Saturday, June 17, 2017

SIIM 2017 Top Ten Observations.

The 2017 SIIM (Society for Imaging Informatics in Medicine) meeting was held in Pittsburgh, PA on June 1-3.
View back to the city from Allegheny
The meeting was well attended both by users and an increasing number of exhibitors. This meeting is mostly attended by PACS professionals, typically PACS administrators, in addition to several “geeky” radiologists who have a special interest in medical informatics. Pittsburgh, in addition to being somewhat “out of the way,” was not a bad choice to hold a conference; downtown was quite nice and readily accessible, actually better than I expected. Here are my top ten takeaways of the meeting:

1.     AI (Artificial Intelligence) is still a very popular topic. The title of the keynote speech by Dr. Dryer from Mass General says it all; “Harnessing Artificial Intelligence: Medical Imaging’s Next Frontier.” AI goes also by the name of “deep learning” reflecting the fact that it uses large databases of medical information to determine trends, predictions, precision medicine approaches, and provide decision support for physicians.Another term people use is “machine learning” and I would argue that CAD (Computer Aided Diagnosis) is a form of AI as well. One of the major draws for this new topic is that some professionals are arguing that we won’t need radiologists anymore in the next 5-10 years as they are going to be replaced with machines. In my opinion, much of this is hype, but I believe that in two areas there will be a potentially significant impact on the future of radiology. First of all, for radiography screening AI could help to rule out “normal.” Imagine for breast screening or TB screening of chest images, one could potentially eliminate the reading of many of them as they would appear normal to a computer, freeing the physician to concentrate on the “possible positives” instead.Second, there were several new startup companies that showed some kind of sophisticated processing that can assist a radiologist with diagnosis, for very specific niche applications. There are a couple of issues with the latter. A radiologist might have to perform some extra steps and/or analyses, which could impact the application’s performance and throughput. As such, the application will have to provide a significant clinical advantage. Also, licensing additional software could be a cost that might or might not be reimbursed. In conclusion, AI’s initial impact will be small, and I don’t think that despite the major investments (GE investing $100m in analytics) it will mean the end of the radiology profession in the near future. A quote from Dr. Dryer also summed it up, “it will not be about Man vs. AI but rather the discussion of Man with, vs a Man without AI.”

2.     Cyber warfare is getting real. The recent WannaCry incident shut down 16 hospitals in the UK, which created chaos, as practitioners had to go back to paper. As we are now living in the IOT (Internet Of Things) era, we should be worried about ransomware and hacking. Infusion pumps, pacemakers and other devices can be accessed and their characteristics and operating parameters can be modified.It is interesting that HIPAA regulations already covered many of the security measures that could prevent and/or manage these incidents, but in the past, most institutions focused mostly on patient privacy. Of course, patient privacy is a major issue, but it might be prudent for institutions to shift some of the emphasis on network security instead of privacy as that could be potentially more damaging. Imagine the potential impact of one patient’s privacy being compromised vs the impact of infusion pumps going berserk, or a complete hospital shutdown.

3.     Facilitating the management of images created by “ologies” is still very challenging. Enterprise imaging, typically done using an enterprise archive such as a VNA as imaging repository, is still in its infancy. The joint HIMSS/SIIM working group has done a great job outlining all of the needed components and defined somewhat of an architecture, but there are still several issues to be resolved. When talking with the VNA vendors, their top issue that seems to come up universally is that the workflow of non-traditional imaging is poorly defined and does not lend itself very well to being managed electronically. For example, imagine a practitioner making an ultrasound during anesthesia or an ER physician taking a picture of an injury with his or her smart phone. How do we match up these images with the patient record in such a way that they can be managed? Most radiology-based imaging is order driven, which means that a worklist entry is available from a DICOM Modality Worklist provider, however, most of the “ologies” are encounter driven. There is typically no order, so to go hunting for the patient demographics from a source of truth can be challenging.There are several options, one could query a patient registration system using HL7, using a patient RFID or wristband as a key, or, if FHIR takes off, one could use the FHIR resource as a source, or one could use admission transactions instead (ADT), or do a direct interface to a proprietary database. There is probably another handful of options, which is the problem as there is no single standard that people are following. The good news is that the IHE is working on the encounter-based workflow, so we are eagerly awaiting their results.

4.     Patient engagement is still a challenge. There is no good definition of patient engagement in my opinion, and different vendors are implementing only piecemeal solutions. Here is what HIMSS has to say about this topic:
Patient engagement is the activity of providers and patients working together to improve health. A patient’s greater engagement in healthcare contributes to improved health outcomes, and information technologies can support engagement. Patients want to be engaged in their healthcare decision-making process, and those who are engaged as decision-makers in their care tend to be healthier and have better outcomes.
Many think of patient engagement as being equivalent to having a patient portal. The top reasons for patients wanting to use a portal are for making appointments, renewing prescriptions and paying their bills. However, none of these is a true clinical interaction. Face-to-face communication using, for example, Skype or another video communication, or just simply having an email exchange dealing with clinical questions are very important. One of the issues is that the population group that is the first to use these portals are also the group who already take responsibility for their own health. 
The challenge is to reach the non-communicative, passive group of patients and keep a check on their blood pressures, glucose levels, pacemaker records, etc. Also, portals are not always effective unless they can be accessed using a smart phone. This assumes of course that people have a phone, which was solved by one of the participants in the discussion by providing free phones for homeless so that texts can be sent for the medication reminders and checking up on them. Different approaches are also needed, as a point in fact, Australia had made massive investments in patient portals but because patients were by default set up as opt-out, only 5 percent of them were using portals. 
One of the vendors showed a slick implementation whereby the images of a radiology procedure were sent to the personal health record in the cloud and from there could easily be forwarded to any physician authorized by the patient. This is a major improvement and could impact the CD exchange nightmare we are currently experiencing. I personally take my laptop with my images loaded on it to my specialists as I have had several issues in the past with the specialists having no CD reader on their computers or lacking a decent DICOM viewer. There are still major opportunities for vendors to make a difference here.

5.     FHIR (Fast Healthcare Interoperability Resources) is getting traction, albeit limited. If you want one good
Packed rooms for educational sessions
example of hype, it would be the new
FHIR standard. It has been touted as the one and only solution for every piece of clinical information and even made it into several of the federal ONC standard guidelines. Now back to reality. We are on its third release of the Draft Standard for Trial implementation (DSTU3), typically, there is only one draft before a standard, and it is still not completely done. Its number of options are concerning as well. And then, assuming you have an EMR that has just introduced a FHIR interface (maybe DSTU version 2 or 3) for one or more resources, are you going to upgrade it right away to make use of it? But to be honest, yes, it will very likely be used for some relatively limited applications, some examples are the physician resource used by the HIE here in Texas finding information about referrals, or, as one of the SIIM presenters showed, a FHIR interface to get reports from an EMR to a PACS viewing station. But there are still many questions to be addressed to use what David Clunie calls “universal access to mythical distributed FHIR resources”.

6.     The boundary between documents and images remains blurry. When PACS were limited to radiology images, and document management systems were limited to scanned documents that were digitized, life was easy and there was a relatively clear division between images and documents. However, this boundary has become increasingly blurry. Users of PACS systems started to scan documents such as orders and patient release forms into the PACS, archiving them as encapsulated DICOM objects, either as a bitmap (aka as “Secondary Captures”) or encapsulated PDF’s.Some modalities such as ophthalmology were starting to create native PDF’s, bone densitometry (“DEXA”) scanners were also showing thumbnail pictures of the radiographs with a graph of its measurements in a PDF format. Then we got the requirement to store native png, tiff, jpeg’s and even mpeg videos in the PACS as well. At the same time, some of the document management systems were starting to store jpegs as well as ECG waveforms that were scanned in. By the way, there has been a major push for waveform vendors to create DICOM output for their ECG’s, which means they would now be managed by a cardiology PACS.And managing diagnostic reports is an issue by itself, some store them at the EMR, some at the RIS, some at the PACS and some at the document management system. The fact that the boundary is not well defined is not so much of an issue, what becomes clear is that each institution decides where the information resides and creates a universal document and image index and/or resource so that viewers can access the information in a seamless manner.

7.     The DICOMWeb momentum is growing. DICOMWeb is the DICOM equivalent of FHIR and includes what most people know as WADO, i.e. Web Access to DICOM Objects, but there is more to that, as it also allows for images to be uploaded (STOW), or queried (QIDO) and even provides a universal worklist allowing images to be labelled with the correct patient demographics before sending them off to their destination.There are three versions of DICOMWeb, each one builds on the next one with regard to functionality and a more advanced technology making them current with state-of-the-art web services. One should realize that the core of DICOM, i.e. its pixel encoding and data formats is not changed, we still deal with “DICOM headers” but that the protocol, i.e. the mechanism to address a source and destination as well as the commands to exchange information has become much simpler.As a matter of fact, as the SIIM hackathon showed, it is relatively easy to write a simple application using the DICOM resources. As with FHIR, DICOMWeb is still somewhat immature, and IHE is still trying to catch up. Note that the XDS-I profile is based on the second DICOMWeb iteration, which is based on SOAP (XML encapsulated) messaging that has recently been retired by the DICOM standards committee. The profile dealing with the final version of WADO, called MHD-I is still very new. There is a pretty good adoption rate though; and many PACS systems are implementing WADO, which unlike FHIR can be done by a simple proxy implementation on an existing traditional DICOM interface.

The radworkflow space
8.     Ergonomics is critical for radiology. I can feel it in my arm when I am typing or using a mouse for an extended time. Imagine doing it day-in and day-out while staring at a screen in half-dark, no wonder that radiology practitioners have issues with their arms, neck, and eyes. Dr Mukai, a practicing radiologist who started to rethink his workspace after having back surgery is challenging the status quo with what he calls the radworkflow space, i.e. don’t think about a workspace but rather a flow space (see link to his video). He built his own space addressing the following requirements:
a.     You need a curved area when looking at multiple monitors with a table and chair that can rotate making sure you always have a perpendicular view. Not only does this improve the view angle distortion from the monitors but also is easy on your neck muscles.
b.    Everything should be voice activated and by the way, all audio in and out should be integrated such as your voice activation, dictation software and phone.
c.     Two steps are too many and two seconds for retrieval is too much. It is amazing to think that retrievals of images in the 1990’s, using a dedicated fiber to the big PACS monitors of the first PACS systems used by the Army, were as fast or possibly faster than what is state-of-the-art today. Moore’s law of faster, better, quicker and more computing power apparently does not apply to PACS.
d.    Multiple keyboards is a no-no, even when controlling three different applications on 6 imaging monitors (one set for the PACS, one set for the 3-D software, and one set for outside studies).
Hopefully, vendors are taking notes and will start implementing some of these recommendations, it is long overdue.

Camera mounted at Xray
9.     Adding a picture to the exam to assist in patient identification. As we know, there are still way too many errors made in the healthcare delivery that potentially could be prevented. Any tool that allows a practitioner to double-check patient identity in an easy manner is recommended. A company that was exhibiting at SIIM had a simple solution as it takes a picture of a patient and makes it part of the study by creating a DICOM Secondary Capture of the image. It consists of a small camera that can be mounted at the x-ray source. I noticed two potential issues that need to be addressed: does it work with a MRI, i.e. what is the impact of a strong magnetic field on its operation? Second, now we know how to identify the patient better, how would it be to de-identify the study if needed? We would need to delete that image from the study prior to sharing it for the purpose of clinical trials, teaching files, or when sharing it through any public communication channel.

Nice dashboard from Cincinati Childrens
10.  Dashboards assist in department awareness. I am all in favor of dashboards, both clinical and operational as it typically allows one to graphically see what it going on. I liked the poster that was shown by Cincinnati Children’s showing the display that is placed in a prominent space in the department and shows its operational performance such as the number of unread procedures, turnaround time, a list of doctors who are on call, and also a news and weather link. They pulled this data from their PACS/RIS system doing some simple database queries. This is a good example of how to provide feedback to the staff.

As mentioned earlier, I thought that SIIM2017 was a pretty good meeting, not only for networking with fellow professionals, but also learning what’s new, and seeing a couple of new innovative small start-up companies, especially in the AI domain, and last but not least, enjoying a bit of Pittsburgh, which pleasantly surprised me. Next year will be in DC again, actually National Harbor MD, which despite its close location to Washington will not be a match for this year’s, but regardless, I’ll be looking forward to it.