RSNA 2019: Enterprise imaging a work in progress for the foreseeable future

Hospitals and health systems taking the leap into enterprise imaging have some pressing questions to consider. Who controls the enterprise data? Can a department other than radiology take images out of radiology’s PACS or VNA and use them for an AI research project? Can the images be commercialized for a third-party entity?

Radiologist Christopher Roth, MD, explored these and other issues in a Dec. 2 session on finance and governance challenges in enterprise imaging (EI) at the 2019 Radiological Society of North America (RSNA) conference in Chicago.

Drawing from his experience as director of imaging informatics strategy at Duke Health, an early EI adopter, Roth recalled being approached by vendors who wanted to use radiology images for AI research.

He put the request before the institution’s tightly organized EI governance committee, and the group soon arrived at a consensus: Whatever the vendor wanted to do with Duke’s imaging data, it had to ultimately improve Duke’s product from that vendor.

“This was complicated, but having good governance and decision-making [mechanisms] in your organization to discuss exactly how you will approach problems like this is invaluable,” Roth said. “If you don’t have that, all of a sudden there’s one person making a decision—or nobody making a decision—and someone is perhaps making the wrong decision for your enterprise.”

Money matters

Transitioning from governance to finance, Roth told attendees wishing to advance EI in their institutions that they might need to rethink how familiar activities are paid for.

He said the EI finance models he’s seen fall into to basic categories. One is a per-unit cost structure.

“Radiology uses this much storage, they have to pay this much to the technical side to support the infrastructure, for example,” he said. And the same goes for cardiology, dermatology and other participating clinical departments.

The other option is “baking everything into the plumbing”—electricity, the cost of the EHR and other broadly shared expenses. In this case, if someone thinks radiology is using too much data, “they should go talk to radiology about it.”

“This is something we’re going to have to think about, especially as pathology and other systems come into the [enterprise imaging] fold,” Roth said. “There’s going to be more and more effort, more and more people, more and more data required to [drive] enterprise imaging projects.”

Outgrowing siloes

As the kitchen fills with cooks, getting buy-in from stakeholders takes some doing. And it can be time-consuming to get approvals from institutional leadership. Such are the acceptable costs of doing things right and well, Roth suggested.

“One thing we found at Duke as we have ‘enterprised’ is that it has taken longer to get projects moving,” he said. “Because there are more governance approvals, there are more people needed to sign onto it, and generally it’s more like the English Parliament now.”

In previous days, the problem was the opposite: siloed departments, each doing its own thing.

The well-governed way is better, Roth said, because now “nobody’s going rogue. Or only a few people are going rogue.”

Who wants what?

That’s not to say that minds magically meld.

“Justification for all of this is hard,” Roth said. “Money becomes something that everyone can sort of anchor on. But different people want different things. There are different incentives out there.”

IT people tend to prioritize privacy, security and a voice in governance, Roth reminded.

Physicians want revenue growth, patient satisfaction and ease of to use.

And administrators “want some of the same things that doctors want and some of the same things that enterprise IT wants, but they also want smooth contracting and procurement,” Roth noted. “They want to know what the strategy is.”

Beware pricey meetings

Given the overlapping yet sometimes competing interests, the EI governance committee at Duke gradually ballooned to a large and somewhat unwieldy group. Moreover, the meetings took a lot of doctors away from their regular work.

In fact, a “back of the envelope” calculation showed each meeting was costing the institution between $8,000 and $10,000 if every physician showed up.

That’s hard to justify, Roth said. “We don’t all have funded time to do this. Some of the folks who were on this committee may have been the youngest, or maybe they drew the short straw, or maybe they were interested. But they were participating on the governance committee on somebody’s time—if not their own, then their department’s.”

To reduce time creep, committee leadership resolved to anchor each meeting on one topic and keep the discussion from straying.

“This month is going to be focused on data storage, next month will be enterprise viewing, next one is image exchange, next one is fill in the blank,” Roth explained. “And we were really concise and really tight with what we were going to do so we didn’t have forever meetings.”

Hard work that’s worth it

Bringing the case study to the present day, Roth noted Duke started its EI project in 2011 and even now faces “a ton of things still to do.”

“We thought we would have been done by now, but that was totally wrong,” he said. Why? Because Duke is ever expanding.  

“Lots of our sites are growing, we’re bringing new sites in, new technologies in, we’re bringing new people in,” Roth said. “We did an EHR installation in the middle of all that.”

Unsurprisingly, Duke’s EI project itself has added people under contract and on staff.

“We’re not even close to being done, and you’re not going to be done for a long time either,” Roth said. “It’s going to take an injection of resources at your sites to do this. It just is.”

Roth urged attendees to be clear with their leadership about the commitment needed and the resources required to launch and sustain a years-long EI effort.

“It’s going to take a bunch of resources to support bringing in dermatology, pathology, cardiology, obstetrics and all these other specialties,” he said. “Even if they’re smaller than radiology, it’s going to take a lot of work to bring them in and make them work well.”

Despite the challenges, Roth concluded, enterprise imaging “is a journey that is valuable. As somebody who is partway through this and regularly using images from other specialties, I’m glad I’m doing it and I think you will be too.”

Roth closed by inviting attendees to join the HIMSS-SIIM Community, which organizes activities and marshals resources for healthcare professionals interested in enterprise imaging.