‘Eye-opening’ misconceptions around enterprise imaging, and how radiology leaders can avoid them

“Enterprise imaging” is a term that’s bandied about in healthcare. But what does it actually mean, and is your organization getting the most bang for its buck out of this very important process?

Radiology Business recently sat down with two experts from hybrid cloud and data management leader NetApp Healthcare to discuss this topic, including governance and how to avoid some of the common pitfalls and misconceptions. What follows is an edited version of our discussion.

Radiology Business: What is enterprise imaging and what does it really mean?

Kim Garriott headshot
Kim Garriott 
Chief Innovation Officer, NetApp

Chief Innovation Officer Kim Garriott: In layman’s terms, any type of clinical content that is generated in the form of an image, audio or a video file is considered enterprise imaging. We see that there will be an evolution toward even more audio files and other types of multimedia that we can’t even dream of right now. In our view, all medical specialties participate in this broad concept called enterprise imaging.

Strategic Partner Manager Tony Turner: It’s a term that gets tossed around pretty regularly, and I think that it’s important to understand what we’re really talking about when we say, “enterprise imaging.” Most folks interpret enterprise imaging as those care areas outside of cardiology and radiology. At the end of the day, they’re all medical images.

Radiology Business: Why would an organization implement an enterprise imaging solution?

Garriott: There are a number of reasons, either based on a workflow or for an initiative like wanting to have a secure and standardized way to acquire point-of-care ultrasound images outside of radiology.

Comparatively speaking, enterprise imaging is very similar to an electronic medical record, which is comprised of modules for a variety of specialty and administrative specific use cases such as obstetrics, patient registration, ophthalmology and others. Likewise, enterprise imaging is made up of a lot of different primary use cases that need to be managed. Take image exchange—the sharing of images between organizations—as an example. Say a standalone center has acquired images because the referring physician sent a patient there and those images need to be shared with a specialty provider. Or it could be sharing images between the acquiring facility and a patient, or the patient sharing images with a new facility or a new physician. Image exchange is a primary use case on which someone could start their enterprise imaging journey.

We are also seeing more and more outpatient clinics, emergency departments and other clinical areas purchasing their own ultrasound equipment so that they can better assess a patient’s condition at the point of care to expedite diagnosis and treatment.

Radiology Business: And this has implications for payment as well, correct?

Garriott: In many care areas, there is the potential for a relative value unit increase, at about half of an RVU uptick on average, if the clinician documents that point-of-care ultrasound was used in the treatment of a patient. To bill for that, CMS requires you to retain the image as part of the documentation. There are a lot of organizations where radiology gets a knock on the door asking, “Can you put these ultrasound images in your PACS for me?” Most radiology organizations are responding, “Eh, not so much. We don’t know about the quality; we don’t know how those images were acquired. We don’t want to see these images coming up on our radiology worklist.” You need this mechanism to securely acquire and retain those images for billing documentation purposes.

Turner: And in many cases, there was probably never even an order created for those.  

Garriott: Right, and that’s a good point. This is an example of an encounter-based workflow, where the images are acquired in a very different way than in radiology. Say, for instance, an endocrinologist has a point-of-care ultrasound in their outpatient clinic to assess thyroid health. In many instances, it is a burden for the physician to put an order in, wait for it to post and then select the order from the DICOM worklist and scan a patient. They don’t have a radiology information system at their disposal, nor do they want one. That’s not their job. And they don’t have rad techs to do that for them like they do in radiology. So, enterprise imaging offers more intuitive workflows to satisfy that need.

An organization will take an enterprise imaging approach for a variety of different reasons. Rarely do you see an organization that wants to boil the ocean and take care of all of these different use cases out of the gate. I have not met an organization that has the bandwidth to consume that much change at one time. They usually come into this opportunistically, driven by a single use-case. It’s a multi-year journey to fully adopt an enterprise imaging platform and all of the capabilities that come along with it.

Tony Turner Headshot
Tony Turner
Strategic Partner Manager, NetApp

Turner: And the initial use case might be we wanting to start capturing images outside of traditional radiology and cardiology to create more continuity of care for physicians and clinicians who use the EMR, because they want to see 100 percent of a patient’s record. But it may take them three months just to do dermatology, and then they have to move on to the next department. It’s hard to do a “big bang” type of implementation.

Garriott: Very few organizations have said, “We’re going to implement Epic and add every single module at the same time.” It’s just too much. One of the most important reasons why organizations move to an enterprise imaging platform is to have a centralized, long-term archive for all of this content. You can really optimize your data storage by consolidating into a single archive, and that’s a big benefit for a lot of organizations.

Turner: There are so many things that start to come into play when you bring in imaging from other care areas. Because traditionally, these objects could have been captured on, say, an iPhone, or they could have been on a separate PC in the department or a USB drive just thrown into a file jacket. There are all kinds of HIPAA implications and concerns around data governance and personal health information that are not being protected. And then all of the data management considerations that come with that. There’s a trend right now where healthcare organizations want to capture all of this data and have it managed in one spot is to leverage it, whether through augmented intelligence or machine learning. Data has value, but if you have it in multiple different silos with no governance, you really can’t take advantage of it.

RB: Can you talk more about the importance of data governance?

Garriott: You need a roadmap over a multi-year period so that what you purchase today is going to serve your needs in the future. How you build and implement the system needs to be universally accommodating to all service lines that participate in your enterprise imaging platform. Having a long-term strategy that cares for the different components of enterprise imaging is an important first step, otherwise you risk spending money you shouldn’t, or encountering unnecessary delays in your projects that you wouldn’t, had you spent time upfront.

On the heels of that is understanding the governance. How will the data be acquired? Is it going to be through an encounters- or orders-based workflow? Those are important considerations because, first and foremost, you want to have usable, relevant data. The only way you can do that is by being thoughtful about the metadata that is being captured. You also must make sure those data values are standardized in a way that enables meaningful and relevant presentation in the EMR, and for other organizations with whom we may need to share that information.

Data governance is also understanding lifecycle management. As part of the work I did with HIMSS in developing the Digital Imaging Adoption Model (DIAM), a survey was created, and one of the questions asked was: Does your organization use image lifecycle management (ILM)? About 99 percent of respondents said, “We don’t delete images; therefore, we don’t use lifecycle management.” The fact that ILM is synonymous, in many people’s minds, with image deletion was very eye-opening to us. Lifecycle management should be much broader. It covers everything from acquisition to disposition of images.

RB: Any other factors to keep in mind?

Garriott: Another key consideration is understanding what type of solution you want. Are you looking for best of breed? Do you want to have a separate exchange or workflow solution? Do you want to take a best-of-breed approach and bring all of these different products together in a meaningful way, or do you want to buy a platform solution from one vendor that covers all of those elements?

RB: What are the different roles and responsibilities within the organization for enterprise imaging?

Turner: The typical perception is that it is a radiology problem, and truthfully, it’s a healthcare organization problem. It’s going to impact all of the care areas in the hospital. Stakeholders aren’t just your traditional radiology and cardiology departments. They may end up being the bulk of the management, or they may not be. But every care area is creating some type of medical image now.

Garriott: This is an enterprise effort. Whether it is radiology or IT leading the change, if they do so in a vacuum, they’re going to miss the mark and their program will fail. It needs to be undertaken with a holistic approach and it needs to have clinical and administrative leader involvement from a number of service areas to get your program off the ground. Oftentimes, return on investment for an enterprise imaging solution is most greatly found in enhanced clinical outcomes and increased caregiver satisfaction because they can—no pun intended—get the whole picture of the patient, and not just certain textual data captured in the EMR. These are intangible benefits. We have hard ROI when we can consolidate on the storage side. That’s where the money is going to come from, or if you have multiple enterprise viewers and you can standardize onto a single one. Another consideration is around viewer technology. Are you going to standardize on a single enterprise viewer? It’s very important for organizations to appreciate the preferences of each diagnostician. If we were to tell radiologists that we’re taking their viewer away, that probably would not go over very well.

RB: What challenges exist when trying to understand and measure clinical and business values after implementing enterprise imaging?

Garriott: The single most important challenge is taking the time to baseline your workflow and productivity before you make any changes. Because that is where you’re going to exhibit the intrinsic value of enterprise imaging, post implementation, and that means having good baselines to go back and compare against. Unfortunately, in healthcare we struggle with being proactive before implementing a solution. That’s just something we don’t do as well as we should or need to in healthcare. We need to get better at understanding and documenting that current state in such a way that we can come back months after implementation and measure process improvement to demonstrate very tangible values and benefits, increased due to an enterprise imaging implementation.

Radiology Business: Who should be guiding this transition at the hospital?

Garriott: Radiology team members, who are the imaging experts, have been at the digital imaging game longer than anyone. There is an opportunity for radiology to become internal consultants to the other service areas across the organization. I am a big proponent of radiology having a meaningful role and serving as leaders in the enterprise imaging conversation.

There are a lot of considerations, but at the end of the day, you need to have solid, executive leadership from the top down to have a successful enterprise imaging program.