In part one of this two-part article, I discussed how medical imaging is considerably more complicated today. Because of the multitude of individual systems involved and the myriad interdependencies between those systems, the selection of any one component or subsystem related to medical imaging across the enterprise should be a process orchestrated by a team comprising the leadership in the imaging departments and IT. There should be no individual decisions.
 
Now is the time for the organization to develop the enterprise imaging strategic plan that will specifically describe how the organization is going to achieve the level of systems integration required to deliver any piece of clinical information to the caregivers in the most cost effective and efficient manner.
 
The team should be made up of the senior leadership in the information technology department (CIO, CTO), as well as those individuals responsible for hardware/ software infrastructure, networks and data center operations. The team should include the directors from the various imaging departments, both those with established PACS, and those without PACS. System administrators (PACS, EMR, HIS, RIS) need to be included. Program directors and senior project managers whose responsibilities are connected in any way to the organization’s medical imaging operations should be included.
 
Of course, this will quickly become a lengthy list, so most of the actual work will undoubtedly be assigned to working groups, but the entire team must be kept apprised of the details and recommendations. It is highly advisable to encourage physician participation in the high-level meetings. Radiologists, cardiologists and any physicians who will actually be using the technology to interpret images should have representation on the team, as their day-to-day work experiences will be directly affected by the department-level aspect of the enterprise imaging strategy. It would also be advisable to include input from the physicians who will be using the EMR to access imaging studies.
 
At the very least, the physicians should be interviewed to gain their perspective and their support of the eventual strategic plan. The planning process is fairly straightforward. The high-level meetings are essentially whiteboard and slide deck sessions. The first of these educational sessions should be designed to educate everyone on the current state of medical imaging across the health care system:
 
• Identify and describe all of the imaging and information systems, their components, and their interdependencies.
• Identify and describe all of the known “burning bushes” including performance issues, impending system upgrades, end-of-life notices, expansion plans, physician complaints/dissatisfaction, etc.
• The physician input. The smaller, more nimble, working groups should focus on investigating current technology options across the broad spectrum of solutions that have anything to do with imaging and data management systems. There are three approaches to this task: Internet research; sitting through vendor presentations; and outside expertise.
 
A working group will also have to collect enough specifics about the organization’s current imaging operations to enable a few selected vendors to create a budgetary quote. A key component of the enterprise imaging strategic plan is the deployment schedule, and it would be nearly impossible to design a deployment strategy without knowing the total cost of ownership of the various components of the enterprise system. The last few educational sessions should be focused on achieving consensus on the strategic plan by presenting the following for discussion:
 
• The technology options.
• The budgetary (cost) considerations.
• IT resource requirements and availability.
• Recommendations. The final high-level meeting, the one in which the final strategic plan is decided upon, should be attended by key physician representatives, as no strategic plan can be successful without their buy-in.
 
The following is a summary of the subjects, issues, and areas that need to be carefully considered in the process of developing the enterprise imaging strategic plan. My list is not the suggested order of importance, as that is the subject of the discussion sessions.
 
• Current and future state of the existing department PACS. What are the upgrade and replacement schedules?
• How to provide PACS functionality to imaging departments currently without a PACS (i.e. endoscopy). Will these departments share an existing PACS (i.e. radiology), or utilize the functions of a VNA combined with a standalone viewer?
• Image-enabling the EMR with both DICOM and non-DICOM images. Will this involve multiple PACS-based viewers or a single universal viewer? Does the organization appreciate the subtle variances in the underlying viewer technologies? When and how does the organization expect this viewer to handle non-DICOM imaging studies?
• What is the organization’s position on the vendor-neutral archive? If the benefits are appreciated, what is the deployment schedule to achieve the dual-sited mirrored configuration and complete the various data migrations? What image data will not be migrated and what is the rationale for this decision?
• What is the organization’s strategy for replacing a PACS: replacement with a “like” turnkey system, or replacement with a carefully matched set of best-of-breed components including VNA, diagnostic display and workflow?
• What is the organization’s position on workflow/worklists? Can a single workflow/ worklist application support the nuances of each imaging department, and thus reduce cost and simplify support?
• Which of the above-mentioned components (diagnostic display, universal viewer, workflow and VNA) must be standalone versus integrated with another major component? What are the interdependencies and implications?
• What is the organization’s preferred infrastructure and architecture of the envisioned enterprise imaging solution?
• What are the IT preferences for hardware and software: servers, storage, virtual environment, operation systems, database management solutions, security and system monitoring?
• Has the organization considered whether it is capable of managing the envisioned enterprise imaging solution, especially if the solution turns out to comprise multiple components from disparate vendors? Have the necessary self-management tools and required staffing resources been identified? Once the envisioned enterprise imaging solution has been described in some detail and the consensus on that design achieved, the remaining step is determining the deployment schedule — the logical and often necessary order in which the various components are purchased and installed. Contributors to the deployment schedule include:
• The cost of each component, associated project management and support.
• Upgrade schedule/issues associated with existing components.
• “Burning bush” issues.
• Non-DICOM imaging study requirements/timing.
• PACS functionality for emerging imaging departments.
• Image-enabling the EMR, including access from mobile devices. Developing an enterprise imaging strategy/ solution is a substantial undertaking. The eventual solution will cross every department, impact every physician and certainly affect patient care. The strategic planning process itself requires a high degree of detail and the commitment of what will likely be the largest assembly of talent that the organization can muster. Now is the time to start the planning process, as no single imaging decision should be made outside of the enterprise plan.
 
Michael J. Gray is a consultant specializing in the digital management and distribution of medical image data, and the founder of Gray Consulting. Gray’s areas of expertise are market analysis, technology analysis, strategic planning, equipment utilization, needs assessment, workflow analysis and vendor analysis/selection.