Sunday, May 1, 2011

Enterprise Information Management and Archiving Hot Topics

During the recent vDHIMS ePosium on the subject of the evolving digital healthcare enterprise, attendees had an opportunity to interact with the distinguished faculty to ask their questions in a Q and A session. Here are some of the notable Questions that were asked ant the respective responses: 

Data migration is still a major issue and Steve Horii from the Hospital of the University of Pennsylvania (HUP) is able to attest to that, going through this experience several times. One of the issues he noted was the potential loss of annotations when migrating the data. These annotations are also referred to as overlays in the DICOM standard. To store this information there are several options. The first option is to "burn-in" the data, which actually means that the pixels are replaced. This is seen a lot with Ultrasound and creates a lot of potential issues in case the information happens to be incorrect and needs to be modified. Some users put “XXX-es” over the text; however, if this annotation not preserved during the migration, there could be a major issue. Another option is to save this information in a database record in a proprietary method, which is what Steve had to deal with in his migration. The proper way of storing overlays is by creating a DICOM standard object, the so-called “Presentation State”, however, this requires the migration software to be able to interpret the database of the PACS system which is used as input to allow for the conversion to the presentation states. 

There are other reasons for being able to interpret the proprietary component of the input data to be migrated, for example, if the archived images were stored on non-rewritable media such as an optical disk, the changes to the patient demographics or the deletion of certain images or even complete studies after the fact, are not reflected in the image archive but only in the database. This is another proof that data migration does not include only the transfer of the images but also requires a lot of knowledge about the input and output database structure. 

Another question that was asked at the ePosium by the audience is what to do with any of the modality disks, as many CT, MR and even some Ultrasound units might have archived their images on optical disks (MOD) long before PASC was installed. These studies might occasionally need to be retrieved. The HUP solution for that was to have the vendor create a special data input station with a single disk reader. Remember, that the CT or MRI might have long be retired and replaced with a newer modality which meant that the “old” MOD or DVD readers could have been retired with the old units and therefore the capability to read this media has disappeared. 

Another insightful series of presentations was from Kevin McEnery about the EHR and their in-house developed viewer which were built using Service Oriented Architecture (SOA) principles at MD Anderson cancer center in Houston. One of the participants asked about the staff at this institution and it was an impressive 200 people strong. Major reasons for this institution to develop their in-house viewer and infrastructure are the very different workflow for radiation therapy, the need for clinical trial support and the submission requirements of treatment data to regulatory agencies. Even for “typical” institutions” there are already significant differences in workflow, making it hard to match the EHR systems, let alone if you take into account the difference between very specialized institutions such as a cancer center. 

One of the issues noted was also the requirement to have a certified EHR to meet the new Meaningful use requirements so that the institution can apply for incentives as part of the Hitech section of the ARRA. As Dr. McEnery noted, it is possible to apply for a “modular” certification, and re- use the certification of a “core” functionality and only certify the additional modules, which will be a big help for many institutions as they are customizing their EHR and MPR implementations. 

If you are interested in the complete text of the presentations of Dr. Horii and McEnery, you can find these archived as part of the symposium, in addition to the other presentations and copy of the hand-outs from this three day event. It is even possible to gain continuing education credits by taking a simple quiz after the presentation so you can keep up with your certification requirements, see for more details.