Governance: The devil in enterprise imaging details

An issue that surfaced repeatedly during the recent annual meeting of the Society for Imaging Informatics in Medicine had very little to do with imaging informatics technology and everything to do with how that technology is implemented: governance.

“Governance is the bedrock of any successful imaging enterprise strategy,” said panelist Louis M. Lannum, Cleveland Clinic, during the session “Governance: The Key to a Successful Enterprise Imaging Strategy,” on May 28, at National Harbor, Maryland.

Lannum, who has transitioned from the radiology department to information services as director of enterprise imaging, should know. Cleveland Clinic is well into an initiative to centralize the storage and management of images being generated not just in the radiology department, but throughout the enterprise.  The endgame: EMR access to all of the images currently living on shelves, in drawers, on smartphones and on modalities outside of the radiology department.

To date, the Cleveland Clinic has identified 60 different departments that are generating images of all kinds and in all formats. Lannum and company have successfully image-enabled 30 of them.

“Most imaging IT initiatives fail because of a lack of effective governance,” Lannum said. “If you allow each department to create their own imaging strategy, you will be losing an important strategic advantage.”

To wit, this magnificent obsession is as much a political exercise as it is a technological one. For instance, Lannum said: “We don't go into any departments unless we have a physician champion.”

Readers are well advised to heed the hard-learned lessons of four pioneers currently at various stages of image-enabling their enterprises. In addition to Lannum, the panel included Amy J. Radonich, MS, CIIP, director of image management, UC San Diego Medical Center; Christopher Roth, MD, CIIP, director of enterprise image strategy, Duke University Health System, and Jonathan Shoemaker, RT®, CIIP, applications director, enterprise medical image management, Sutter Health.

Three levels

Lannum identified three levels of governance:

  1. program governance to ensure strategic alignment of all departments;
  2. technology governance, to ensure that all images can be ingested in the vendor-neutral archive; and
  3. information governance, which refers to how the image’s metadata is managed, including how it is described and how it is associated with an order, an episode of care and a patient. (Radiology may be inclined to take metadata for granted because the DICOM standard automates the linkage of metadata with the image.)

Take a radiology-centric approach to enterprise imaging at your own risk, warned Radonich, who is in the process of implementing a VNA. “We were very unaware of how many ancillary departments did their own imaging, the ED, labor, orthopedics. We were always telling people why we couldn't do what they wanted, why we couldn't burn 200 CDs in two days. We didn't understand our customers. Enterprise imaging has to have input from all major stakeholders—oncology, orthopedics, neurosurgery—as well as patients.

“The bottom line we came to, in a very ugly manner, was that radiology is not the place to manage an enterprise imaging strategy,” she said.

The current enterprise archive team includes vice chair of radiology informatics as well as neurosurgery, oncology, orthopedics, trauma and the assistant chief patient experience officer. It reports to the senior director of peri-operative services up through the chief administrative officer, with funding that comes directly from the CFO.

“We do not report to IT proper,” she said.  “We have found our ability to understand workflow has improved by being close to our customers.” For instance, neurosurgery physician leadership is pushes relentlessly for the ability to import MEG data.

The big tent

At Duke, the VNA and EMR are in place, and Roth is engaged in incorporating DICOM and non-DICOM images across the enterprise. Instead of having a central committee, the imaging project has three layers of governance and all comers are welcome as long as they check their specialty at the door. “We consider imaging no different than other forms of care,” said Roth.

The first layer of governance is responsible for understanding gaps and problems and translating requests across specialties. The second level drives physician orders and the prioritization of requests. The upper level, composed of vice chairs and enterprise IT, sets the vision.

Projects are scored based on a rubric that assesses training impact, user impact, effort to build, financial cost and the revenue win. Roth recommends that project directors over-communicate and be transparent about decisions.

At Sutter, Shoemaker is engaged in consolidating 14 PACS on one platform and normalizing data from multiple institutions. Your governance framework should define the following: roles and responsibilities, scope of authority, membership, goals and objectives, and areas of oversight.

"If you have weak governance, you will not succeed," he said. "If governance structure is not in place, you shouldn't proceed."