Monday, March 14, 2016

How many PACS SA's do you need?

The quest for the right number of support people for a PACS (Picture Archiving and Communication System)  has been asked many times, and the correct answer is: “it depends.” I have seen organizations that have a single PACS SA (System Administrator) supporting multiple campuses, and others having eight people as part of their SA staff supporting the system 24/7 using three shifts. To be precise, based on a survey, I found that 53 percent of institutions have a single PACS administrator, 23 percent of them have two, 13 percent have three and 11 percent have four or more. 

Here are my top ten criteria that influence the proper PACS SA staffing level:
1.       System size: How large is your institution, what is the number of annual procedures, the number of facilities that you are supporting, additional clinics, and number of radiologists?
2.       Imaging scope: Is your EMR image-enabled, is cardiology included in your support duties, what about surgery, dentistry, and other “ologies”?
3.       System scope: Do you support CR/DR connectivity, RIS, speech recognition?
4.       Provider expectation: Is 24/7 presence required, are you on-call, what about back-up if you go on vacation, get sick or have other personal things to take care of outside work?
5.       Level of management involvement: Are you part of the planning committee, steering committee, change control board, implementation committee, in other words, how much time do you spend in meetings?
6.       Level of organizational support: Does biomed do the modality integration, do your technologists fix their own studies, is medical physics taking care of monitor calibration and image quality verification, and is there an IT help desk to take first call?
7.       Level of vendor support: Do you rely on the vendor to provide troubleshooting, monitoring, providing reports?
8.       Educational support: Does your employer allow you time to attend professional meetings, take an on-line or face-to-face training seminar, pay for you to get certified as a PACS professional, and keep up with your peers and the industry?
9.       Experience and skill level: How much experience do you have? An experienced PACS SA takes less time to deal with an issue, such as doing a quick SQL query to the database, or to find or fix a problem, use a network sniffer to find out the reason a DICOM connection was rejected, or look at a log file of a HL7 transaction to find a missing or duplicated Accession Number.
10.   Last but not least: Budget restrictions: Unfortunately, some organizations do not allocate the proper resources which impacts effectiveness, readiness and, indirectly patient care by not making sure the PACS is properly supported.

Based on feedback from SA’s in our PACS training classes, I have found that if you are spending more than 50 percent on support and maintenance (fixing, putting out fires), you are understaffed. The ideal allocation would be 50 percent support, 35 percent on implementing projects and 15 percent on education and training. If you are too far off from these numbers, I suggest you have an honest talk with your supervisor.

Thursday, March 10, 2016

My top ten from HIMSS2016

The annual healthcare IT conference (HIMSS2016) was held in Las Vegas this year, which is always a welcome location during the winter, especially for those attendees from the north.
When walking the exhibition floor, I noticed several trends and new products, my top ten are listed below:

typical alert dashboard
  • It’s all about Alerts: Most medical devices ranging from infusion pumps to EKG’s are getting connected to the Internet. The same trend that we see in the consumer world with the Internet of Things (IOT) is also present in healthcare. The average number of patient care monitoring devices has increased with now more than 10 for each patient bed. The good news is that we can manage them remotely and also collect alerts from them for patient monitoring purposes. There were quite a few companies showing their alert dashboards.
    Hire a hacker
  • Security audits are critical: With the increase of the IOT, there is also an increase in the potential number of entry points for hackers to get to patient data through a “backdoor.” Audits are critical, and you might actually consider hiring a “white hat” hacker instead of a traditional security firm to find out if you are well protected.

keep your devices secure
  • Phones are becoming medical devices: physicians are increasingly taking pictures with their cell phones to monitor wound care and document patient information. To protect this information through encryption and secure upload into a cloud based system and/or EMR one needs to make sure that dedicated software aps are being deployed.

    talking with your physician on-line
  • Healthcare is being “Uberized”: The same fundamental changes that Uber brought to the conventional way that people use taxis are about to change how primary healthcare is being delivered. One can simply click on an app on a smartphone and have a consult with a physician while using the camera as an additional semi-diagnostic tool

remote viewing of your eye
  • Telemedicine is becoming affordable: in addition to the “poor-mans” teleconsult using a smartphone, companies are offering a telemedicine cart that has a larger screen and captures vital signs and other relevant information that can be shared. This is very useful for remote communities, nursing homes, and military and disaster areas.

  • Dashboards are becoming ubiquitous: Doctors are generally not that happy with the recent
    typical dashboard; very configurable
    transition from paper-based records to having everything computerized. However, they often overlook that the real power of the EMR is not so much the electronic data capture, but much more what you do with the data captured. Not only can you use it for decision support but also to support managing the healthcare delivery process. Dashboards that can display key performance indicators are becoming standard.

RFID detectors, either for wristband or tape-on
  • Device and patient tracking is getting more sophisticated: The time that a patient is “forgotten” while waiting in the corridor, or devices “disappear” is gone as many providers can now track these using RFID (radio frequency identification) chips. It is still a big investment as a barcoded wristband might cost a few pennies while a RFID band can cost between $50 and $100, but the benefits are much greater.

  • Interoperability is getting better: There were a lot of complaints from implementers and
    lots of interest at IHE booth
    integrators who are trying to connect to the big EMR vendors, to the extent that even the EPIC CEO felt that she had to defend her bad rap in an interview with one of the major healthcare IT magazines. But, to compensate, there was an even larger number of stories of successful implementations of IHE profile based interoperability. It appears we are on the right track.

no it is not a coffee maker,
but a drug dispensing machine
  • Automatic dispensing machines are becoming popular: Instead of giving a patient a bottle of medications, it is more effective to provide them with an automated drug dispenser which is also connected to the IOT and provides alerts and feedback in case the medication is not dispensed at the right time. The only thing missing is ensuring whether a patient actually swallows or administers the medication, something researchers are working on as well by including tracers in the meds themselves.

  • Its’ all about the gadgets: HIMSS is kind of different as each booth has either an eye catcher in
    Masserati, McLaren? your best guess
    the form of a great car, Vegas show girl, or a take-away ranging from USB chargers, phone backup batteries, pens, toys, T-shirts, hand sanitizers, stuffed animals, liquor, bottled water, coffee, chocolate and much more. The backpack that you get as an attendee is definitely not big enough to carry all of it if you are into this. I brought home a cell-phone stand and back-up, that was pretty much all I could carry back.

In conclusion, this event is worthwhile attending: The use-cases (intelligent home and IHE interoperability showcases) were awesome and very well done. The educational sessions are not bad (although some were poor), the keynote speech by Peyton Manning was worthwhile if you are into American football, the industry exhibits are interesting, networking and finding out what is going on in the industry is critical, and it is good to share experiences with peers. And of course, what happens in Vegas… there are good shows at night, and the food is pretty good. It will be hard for Orlando to match that next year.

Tuesday, March 8, 2016

HIMSS2016: Imaging is still an IT stepchild.

Typical traffic pattern at the show.
Imaging has long been an IT stepchild. Unfortunately, despite the fact that managing healthcare imaging
is moving from a department (radiology, cardiology etc.) level to an enterprise level, and becoming a CIO responsibility, over the past few years, HIMSS has been doing very little to prepare its members to do this effectively. As a case in point, of the 287 educational sessions at the recent annual meeting (HIMSS2016), only two dealt with imaging, (not counting a vendor session on this topic), which is less than 1 percent.

After IT capital investments including EMR, and facility improvement allocations, imaging is the third biggest hospital budget item according to a recent survey. Who is managing this effectively to prevent yet another department from purchasing a different image management solution? Who is defining an enterprise wide imaging and information management strategy that includes archiving, cross enterprise image exchange, life cycle management, and, last but not least who is establishing a comprehensive set of rules for security and privacy for these expensive acquisitions? I would guess the CIO, but HIMSS better be prepared to provide these professionals with the right skills and resources. Otherwise, how are images being effectively managed to allow sharing and displaying in the EMR? It is not only the images from the traditional sources such as the CT’s, MR’s, ultrasounds, scopes, and many other medical devices, but in addition, the many images taken for wound care, dermatology, and many other applications by physicians on their smart phones. There is a big need for policies and appropriate encryption and EMR interface management.

There is a disparity in the HIMSS approach as it provides significant investment in the form of personnel for the Integrating Healthcare Enterprise (IHE) and allocating a lot of resources for the annual interoperability showcase at the annual meetings. For example, the IHE currently has 12 domains, of which 50% deal with imaging: pathology, cardiology, dentistry, eye care, oncology and radiology. Also, four of the ten showcases demonstrated at the interoperability showcase included imaging. So, from an investment perspective, HIMSS is doing the right thing, but maybe not at the right place.
There is a glimmer of light at the end of the tunnel as there was an HIMSS-SIM workgroup report during the meeting and at the European Society of Radiology (ESR) meeting there was an announcement of a diagnostic imaging model by HIMSS analytics (see link). However there is still a lot of work to do.

Hopefully, HIMSS 2017 will be a positive change for the imaging world to provide CIO’s with the right education and tools to develop the appropriate imaging strategy.