A recent survey found data storage to be one of the more pressing issues weighing on the CIO mind. And when one tries to pinpoint the culprit for most of that data, it’s inevitably imaging. Just think of your inboxes, how easy is it to just delete the photo attachments from messages and shrink your footprint in seconds. For CIOs, multiple PACS and image redundancy are sure ways to exponentially increase storage costs. Recently, HCI Editor-in-Chief Anthony Guerra chatted with Jim B-Reay, vice president, business development at Healthia Consulting (acquired last year by Ingenix), about how CIOs can work to get their imaging houses in order.
AG: Do you think that it’s the CIO’s role to make sure this gets done properly? Do they have to be the gatekeepers who say to cardiology, ‘No, you can't have that system you want because it’s redundant or it’s just not necessary’? How should that dialogue go?
JB: We’ve always fought that fight, and when you get to the custom functionality piece, you’re going to get into the same level of argument, as they’re going to present why they need to have a new cardiac CT or why they need to have a PET CT. They’re going to say that having this level of diagnostic toolset is a value-add to the patient and leads to better patient care. They’re going to come at you more at a patient-care direction. If you’re trying to come at it saying we’re trying to consolidate toolsets and we’re trying to gather economies of scale, if you come at it too hard that way, they’re going to push back the same way that they would push back if you tried to deny or cut back on the number of modalities that they have in their department. I’ve just seen that more than once.
Radiologists, as a specific group, tend to be a little bit more flexible, simply because a lot of them work at multiple facilities or share services. They’re very used to seeing multiple toolsets and are less emotionally invested, usually, in exactly what they use for reading. Whereas, when you get more into specialties, they’re going to start to say that this is less about a report that I’m writing and it’s more about a diagnosis that’s going to change this person’s life, even though that’s exactly what radiologists do as well.
AG: You say that working with an outside organization that can play bad cop is sometimes easier?
JB: I think that’s a fair assessment.
AG: Other than that, other than possibly bringing in that outside entity that can speak impartially, as it were, what are some other tactics that CIOs can employ to navigate these waters? Are there key people they have to get on board and make sure they have their support?
JB: Yes. On an inside of the IT level, it’s extremely important, I think, to align imaging into its own group. What that means is that you need to have the people who are responsible for cardiac, for mammo and for traditional radiology all within the same organization. They can’t be departmentally owned. So what happens then is the people who are responsible for supporting it wind up with a better enterprise view of exactly what’s happening. They will then become better able to offer frank and real recommendations upward to the CIO level. Then, usually, you’ll have a director-level person who is over Enterprise Medical Imaging, or something like that. So that is a level which makes a lot of sense to cultivate.
To that end, then you also need to pull almost all PACS administration out of the departments because when responsibility for training and for infrastructure and all that remains inside of radiology — and then there is a parallel organization like that inside of cardiology and there’s a parallel organization inside of the mammo groups and oncology — then what winds up happening is that they’re fighting for resources and not necessarily fighting for what’s best for the enterprise. So, if you can pull them all up and put them into an integrated group, then the CIO will have a team that he or she can be working with who truly has the enterprise view in mind.
Then that strategy needs to be bought into by the directors of all imaging areas — your director of radiology, your director of cardiology and those groups — have to buy into that. The way that you can sell that to them is that they’ll actually get better service. Instead of having three, two person or three person groups, by having one eight person group it’s much easier and better to have 24 hour on call support or 24 hour or extended hours for on-site support and training. You could say that this group will then offer you better support. That actually does work as long as you’re willing to follow that up and not say that these eight people now can become six people. You don’t want to look at it as a cost savings. You want to look at it as a benefit.
AG: Let’s say a CIO likes what you’re saying and puts a plan down on paper. Where do they take it for support? The CEO? The board?
JB: It needs to come to the executive steering, however that works. If the CIO is at the table of the executive steering committee, or if they need to have the CEO speak for them. They should have at least on ally at the table before they pitch it.
A lot of times, you can actually get the chief medical information officer to become an ally in this one because they’re usually most in tune with the need to consolidate toolsets, and they’ve almost always been the EMR champion. So, what you can sell to them is that if we can work on an enterprise strategy on this one, we will probably be in a better position for you to, while doing a chart review, be able to click and be able to view an echo from within the chart without having to go out to eight different toolsets. So then they’ll get excited about that.
AG: When each “ology” director says they need a specific application, the CIO may have to explain to the steering committee what the ramifications are of going down a road like that, and how much you’re going to have duplication of storage and all the negative ramifications of this. Is that correct?
JB: That’s correct, but it’s not always handled that way. In at least two of the facilities I was in, the CIO, because of the way they approached it, left themselves open to the criticism that they just don’t want to support another tool or they just don’t want to put another server in the server rack. I think people are starting to understand that disk is getting cheaper; servers are getting cheaper, that shouldn’t be the barrier even though it really needs to be a factor. I would say that the CIO has to approach it from a functionality perspective and be able to say, ‘I understand why you need this toolset, can we look at our existing PACS and see if there is a plug-in that will work.’
For instance, I’m looking at the nuclear medicine arena, nuclear cardiology. Up until this point, nuclear medicine has always required an extremely high processing workstation. It’s getting to the point now where standard workstations can handle the calculations that nuclear medicine takes. There are a number of vendors now who sell plug-in versions of their software that will run on top of, say a Philips iSite PACS, instead of having every single nuc be sent to a wide-stream read station. The same thing is happening with Terra Recon. That’s 3D heart reconstruction software. Again, that now is working in a plug-in fashion, it’s a separately licensed tool and it has its own servers, but it can run against, it can run inside of your enterprise PACS, and it can be launched from inside of your enterprise PACS. So plug-ins are really getting to be the way a CIO can say, ‘I understand your special tool, I understand your needs here, instead of buying system X, can we instead look and see if there is way that we can expand our existing PACS investment through use of plug-ins?’
AG: So it’s about walking that line as a CIO between standing up for the enterprise and making sure you have a good architecture and your ongoing total cost of ownership spend is manageable, versus you don’t want to come across as someone that’s a road block. You mentioned some good tactics for dealing with that, trying to solve the problem in a way that works for everyone.
JB: Right. It’s the old tried and true. Never say no, say yes … but. Because especially in some of the higher reimbursement areas, especially like the cath lab and some of the oncology areas, these guys know what they mean to the hospital and if they’re told no without a really good path to their yes, they will do an end run and the CIO will often get torpedoed on this. I’ve have seen it too many times and then, in two years, it’ll be an integration and clean up effort. I think the smarter the CIO can be about recognizing that there really is a purpose to this specialty toolset, there really is a need for it, and trying to find ways of supporting in more of an enterprise way, the better off they will be.
AG: Just as a final question, it sounds like the biggest mistake that CIOs make is either being too strict or not strict enough.
AG: So, that’s the problem. People are either one or the other.
JB: The people are either one or the other, and so the smart CIO then, in this case, is going to be the one who collects all the imaging functions into one reportable area under him or her so that at least there is a cross-pollination of knowledge. There needs to be a demystification of the strangeness of cardio versus the needs of old-line radiology. I keep putting those two in, but you can put any of them across. They’ll do that.
They will also look, whenever possible, at plug-ins to their existing systems. They’ll recognize the need for unique tools, but try to use them within their existing investment or framework.
Then the third thing is that they maybe have had to say no three or four times, if they wind up in a software architecture that is not able to be extended, if they recognize that their PACS, while serving one group, simply is unable to serve other groups. I think they need to not be afraid to be the ones, even if radiology is perfectly happy with their PACS, they need to say I’ve got this request and this request and this request, can I take a look at a more enterprise solution across the board. They need to actually be willing to propose a solution where maybe cardiology isn’t the one who is compromising. Maybe radiology does ever so slightly.
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