Tuesday, October 22, 2019

What is your Enterprise Imaging Strategy: Bottom up or Top-down?

Enterprise imaging is the latest trend; however, a well working solution can be challenging to implement. The most common challenge is the differences in the various workflows. To implement an enterprise solution, three methods can be used:
  1. A "top-down" approach – This model implements a vendor-neutral archive (VNA) for radiology, cardiology, and several other departments, all pretty much at the same time. The problem is that every department has a different workflow. Some use the DICOM Modality Worklist, some use a HL7 feed, some don’t use any prior order or worklist mechanism causing the images to be reconciled with the patient information after the fact. As a matter of fact, if you look at all of the different possible combinations, there are more than 100 different scenarios as described here. Using the top-down approach will set you up for chaos if there are no well-defined workflow options and you let every department decide on their “favorite” workflow.
  2. A "bottom-up" approach – This model, which was used for example at Stanford University Healthcare, implements a VNA beginning with one department, and then adds other departments using the same workflow. This solution results in an initial struggle to adapt everyone to the same workflow but as soon as people start to see the results, everyone will get excited and be ready to tackle the next one. As of today, Stanford has several departments on-line, but everyone uses the same workflow. Interestingly enough, radiology was not the first department they started with. Also note that this is a multi-year process, which will take longer than the top-down approach.
  3. A hybrid approach – This method, which was adopted for example at the Mayo Clinic, is a combination of both approaches as it might not be feasible to have everyone using exactly the same workflow. In this particular institution they have identified five distinct workflows and all of the new departments pick from these five options. These options include the traditional order-based workflow, in their case driven by their EMR, the non-order-based workflow using Patient ID look-up for demographics and creating an EMR order after the fact, DICOM wrapping of JPEG’s and a couple of variants.
Therefore, to implement enterprise imaging, don’t go for the top-down approach as it can be chaotic, as each department uses a different workflow, but rather, develop a handful of workflows (preferably 3 but no more than 5) and steer the departments to these options. The options will be different for most institutions as each one has a different IT infrastructure and different access to patient order and encounter information. Before starting your implementation, develop these workflow options and spend time testing them to see how they work, and if they do, stick with these, even though it will require that users to change their behavior. As soon as they see the benefits, it will be successful.
For a video version of this presentation, including some thoughts on recent developments in PACS technology, see the live interview here.