Tuesday, March 1, 2011

Tips from a road warrior (6): Always know how to get back to where you started

The reason that conference organizers often pick nice locations such as Hawaii, Vegas, Athens, or, even on board of a cruise ship, is not only to attract more attendees, but also speakers such as myself who are willing to "sacrifice" their time for a modest speaking fee and travel reimbursement. I have to admit that I occasionally fall for that enticement, which is why I ended up in Athens about two years ago. 

I had taken the bus to the Parthenon from my hotel and after a couple of hours sightseeing, I hailed a taxi to take me back to my hotel to pick up my luggage on the way to the airport to continue my trip. As is common in many countries, taxi drivers often speak only their native language. Not having opted for Greek in high school, I simply told him “Sheraton” hotel, and off we went. After about half an hour of driving, I started getting nervous, as it had only taken 20 minutes on my trip from downtown. I then told the driver the part of town where the hotel was located, but that did not really help him or me. 

After several more minutes of fruitless communication, I was desperate enough to consider calling my spouse back home in the USA to see if she could find in my records the address of the hotel. However, it was unlikely that I would be able to get a hold of anyone due to the time difference, as it was about 3 a.m. in Texas. As my flight departure time approached, I finally recognized the road we were driving and was able to point the driver in the right direction to the hotel. The fact that the hotel had been recently acquired and renamed was apparently a major part of the confusion. Another lesson learned: always know where you came from, and, as a hint, take a business card from the hotel printed in the native language with you. 

When upgrading a system it is also critical to document the departure location and configuration, as it often is required in order to return. One very well run institution in Dallas has as a golden rule that no single upgrade or change is made, unless there is a well-documented “road back”. They have had to use the rule several times. I use it myself as well, as a matter of fact; all of our laptops that we use in our hands-on training have a “roll-back” disk image so that I don't need to worry about students messing up the computer. We simply roll the computer back to the original image at the end of each class, which takes only one simple command. 

I have heard about several other “roll-backs”, for example, at one site a PACS viewing system upgrade was installed over the weekend. Unfortunately, the upgrade was poorly prepared from a user training perspective. On Monday morning, the radiologists had to figure out how to navigate new toolbars and menus and were at a total loss. After two hours of complaints the IT department was forced to reverse the upgrade by noon. In another case, a site had rolled out a Microsoft security upgrade to its Windows browser, which broke the viewing application. The CIO had weighed the risk of installing the upgrade, which was not yet approved by the imaging vendor, against the increasing risk of being infected by a virus that was making use of a newly discovered security gap. However, the upgrade had to be rolled back immediately due to an incompatibility issue. In many cases, the upgrade introduces problems that cause unacceptable patient risks from a clinical perspective. This can happen with any system, even, or maybe especially with systems from the top five vendors. I have seen incorrect Left/Right markers appear on the images with a software upgrade, incorrect measurements resulting from different and incorrect image header attributes for calculation, and patient studies stored on CD’s as separate studies instead of a single one. 

One of the mechanisms to limit the risk of an upgrade is to use it first in a test environment. This will eliminate many of the potential issues, however, based on a recent poll through our OTech newsletter, I learned that the majority of the existing installations do not have a fully functional test system in place, in which case this is not an option. Although I must say that many institutions have learned the need for a test environment and are more frequently specifying them in RFP’s. However, even when tested, often it is hard to predict all possible effects. In addition, one cannot always completely simulate the real environment, especially when it involves upgrading imaging modalities, one could argue that it is not feasible to have another million-dollar device around just for the purpose of testing. 

My lesson learned from this travel experience is that I now trace where I came from so I can get back to my starting point. An analogue lesson learned for health care imaging and IT professionals is that they should always be able to get back to where they started in case any changes and/or upgrades end up taking their systems in the wrong direction. 

HIMSS2011 Recap: It?s All About Integration

The 50th HIMSS meeting held in Orlando, FL, drew more than 30,000 attendees, with large representations from outside the USA. For example, the Dutch arrived with a group of 250 people, which is quite a large contingent considering they have 140 hospitals, this is almost two for each institution. 

The Netherlands is somewhat an exception in healthcare however, especially compared with the US. A recent survey by the Organization for Economic Cooperation and Development of seven countries, published in Nov 2009 compared the quality of healthcare in Australia, Canada, Germany, New Zealand, the UK, the USA and the Netherlands. The results showed, not surprisingly, that the USA was rock bottom in most of the categories, and dead last overall. Perhaps more surprising was that the Netherlands ranked number one. I suspect that this is due at least in part to the high penetration of healthcare IT throughout the Dutch healthcare system. Most primary care physicians already have an electronic health record system, something we in the USA are just starting to implement. 

Electronic records were definitely at the forefront of the HIMSS conference this year. A quick glance of the program showed that at least 10 percent of the presentations have the word "meaningful use" in the title. If you than add the terms of DSS, EHR, and EMR, you can probably add another 10 percent. 

At the same time there were many examples of technology integration, and at a higher level than ever imagined. Radio frequency identification (RFID) technology, for example, now allows for tracking of patients, supplies, and providers. Medical devices are being integrated directly with the patient EMR, home based solutions are capturing information such as glucose levels, cardiac rhythms from heart patients and also basic vital signs. EMR-to-EMR communication was shown, and demonstrated the need for much greater integration in the future. A poll during one of the presentations that I attended asked for the number of disparate systems that a hospital has to manage. A typical hospital has on the average 150 systems for managing the different departments and applications; in this audience there was one CIO who has 350 systems to manage. Imagine the amount of traffic that is going on among these systems. The backbone of the communication interchange is still HL7 Version 2. There were some early adopters who tried to implement the HL7 version 3 messaging but due to its verbosity, failed miserably. 

The good news was that a poll also showed that the majority of the audience had a certified EMR in their facilities, a sign that institutions are catching up fast. There are some requirements in the meaningful use specifications, however, that have impacted data collection. For example, ethnicity is now required, which has raised quite a few questions from patients according to many in the audience. 

Another “buzz word” at this year's conference is the “cloud” used in the context of archiving and/or computing. This is not just a healthcare IT trend, as the national CTO, Aneesh Chopra noted during his presentation. He said that the US government would use this technology for more than 20 percent of its operations in the near future. It is interesting that the “cloud archiving” practice has been around for at least 10-15 years, albeit under a different term, i.e. ASP or SSP whereby institutions archive their images off-site with a provider. The advantage is that this provides a built-in redundancy and disaster recovery solution. Many institutions, especially provider networks, provide their own “cloud,” or as in Canada where cloud computing was implemented on province systems a few years ago. 

With regard to vendor news, it was interesting to see that Microsoft finally seemed to make a commitment, at least from a marketing perspective, to the healthcare IT segment as they were now an anchor exhibitor and had a good-size booth. They also announced a major collaboration with Philips using the Microsoft platform. 

Lastly, it was also interesting to see how little emphasis there was on imaging. The imaging vendors had relatively small booths, and to be fair, the word PACS was nowhere to be found in any of the talks and presentations, indicating that this is certainly not a priority for most CIO’s. 

In conclusion, the show was well worth attending. The presentations were good, although some were overrated, especially the big events with the luminary speakers. Otherwise, it was big, flashy (quite a few sport cars in the booths), fun and pleasant in sunny Florida. Next year will be in Las Vegas, and it is expected that this will boost the attendance with easier access to West Coast attendees; however, we will see whether the Vegas gambling and entertainment scene will draw more than the Florida tourist attractions.