Beyond the Software: Creating the Optimal Enterprise Imaging Environment
A familiar face on exhibit floors from Chicago to Vienna and in hospital radiology departments around the world, Robert Cooke, has participated in the commercial development of PACS from its very early days. Currently vice president and general manager, network business, FUJIFILM Medical Systems, Stamford, Connecticut, Cooke has spent the past seven years working on the development of SynapseTM PACS®. He shares his thoughts on the people and processes that distinguish a successful imaging environment from others, as well as his insight into the source of the next paradigm changes for imaging informatics.
“One of the things I’ve learned through the years is that people are everything. They are the only assets you have to drive success. Certainly, people need to be motivated, to have clear understanding of what their roles need to be, and to have the ability not only to drive change, but to embrace change."-Robert Cooke, vice president and general manager, network business, FUJIFILM
Robert Cooke We know that two different organizations can implement the same software and hardware with vastly different levels of success. What are the key questions that a facility should consider before tackling the implementation of a true enterprise imaging environment? Cooke: The basic issues are these: One, define what that enterprise really is; two, identify the clinical stakeholders who need to be communicated with; and three, identify the external systems that need to be integrated. Those really are the key questions that a facility needs to consider before tackling the implementation of an enterprise imaging environment. In any health care institution, about 80% of the data come from radiology and the cardiovascular domain. These imaging areas are the most mature in terms of standards, compliance, and the ability to generate a meaningful linkage between the image and the patient data. Other imaging areas are, of course, coming along, but the level of implementation and the integration of a full digital environment clearly are not as mature. Here’s the other side of the coin: The main purpose of an enterprise imaging environment remains to facilitate better care decisions, so the information must be presented in the right way to the clinical stakeholders. Whatever solution gets implemented should, of course, have the ability at least to aggregate the variety of data coming from the most mature imaging areas, in terms of digitization, as well the ability to distribute and share those data with the various clinical stakeholders. Realistically, any facility should take some time to define the scope of the imaging enterprise and how that scope will evolve. Ideally, the solution it picks might include the key aspects of the enterprise that are in scope now and then be capable of evolving along the lines of changing needs. Understanding these aspects can dramatically change a number of possible solutions to the problem. What are the common factors that you see for facilities that have been successful at implementing an enterprise imaging environment? What are some of the challenges? Cooke: In any project, the most important success factor is having a plan. The attributes of a plan should include having clear, assigned, and accountable parties on the vendor and the client sides. Beyond that, there must be established clinical IT leadership, and it is very important to understand the project goals and the environmental factors, such as external systems and workflows in terms of remote reading. Those goals have to be defined clearly in advance of starting the project. Some of the challenges that we’ve seen customers face relate to a mismatch between the goals of IT (for lack of a better description) and the goals of those within the clinical domain. The most important factor, in that case, is to remember that these are health care solutions first, and IT is the enabling force. In an enterprise context, you are bridging all of the communications across clinical areas, and episodes of patient care are perhaps the critical aspect of any successful project because that should be the goal. How important are the people? What role do human resources play in the success of an enterprise imaging informatics implementation, both before and after implementation? Cooke: One of the things I’ve learned through the years is that people are everything. They are the only assets you have to drive success. Certainly, people need to be motivated, to have clear understanding of what their roles need to be, and to have the ability not only to drive change, but to embrace change, whether it be the radiologists moving from the lightbox to a diagnostic workstation or the technologists having to change their workflow in terms of the way they send exams into the system. The ability to adapt and lead change is really critical. Identifying accountability and authority, both within the health care organization and in the vendor organization—before, during, and after the implementation—is crucial. Transparency is a priority for us because there is a clear link between the quality of service we deliver and the knowledge of the staff that we deploy on-site. We have been increasingly trying to avoid stovepiping in order to provide uniform knowledge across the board to the people supporting the system, as well as to the client. Having that uniform level of knowledge and information is a critical success factor. A great example of this is that we publish our knowledge base for our clients, so that they can readily know what has been fixed, what the known issues with the software are, and what our solutions to common problems are. That is exactly the same level of knowledge that our people get. Both the client and the FUJIFILM people on-site having that same level of knowledge is a great equalizer and tool for collaboration, and it helps us to be successful. As the Society for Imaging Informatics in Medicine and others have asked, who should own imaging, radiology, or IT? In your experience, what ownership model works best? Cooke: We have to understand that we are in the health care business. The goal is to make sure that the right medical decisions get made. I’ll take the leap to say that IT embraces the priority of patient care. The IT department is fundamentally a service that the hospital has, and if the IT department is in sync with the goal of driving the right medical decision, then we are way ahead of the game. There is no question that these are IT systems that have to store and integrate a large amount of information, not to mention distributing these data to potentially thousands of desktops. There’s also no question that this is well beyond the scope of the radiology department. If IT fails to recognize that, there is a problem. Modern software (take Synapse, for example) should be able to adapt around the IT standards while still enabling users to perform the clinical missions. If you could deploy an IT-friendly solution, which includes things like virtualization and which is both server and storage independent, you are well ahead of the game. My feeling is that this ownership debate relates to a lack of clarity regarding the roles and responsibilities of IT and the clinical service. The other possibility is that it has been created by applications that can’t easily adapt to the needs of both groups. What responsibilities do the industry and vendors have in ensuring that systems can be effectively integrated? Are organizations like the Healthcare Information and Management Systems Society and Integrating the Healthcare Enterprise (IHE) playing effective roles? Cooke: The industry and the vendors jointly own the responsibility. DICOM and IHE have been fantastic developments that continue to grow, but I think the Health Information Technology for Economic and Clinical Health Act has been a bolt of lightning from Mt Olympus that is going to spawn a whole new set of integration requirements. I think these standards and requirements that are being generated now are going to have a profound impact on the existing committees, and have already spawned a slew of new committees and organizations designed around the integration challenge. My bias, however, is that although industry bodies will continue to play a major role, the real innovation is going to come from a bottom-up approach, perhaps using knowledge and technology from outside health care. I predict a paradigm shift not unlike the shift we made from vinyl records to downloadable media. The stakes are sufficiently high. The mandate for communication, aggregation, and analysis of health care data (including imaging) is clear, and innovation is really going to be the primary driver of integration into the future. Some of the integration methods that FUJIFILM has deployed in the past, such as URL integration (as well as the advance of industry standards), have allowed us to enable imaging in a wide sector of the health care enterprise, in disparate environments, in what remains a pretty innovative fashion. What, specifically, is FUJIFILM doing to move customers toward an optimal imaging environment? Is the company using changes in software, product development, or strategy? Cooke: D, all of the above. I’ll give you a few examples. First is the move towards virtualized technology, which allows us to deploy a cutting-edge, easy-to-manage IT environment. Second is integration; we can deploy a single Web application that covers all imaging domains (including radiology, cardiology, and mammography) and that brings all results and all operational data into a single Web interface. In addition to virtualization, we are continuing to focus on adaptable solutions that can integrate with IT standards for disaster recovery and high availability, but also continue to contain the necessary tools for the clinician to generate the appropriate results. Again, all of this boils down to the mission of enabling users to make a medical decision. Traditionally, PACS has been the first area of the enterprise to adopt digital imaging, so it is a logical launch pad to start from, but we’ve built enterprise imaging into Synapse, and the licensing model is easy to expand to accommodate the other clinical imaging domains. What role do your customers, the people and organizations that use the Synapse portfolio, play in helping to push the envelope of your technical solutions? Can you describe an innovation that grew out of a site seeking to use the software in innovative ways? Cooke: We take pride in our ability—despite the continued growth of our installed base—to maintain our close communication with our customers and to hear their suggestions and concerns for the product. Virtualization is a fantastic example. We saw our client base adapting this technology, and they were pushing us to endorse and support this approach. Since then, we’ve not only embraced this class of solutions, but it’s actually our de facto deliverable item, and we are the only vendor in this space that is certified to work within the virtualized environment. Acquisition has played a significant role in product development throughout the PACS vendor community, and it has resulted in expanding the breadth of Synapse as well. What are the pros and cons of this method of product development? Cooke: If you do your job correctly, an acquisition can give you immediate access to domain experience, a complementary customer base to leverage, and some incremental revenue. The key to success in the long term, however, is to look beyond this initial goal and really focus on how to bring the best of the organizations (including people, processes, and technology) together in a meaningful way that can drive your business over the long haul. I don’t think anybody has a monopoly on success in this environment. Thus far, the acquisitions we have made have been very selective and well integrated into our portfolio to give us this long-term success. If you fail to realize those factors, though, you might actually end up hurting your business over the long haul. Obviously, that doesn’t serve your shareholders or your clients. Aside from customer demand and acquisition, what are the other drivers of innovation in the product? Cooke: Users absolutely play a role. For example, in the next month, we will host a fairly large group of our users who will interact with our product, support, and development teams to help us understand the things that are working best for them now, as well as those things that are challenging them now, and we will adapt our product-development strategy along the lines of their input. We are in tune with the regulatory environment as well. This area, specifically, can dramatically change the value equation that our clients have for our technology. Another key driver, really, is what is possible with the technology. It is important to remember that most of the software in use in the world comes from outside of our industry. We have to keep a very close eye on developments external to health care. Otherwise, we face slowing the pace of innovation. There also is the patient. With the Internet and its vast amount of educational resources, the patient increasingly is becoming empowered to ask questions about either diagnosis or treatment. I think it is incumbent upon the imaging domain to understand this and to place a more human focus on results, perhaps even including things like educational content, as well as using plain English in the results. The health care community needs to understand that patients are going to be driving a lot of their health care decisions based not just on what their physicians tell them, but also on the vast resources of the Internet. These (when used appropriately) can be a force for good—but if used inappropriately, can potentially harm the patient. I think the medical community, and imaging in particular, must understand this, embrace it, and put a human face on the imaging process. A few years after FUJIFILM introduced Synapse, you coined the phrase, “PACS is a software solution.” We’ve gone from thick-client to thin-client PACS and from department-centered systems to enterprise imaging. What is the next paradigm change in imaging informatics? Cooke: There is no question that FUJIFILM is a pioneer in the development of a software-only approach to PACS, and no question that all of this stuff is just software. There aren’t too many software applications that can run without hardware, however, so we have to be cognizant of trends in the IT space (such as cloud computing and virtualization) and adapt along those lines. I think we’ve done a pretty good job of that. Because we primarily are talking about software, I think the next paradigm shift in the industry will come from trends like enterprise mashups, designed to bring together a variety of disparate information sources, to provide business intelligence, in a single place, for making a decision. There’s no reason this can’t be adapted to health care. The other thing to keep in mind is that there really are some established Internet concepts, such as social networking, that are also going to have a profound impact on the paradigm shift we are going to see in imaging informatics. If anybody has had a chance to look at and evaluate what Google is doing in the area of Google Wave technology to bring together complex multimodal discussions, information, images, and so forth, I think that is going to really set the direction for the next 10 years for this industry. In general, the goal of increasing the value of the imaging process in support of the medical decision remains: getting the right information from an increasingly wide variety of sources to the interpreting physician, who then adds value for the primary care giver, who (in turn) has the role of making a medical decision that decides the course of treatment for the patient. That’s health care. Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, ImagingBiz, Tustin, California.