solid, he has not had to reboot his PACS database for more than a year.
The same applies to operating systems. We all know people who went to Microsoft Windows Vista very soon after it came out, and regretted it. Unfortunately, one sometimes has to pay a premium for getting previous releases, as an example, when one wants to have XP on a PC instead of windows 7. I. In many cases, medical devices and/or software do not turn over as often as the operating system, and support for those devices with new operating systems require a lot of validation and testing, which is why the medical device industry is seemingly slow with adapting new technologies and operating systems.
Slowing down and doing due diligence also applies to installing new devices and/or systems. No reason to rush, but, rather, validate the system first on paper comparing all of the interface specifications such as IHE profile definitions, HL7 specs and DICOM conformance statements with the devices it will have to interact with. Then, one should do extensive testing within a test environment.  After that, run it in a test mode using test transactions instead of the regular production messages. If the system generates images or other objects such as structured reports, load those from a CD or flash drive onto the system that is supposed to be rendering and interpreting those to make sure there are no issues.
In conclusion, in some cases you might feel a little bit that you are not in control, but there is a lot you can do to steer a system and organization by taking the front seat and actively being involved in the direction that it should take to provide safe and efficient patient care.

Thursday, March 8, 2012

PACS Administrator certification: CIIP vs PARCA


Background:
It's not about the race,
but it's about the journey
As PACS systems were getting more sophisticated and complex, the need for one or more full-time individuals to support these systems, and taking responsibility for the data integrity and availability of the images and related information, became obvious. The profession of a PACS System Administrator (SA) naturally evolved by having both clinical (Radiological Technologists) as well as IT folks taking up the slack to support the PACS. These early SA’s were basically learning on-the-job, because there was initially no dedicated training available. Over the past 10 years, professional organizations, notably SCAR, now called SIIM, have started to include dedicated tracks to educate these folks, and several academic and commercial training institutes started to offer training courses, seminars, and hands-on workshops[1]. Vendors also provide SA training, but it is generally recognized that these vendor specific training sessions do not address any of the basics and rather mostly concentrate on the how-to and specific user interfaces of their equipment. In addition, there are now computer based training courses as well as text books on the subject of PACS, and the essential standards to make these systems work, i.e. DICOM and HL7. As these training classes developed, it also became obvious that there was a need for certification, for two reasons: to provide some indication of acquired skills, and also set a baseline for training: it became evident that there was a need to differentiate the large variety of training programs with varying depth and also spread of knowledge.

Certification:
When defining the certification requirements, it appeared that almost no-one seemed to agree upon the job requirements of these SA’s, because their jobs vary highly depending on their background, strength of other departments, culture, and history. For example, a SA with a strong IT background migth be able to troubleshoot connectivity issues between a modality and the PACS him or herself, potentially even looking at a network sniffer that shows the DICOM protocol data units and TCP/IP packets, while another SA would have to leave this up to their IT counterparts. However, after many meetings and discussions, there seemed to evolve three different tracks with potentially three different career paths, even although in many cases, all these skills could be present in one-and-the same SA. But before we elaborate on this more, it also became clear that there is definitely a common ground and vocabulary, i.e. all SA’s need to be able to communicate on the same level. They need to have a basic set of clinical AND technical vocabulary and understanding. That mean, for example, for people with an IT background to know the difference between different positioning such as a PA and LAT chest so they can configure the proper hanging protocol. Similarly, it would mean for the clinical folks to know the difference between a switch and a router in case the network performance was bad. Therefore, every one agreed that basic IT and Clinical skills are a must. After having this foundation, i.e. being able to communicate at the same level, there are those professionals that specialize in standards, so that they could assist in, for example,  mapping HL7 to DICOM Attributes at an interface broker to make sure all appropriate exams show up on a modality worklist. The second group of professionals would concentrate on the PACS workflow issues, so they can re-design a system to become more effective and efficient, and a third group might be mainly involved with the coordination and project management of new modalities, implementation of speech recognition, 3-D, or whatever projects are current. The first and second career path is clearly addressed by the PARCA certifications, while CIIP is covering the 3rd track.

Certification options:
As of today, there are two options for PACS administrators, aka imaging professionals, i.e. PARCA and CIIP. Before going into the many differences between these organization, because they are quite different because of the way they initiated, let’s first concentrate on the different certification requirements. These requirements are posted on-line, both for PARCA at http://www.pacsadmin.org/ and CIIP at www.abii.org. Even although the PARCA certification guidelines are more extensive than the CIIP requirements, which only has a test content outline, there is enough detail to be able to compare both certifications. Both certifications require clinical and IT credentials. In the case of PARCA, this is achieved by taking the CPAS exam, which tests extensively the clinical and IT skills of a candidate. In the case of CIIP, this is achieved by having certain education requirements, combined with a certain experience. Either one method has its advantages: The PARCA approach does not require experience but rather, current skills and knowledge, the CIIP approach favors experience over current knowledge. This means that professionals who would like to get into this field, and lack the required experience, only have the option to go the PARCA route. Even if you have the required experience, it might be a good choice to take the PARCA CPAS exam regardless, to get your skill at the current level.
PARCA has then two different routes, the Interface Analyst (CPIA) and the System Administrator (CPSA) track. The CPIA deals with interface standards such as DICOM, HL7 and IHE, the CPSA requires knowledge about PACS components, workflow, integration and security. The CIIP certification also deals with any of these topics, but in addition also with topics such as project management, procurement, operations, training and education and systems management. Recently, PARCA announced a capstone certification for CIIP and PARCA certified professionals which allow them to grow into a more enterprise role. This certification called CHEA or Certified Healthcare Enterprise Architect certification, concentrates on image enabling Electronic Medical Records and has a significant hands-on component.

Differences between PARCA and CIIP
In addition to the different areas and skills that these certifications are addressing, there are also differences in the approach between these certifications. PARCA is available since early 2005, and CIIP had their first pilot in June of 2007 and as of today candidates for both certifications are rapidly approaching 1000 certificates. Consequently, there are books and study guides available for PARCA as well as for CIIP Also, most training institutions by know have learned how to adjust their training programs to make sure all PARCA and CIIP requirements are covered.
The way the exams are performed is also quite different. PARCA has a anytime-anywhere philosophy, providing the exam on-line. This means that it is available for professionals from remote locations who might not have the travel funds readily available, especially non-US countries. Consequently, PARCA certificates are issued to as far as the Middle East. CIIP exams are conducted a couple of times/year at predetermined testing centers and are proctored making the CIIP a more predominant US certification vs. the global reach of PARCA. In addition, the exam costs also differ significantly, i.e. $100 for the PARCA CPAS exam with a “free” retake capability of two times within a year timeframe. CIIP exam cost is $400 and a $200 retake fee in case you don’t pass. The organizational structure is also different: PARCA (still) being an independent organization and CIIP under the auspices of ABII, which was founded by SIIM and ARRT.

It’s not about the piece of paper.
Certification is a major effort, and, as many people have said before us: the race is not about the finish but all about the journey. I have first hand experience about races having finished two NYC marathons: it is not about the race itself but about the many months of training and preparation. The same holds true for this certification, it takes many months of studying, reading text books, in many cases tanking classes either face-to-face or using computer based training, attending conferences, or whatever it takes. The effort should not be under estimated, but the good news is that it is an excellent reason to learn about those subjects that you might need now and in the future. It is especially a great opportunity to focus on the weak area’s, which for the clinical folks is the IT sector and for the IT folks the clinical area.
Certification is also about empowerment: How better to empower yourself with more knowledge and skills so you can better manage these complicated and sophisticated systems and ultimately provide better patient care. Managing includes taking care of image quality issues, improve workflow, reconciling studies, exams and patients, and supporting the expedient processing and reporting of patient critical images and related information.

Conclusion:
PARCA and CIIP have gotten a lot of momentum witnessed by the fact that the number of combined PARCA and CIIP certified professionals is between 1500 and 2000 professionals. The titles are showing up both with signatures and in job requisitions. There is still a long way to go for all those thousands of professionals that are still preparing themselves for this. Initial polls showed that more than 90% of the SA’s found that certification is important, while more than 80% was seriously considering it. Each certification has its own pro’s and con’s both from an organizational perspective as to what is covered as part of the requirements. Each one supports distinctly different career tracks, although many professionals might opt to go for both, making sure they master not only the technical but also the more organizational skills. There will also be retraining needed, just look at the many different specialties that are just becoming reality, such as Optical Coherence Tomography for Ophthalmology, Tomo-synthesis for digital mammography, and just wait till pathology comes on-line with their digitized images. New challenges, requiring additional knowledge and skills; that is what being involved in this high-tech industry is all about, change is the only true predictor. Certification will help to master those skills in a consistent manner to provide excellent career opportunities and also to provide some type of standard so that the people who are hiring these professionals have something to go by.







Tuesday, March 6, 2012

Dubai hosts 5th PACS/EHR Seminar April 8-11



View at the bustling Dubai Creek

OTech will deliver its 5th Middle East seminar in Dubai as Middle Eastern countries are making major investments in healthcare imaging and IT. Wisely, in many cases, it pays off to NOT be on the bleeding edge and instead implement what is proven and seems to work, albeit with adaptations for local workflows and practices. This is what is happening in the Middle East as healthcare institutions are rolling out PACS and EMR implementations that are based on mature versions of software and hardware that are in many cases provided by the same manufacturers as the systems being used for many years in the US and western European countries. There are also local companies that have sprung up and provide Teleradiology applications, which is an important segment of the market. In addition, the open source Vista EMR as developed by the US Department of Veterans Affairs is also being installed and used in several countries, notably Egypt and Jordan.
However, there are still quite a few local challenges, the top three I have noticed are the following:
·         There is a lack of universal policies and procedures governing who is supporting who, what and when. The role of PACS administrators is not as widely accepted and therefore, many PACS and EMR support duties are provided “ad-hoc” or fall in between the cracks.
·         IT infrastructure and support is lacking, as many institutions do not have proper personnel and systems in place. Point in case is that one of our seminar attendees told me that her number one issue is the ever present threat of viruses and other malware infecting their system.
·         Last but not least, the universal lack of training and learning resources. It is not as easy for someone to travel to western Europe and/or the USA to take classes on the subject or even attend trade shows.
The education gap is being filled with training by OTech on location as its 5th seminar on this subject will be provided April 8-11 in Dubai. This seminar will cover both PACS and EMR topics and also teach basic troubleshooting skills that are essential to support these complex systems. Students will get access to electronic text books on DICOM and HL7 and be trained using RIS and modality simulators so they can monitor and troubleshoot the various transactions that are exchanged between the different subsystems. This will allow local healthcare imaging and IT professionals to address their major challenges and elevate PACS and EMR systems operations to a level so they can operate effectively and efficiently to improve patient care.