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Beyond PACS: An Imaging Informatics Breakthrough

October 14, 2011
by Mark Hagland
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The leaders at Houston’s Memorial Hermann Health System self-develop an innovative solution for regional image interchange

Among the pioneering organizations in advancing interoperability in the imaging informatics arena is the 11-acute-care-hospital Memorial Hermann Health System, based on Houston. Because of the interconnectedness and complexity of the Memorial Hermann system, any solution the system’s leaders might choose to adopt would necessarily have to be somewhat comprehensive.

What has in fact happened is that the Memorial Hermann organization has self-funded the development of a cloud-based diagnostic image exchange called the MHiE Image Gateway, part of the Memorial Hermann Image Exchange, which is making available the thousands of new diagnostic imaging exams performed each day to appropriate clinicians and entities within the organization itself and to clinicians and entities that are a part of the image-sharing initiative (the Memorial Hermann folks worked collaboratively with the Phoenix-based DICOM Grid to create the cloud-based storage solution for the initiative). Created in less than six months from conception to go-live, the program has enhanced care quality, care management, and transition management, and expedited care; created savings from the elimination of duplicate exams; eliminated diverse problems related to the use of CDs carrying diagnostic images; and helped to strengthen and enhance relations among clinicians and facilities.

Recently, David Bradshaw, the chief information, marketing, and planning officer at Memorial Hermann, and Robert Weeks, the director of the health system’s information systems division, spoke with HCI Editor-in-Chief Mark Hagland regarding their organization’s breakthrough in image management. To find other compelling case studies in this area, please turn to the November cover story in the print edition of HCI. Below are excerpts from the interview with Messrs. Bradshaw and Weeks.

What was the core strategy or vision behind the creation of the MHiE?

David Bradshaw: As an organization, we believe that the interoperability between independent physicians who are part of our IPA, our contracted, post-acute providers, and our network of wholly owned delivery capability (from doctors’ offices to imaging centers, to surgery centers, to freestanding rehab centers, to our hospitals, to home health)—we believed we needed an interoperability platform for today’s and tomorrow’s needs. There are three main functions of the MHiE—one is around hooking up physicians, the EMR to our labs, and the EMR to our imaging centers; second is the image gateway, which moves images from imaging centers to hospitals to providers, replacing CDs that often don’t get created. And finally, a care continuity document (CCD)-aggregated exchange.

The image gateway is a cloud-based solution we’ve created with DICOM Grid, a company out of Phoenix. And we’ve got some really good use cases and stories about that.
David Bradshaw

Was it difficult to achieve and implement the vision?

Bradshaw: No, because we have a very clear business strategy, and when you understand our business strategy that we need to have in order to achieve our vision.

Please share with us some of the details of what types of images and data are shared.

Robert Weeks: There are three main use cases: trauma transfers, routine transfers, and serving as a kind of vendor archive-in-the-sky, a PACS [picture archiving and communications system] backup, so we have a redundant copy in the cloud. In the event of a large-scale system failure, we’d have that redundant copy of everything in the cloud.
Robert Weeks

How long have you been live?

Weeks: We’ve been live on the image gateway since the end of March. The initial scope included trauma transfer with Beaumont Baptist Hospital and Beaumont Orange Hospitals. Another one is Huntsville Memorial Hospital, which brings us trauma transfers from the north; and we also included a large orthopedic group, the Richmond Bone and Joint Orthopedic Group, a 20-orhopedist group with two locations. And we do image-share with them. Those 20 orthopods do surgery on many of our patients at Sugarland Memorial Hermann and Katy Memorial Hermann Hospitals. And often, patients would show up at their offices with CDs. And the orthopod might order more studies from us. And we send the images through our image gateway. So the beauty is, when one of those orthopods comes in to operate on one of our patients, we have any outside-created images and internally created images right there in the OR when they’re operating.

But the most awesome story I can share with you is around our trauma patients. Here’s an example of a trauma transfer case I’ll tell you about. From Beaumont, we had a 10-year-old girl who was running and fell and fractured her hip and femur; it was a very complex fracture. They imaged her, and realized she needed a high level of care. She was transferred from Beaumont to our Memorial Hermann Texas Medical Center. But the beauty of it was that they were able to get those images electronically to us here before the patient arrived. So the surgeons were able to study those images in the OR before the patient arrived. And that’s a very good thing.

Because sometimes, we’ll get a CD with a patient; sometimes, old-style film; and sometimes, those CDs will have proprietary software on them so we can’t read them. So this is a big advance. And also, on that 10-year-old girl, no additional studies were needed. And understand that this was a 10-year-old girl—not only do you want to over-radiate a patient, you really don’t want to over-radiate a pediatric patient, and you really, really don’t want to over-radiate a pre-pubescent girl. So we improved care delivery, patient safety, expediency, eliminating over-radiation and duplicate tests, as well as cost.

Can you discuss the volume involved in the image transfers and the image storage load?

Weeks: We’re using the image gateway in two ways: one is to store a copy of all our images; and two is to accept external images from affiliated or collaborative organizations. We annually do 1.8 million studies across 1,100 modalities—pieces of equipment across imaging centers and our hospitals, and those studies are read by about 250 radiologists. So we’re feeding about 1,500-1,800 studies a day into the system. And all that gets up into the cloud today. In addition, we are sending about 4,000 studies a day of historical backload up to the cloud. We’re trying to create availability of six to 12 months’ worth of studies. So altogether, we’ve been feeding 6,000-7,000 studies a day up to the cloud. And we’re receiving about 600-700 studies a day from external sources. And as we add external entities, and by the way, we’re meeting with folks all across a nine-county region to link with us, and they’re not only able to exchange images with us, but with anyone else in the exchange as well.

What feedback have you gotten from physicians?

Weeks: Obviously, orthopedic physicians, surgeons, ER physicians, and radiologists, as well as neurologists and neurosurgeons, have all been very enthusiastic. And the ability for that person to be able to see a study within mere minutes of facilitating a transfer—we’ve gotten very strong, good feedback. And they want to go fast—they want to deploy this widely as soon as they can, even to be able to develop the ability to read from the cloud, which is a way of saying that the minute it hits the cloud in the sky, they’d like to be able to fetch a study and read it. So it’s really been a very positive reception from physicians.

Can you provide a global cost estimate?

Bradshaw: That’s confidential. But it’s been affordable for us. And a lot of organizations and communities are trying to do this on grants. We’ve been able to pursue this through writing the checks ourselves, because this has been so much a part of our core business strategy.

What have the lessons learned been so far?

Weeks: We were very skeptical about this technology, because there are so few vendors right now that can do this well. But with DICOM Grid, we’re sending them 6,000-7,000 studies a night, and I was positively surprised by their ability to handle this level of volume. I was also skeptical about the patient data security, but they’re using patented technology, called Split-Merge, which takes an image file and removes the PHI from it, and so all you have is an image with no data on it, and the PHI data and image are separately encrypted and sent, and are never put back together until after they’ve been successfully transferred. And I was very pleased at the success of that security regime. We got what we were sold, which was a very secure, very fast solution. So though I was skeptical, I was very happy to see that this vendor was able to deliver on what it had promised.

What would your advice be for CIOs and other IT executives who might want to create a similar sort of program?

Weeks: When you really boil it down—if you’re going to wait around and see what happens and wait for others to do something first—and there’s some hesitancy out there to go forward on this. But having done this, we’ve gotten tremendous interest, not only from those referral sites I talked to you about, but we’ve gotten tremendous interest in the local communities, and there’s potential for other health systems to join the exchange.

Even for competitors who might want to join the exchange?

Weeks: Absolutely. And we would absolutely welcome them, because it’s of great to the southeast Texas community.

How many are involved day-to-day in this?

Weeks: Day-to-day, we have two FTEs, a primary person and a backup, who support and maintain the system. And I have a person who’s called a road warrior, and after one manager and I go out and meet with people for introductory meetings, we have a road warrior who does the connectivity; and another person who does the day-to-day maintenance and feeding of the cloud.

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