Enterprise imaging is top of mind for radiology because radiology has a place at the top of many efforts to drive “every-ology” image access into hospitals and health systems across the U.S.

One health system lighting the way into enterprise imaging’s future is Mayo Clinic. The multi-state, Rochester, Minnesota-based institution has been pursuing enterprise imaging since as far back as 1999. That year a taskforce recommended creating an institutional digital image archive, based on the DICOM standard, to serve as an enterprise image archive for all of Mayo’s clinical images. The archive went live in 2003. Today, it contains close to five billion medical images—that massive figure includes clinical photos and other non-DICOM images, all wrapped in DICOM—and it serves most of Mayo’s clinical departments and facilities.

And Mayo Clinic has an entire IT department in Rochester, Minn., dedicated to enterprise imaging. Ken Persons, the department’s imaging IT architect, joined with his colleague in radiology, Bill Nye, section head of enterprise radiology systems, to field questions from Radiology Business Journal. (The February-March issue of RBJ drills into the economics of enterprise imaging.) The interview touched on how the two departments work together on enterprise imaging, what technologies are involved and why ROI can prove difficult for some organizations to see. Here are excerpts.

Radiology Business Journal: What kinds of technology investments do hospitals and health systems need to make in order to attain and sustain Mayo-like proficiency in enterprise imaging?

Ken Persons: That gets to the question of whether we’re talking more about the enterprise imaging side or the departmental side. The infrastructure investment has to be made on both sides. From an enterprise imaging perspective, there is investment in the toolsets and services that are common enterprise services. Image archiving is the obvious one. Clinical image viewing is another important toolset, along with image exchange, workflow management and analytics.

A number of technology investments are not limited to a departmental perspective. They are a common service, and you want to leverage that at an enterprise level. That’s what enterprise imaging does. But at the department level, there’s another set of enterprise imaging infrastructure you need to invest in—those [specialty-specific] services and departmental tools that are standards-based and best serve the department’s needs.

That’s a lot to corral and manage across a lot of different departments. Do you expect vendors to, at some point, start promising all-in-one enterprise imaging solutions handling everything at both the centralized enterprise level and the department-specific level?

Bill Nye: Well, this is where adherence to standards becomes critical. I have been in this business a long time, both in industry and academic medicine, and I don’t think we are ever going to have a situation where one vendor can do it all with enterprise imaging. The constraints of a single-vendor strategy, where one vendor tries to provide everything in an enterprise imaging world, are greater than whatever the benefits would be. That’s my opinion.

Here at Mayo—because of standards and adherence to standards—we’ve been able to do some pretty cool stuff, in terms of integration and making disparate systems from different suppliers work very seamlessly in a [geographically far-flung] environment.

Persons: Mayo still has all its original MRI and CT scans going back to 1993. They are all available digitally, online, and that’s thanks to standards. If we had stuck with [siloed] systems over the course of those 25 years, the scans would all be in different systems that couldn’t talk to one another. The DICOM standard in particular has really been one of the big enablers for us to maintain our data, and access to it, stretching back over all those years.

And the strategy we have here is really a data-centric strategy. It’s the data that’s important, not the systems that are creating and managing the data today. We want the data to be around for 50 years. As an academic medical institution, doing a lot of research along with teaching and providing care, it’s very valuable for us to keep that data. And the cost of keeping it has not become excessive, as was feared maybe 10 or 15 years ago. Storage costs have become relatively cheap compared to the value of the data that we’re storing.

Can you talk about the importance of making the EMR the primary point of engagement for clinicians who need access to clinical images from across the enterprise?

Nye: For radiology we have adopted an EHR-driven workflow. In our case, Epic is what’s providing that workflow. For all our reading work lists and so on, the radiologists are interacting with Epic. When they pick something off a work list in Epic, Epic launches the primary viewer or the appropriate viewer for specialty PACS, which is also integrated with Nuance’s PowerScribe 360 to dictate the interpretation.

So when they sit down to begin their shift and are ready to read their first study, they basically log into the EMR. That’s their first stop?

Persons: Yes. And that statement is true for a lot of -ologies. Workflow orchestration in a lot of specialties begins in the EMR. There is a movement toward that. Epic is being rolled out here in phases. The second of our four deployments happened last fall. The third will be Rochester next May, and then finally our Florida and Arizona sites next fall. And then we will have a single Epic EMR across all Mayo sites.

A year ago, before we started deploying this, we were on three different EMRs, and it was difficult. But with the deployment of a single EMR, we are also moving toward using the EMR for workflow origination and orchestration, especially for the orders-based workflows.

I’ve been hearing that trying to measure what you get for your money spent on enterprise imaging can produce fuzzy results. Is that what you’ve seen at Mayo?

Nye: Well, if you look at architecture with enterprise imaging and radiology and the departmental imaging contributors, you will probably find most institutions that have pursued an enterprise imaging strategy still have long-term archives on their local systems. They are not leveraging the VNA as a single archive. So when they start looking at return on investment, their ongoing storage, support and maintenance costs are going to be much higher than they need to be.

I think we have done it the right way here, because our VNA is our long-term archive. We do not redundantly archive and have that double hit on those types of expenses when it comes to storage and so on. And even if you look today at offerings from PACS and VNA vendors, they still very often have both—the local archive and the VNA—in their architecture. That’s redundancy you don’t need if you’re fully leveraging your VNA.

And that’s where the vendors are trying to get to. They don’t have their strategies down yet around how they are going to play. If you look at some of the literature, the PACS vendors that have been successful are trying to figure this out without eating their young. And it is really quite difficult for them, because things have moved so quickly over the past couple of years when it comes to enterprise imaging. The whole concept of PACS 3.0 and deconstructed PACS—the PACS vendors didn’t take those concepts seriously. And I think they still don’t take those concepts seriously.

Persons: Back in the old days, PACS was everything. It was the archive, it had the clinical viewer, it had workflow orchestration. Everything was in there. Eventually they pulled the RIS out of it so it became RIS-driven PACS. In the new model, you look at it more from a services perspective. You ask: “What imaging services are common shared services that the enterprise should provide for departments, so that each department doesn’t have to create and manage the same services for their data—and so there is a patient-centric view across all of the imaging data?”

A few of the obvious enterprise services are image archival, query/retrieval, image exchange and clinical image viewing. Numerous others are less obvious. All of them are there to support the departments. They don’t compete with the departmental services. So here at Mayo, there is no longer any kind of battle between radiology and the enterprise imaging department or between radiology and IT. It really is a services view, having the right toolsets and the right services in place where they belong. And then leveraging them so the services that are truly enterprise imaging services are shared across all departments.

Nye: From the radiology perspective, the fact that we’ve broken down all those individual silos has been the biggest win for radiology in an integrated practice environment. It’s quite amazing when users have access to all the data they need. And we’re getting to see this as we continue our rollout of Epic and, with it, a new image viewing platform.

The images are all there. The end users just have to go get them in a different way than they used to. But here they’re already so used to having everything seamlessly delivered to them, following the initial waves of our Epic rollout, that the expectation for instant image access is there. Moving forward, this is going to have a dramatic effect on our practice.

Editor’s note: For more on the economics of enterprise imaging, watch your mail for the February/March issue of Radiology Business Journal or read the issue beforehand at RadiologyBusiness.com.