One of the most respected consultants in the imaging and imaging informatics industry, Joe Marion, principal in the Waukesha, Wis.-based Healthcare Integration Strategies LLC consulting firm, is participating in his fortieth annual RSNA Conference (his first was in 1976). Marion who blogs and writes regularly for Healthcare Informatics, continues to see waves of change lashing the shores of the radiology and imaging informatics world. On Tuesday, during RSNA 2016 at the McCormick Place Convention Center in Chicago, he sat down with HCI Editor-in-Chief Mark Hagland to reflect on this year’s conference and the trends he’s seeing. Below are excerpts from that interview.
After a little over a day here at RSNA 2016, what are your impressions of the conference so far, and of things you’ve seen and heard?
There were a couple of things I wanted to focus on this year, to find out what the trends are. The first is the whole question of population health and differing viewpoints and perspectives on that. Some vendors in the imaging informatics space are keeping an arm’s length away from the population health concept and saying, ‘That’s the EMR, the EHR.’ Others are more involved. Watson Health, big data aspect. But there are interesting options to Watson health, applications, and such. So that’s going to become more and more of a topic. The second one is the question of anything new in the context of PACS [picture archiving and communications systems] and core solutions. I think what’s happening there is that the movement right now is definitely around the whole basis of the universal view, in the context of server-side rendering—instead of physically moving the data to the workstation—in essence, any browser becomes the workstation. That’s advancing. Visage was essentially the founder, they basically pioneered and promoted that initially. Fujifilm has gone that direction with their Version 5. TerraRecon, Vitals, have been going in that, too—in other words, a number of companies have turned to that strategy.
Is traditional PACS, as we’ve known it, dead now?
The old PACS, I think, is dead, yes.
Now, people, including you, have been discussing “deconstructed PACS” for a while. But people mean different things when they use that term. How do you see it?
The initial definition or approach was, since you’re moving to a VNA [vendor-neutral archive] or universal viewer, that functionality no longer needs to be a part of the PACS, so you could replace the viewing portion of your diagnostic capability without having to buy a completely new PACS. What people have discovered is this: they thought that they could just put in a VNA and hang some diagnostic viewing stations off that, and not need a PACS. But people came to realize that that doesn’t work in terms of the workflow. One client of mine in New England told me recently, “Oh, I don’t need a PACS anymore.” I said, “OK, I have a scenario for you: three radiologists are looking at the same set of images at the same time, and want to analyze it. How do you make that work for them?” You need the workflow.
So, it turns out that you still need the workflow capability and the diagnostic-level workstation in radiology. Companies like Agfa have done a marvelous job of enterprise-wide platform development, for radiology, cardiology, dermatology, pathology, etc. And I think that’s the direction things are going in. Here’s an example: Tomtec is a European vendor that provides image analysis tools for cardiology. And, given that, the folks at Agfa said, why reinvent the wheel? So they just licensed the Tomtec tool set for cardiology; GE did essentially the same thing. So I think you’ll see a lot more of that.
Is anything changing right now in terms of the VNA concept?
I think people have wrestled with it; in fact, there are sort of two perspectives on it. There’s the clinical perspective, which says, I just need more storage space or archive, so I’ll just engage a VNA vendor instead of a PACS vendor. But if IT gets involved, they’re going to be looking at centralized, enterprise-wide platforms, rather than separate silos or platforms. The latter is still evolving; IT is still wrestling with the value of doing that. The next couple of years will be crucial for that.
How will some of the current policy and payment trends be intersecting with these operational and technological trends in the next couple of years?
Eliot Siegel [Eliot Siegel, M.D., the chief of imaging at the VA Maryland Healthcare System, vice chair of radiology at the University of Maryland School of Medicine, an adjunct professor of computer science at the University of Maryland, and of biomedical engineering at the University of Maryland-College Park], has been outspoken in saying that Watson won’t replace radiologists. I think the Merge and IBM people don’t think that’s the case, either. They’re looking to augment the radiologists; there is so much data for them to potentially use in their work. I think that’s going to evolve into two forms. One is, initial analysis of the image, where the radiologist has more data at the point of analysis. One area of potential is in getting more out of the image data. How do I analyze the arrangement of the pixels and other elements? There’s another stream of thought that says, it’s the other data that really helps. Agfa is focused on that with Watson. So you select the image, and then you get associated data, with that, in the form of clinical decision support. And that’s the path that everybody’s going down. And in terms of reading chest images, they’ll have to do it more quickly than ever. So those two areas will be important.
And policy and payment developments will be important. Mitch Goldberg, who has been in the industry for many years, is now with NTT Data—the services arm that had been spun off from Dell, has been working in the context that a lot of people go from one PACS to another and have to migrate the data. And you have to consider the demographic content—patient-matching; and supplementary data, things like overlays and annotations. Mitch is now promoting this concept of being able to analyze the pixel content, and providing radiologists with analytical content at the pixel level, offering radiologists a chance to catch elements they might have missed; it’s definitely a form of clinical decision support. That’s another huge opportunity. So, mining the pixel data will become more relevant in the future.
And, given a variety of crosscurrent-type trends, the remote-read sector will become increasingly important in radiology, don’t you agree?
Yes, I agree. And there is this whole question of services, and the way that companies are starting to look at the industry, and how they deal with the industry. And teleradiology is clearly one of those areas. And the technology is available now to do this. It’s not like I physically have to move the data from A to B; I can give B access to the data to see it. I think the remote-read aspect will still be somewhat restricted by the licensure issues. I’ve been doing work with a radiology group in New Hampshire, and we’ve been sorting through some of the issues that could affect them with regard to work they’ve been doing for a hospital system in Connecticut—the licensure and cross-licensure issues. Will cross-licensing happen? That’s a huge issue.
Meanwhile, more and more vendors are repositioning themselves as providers of services to patient care organizations, with hospitals and health systems signing long-term contracts based on monthly-fee models. Marin General just signed a huge, long-term, multi-year contract, with Philips, for a monthly fee. I think we’ll see a lot more of that evolving forward. Others are looking at services a little bit differently. Agfa, for example, has a whole services organization for analyzing how you’re operationally using your PACS. And they can provide consulting services to make you more efficient. And data security is obviously a huge issue. I was impressed with what they can do on that front, too, providing a subscription service, they’re doing behavioral monitoring.
Do you see the possibility that image-sharing could leap the level of traditional health information exchange and somehow become speeded up?
Yes. A lot of companies are promoting their image-sharing capability. And with video-streaming capability and service-site rendering, I don’t physically have to be moving the data. So yes, I think it’s inevitable. If I want you to see my records from the large integrated health system that is my provider as a consumer, I can just send an e-mail with permission, and can get access. So the technology is there; and within the next five years, you’ll see a lot of this. Even with the change in federal administrations, in terms of the HITECH stuff, that will probably continue to progress, and some of this will be driven forward in the context of image enablement. Why can’t I just have access to my images within my healthcare environment. In the health system that takes care of me, I can see my lab results, and I can see my radiology results, when someone’s gotten time to scan the physical document in, which is ridiculous—but there’s a whole slew of images I can’t currently get access to. So I have eye images that are printed out from a PDF, and scanned into the EHR. If my IDN were thinking about patients—as long as it’s in the system, there’s no reason they couldn’t just provide a viewer that will allow me or appropriate clinicians to view the images. And within five years, that will be a reality.