IHE Implementation HurdlesIHE Implementation Hurdles

Paul Nagy, PhDPaul Nagy, PhD

pnagy@umm.edupnagy@umm.edu

University of MarylandUniversity of Maryland

Maryland Institute for Medical Imaging Maryland Institute for Medical Imaging Informatics (MIMII)Informatics (MIMII)

Learning ObjectivesLearning Objectives

1.1. What other industries call IHE.What other industries call IHE.

2.2. Understanding the role of diffusion of Understanding the role of diffusion of innovationinnovation

3.3. Top five obstacles when implementing Top five obstacles when implementing IHEIHE

4.4. Getting over the humpGetting over the hump

What does your technology What does your technology strategy look like?strategy look like?

Each department solving its own internal Each department solving its own internal problems.problems.

To get data from the department you need To get data from the department you need to go down to it.to go down to it.

IT RevolutionIT Revolution

Allows the role to be turned inside out and Allows the role to be turned inside out and to be patient driven.to be patient driven.

Makes the process more transparent to Makes the process more transparent to identify delays in care and errors.identify delays in care and errors.

Integration for HealthcareIntegration for Healthcare

MPICPOE(EMR)

Physician Portal

Data Level

Business Layer

Presentation Layer

Meta DataKey Images, Annotations

Single Signon, Results reporting

Images(PACS)

Results(RIS)

What other industries call it.What other industries call it.

EAI (Enterprise Application Integration)EAI (Enterprise Application Integration)SOA (Service Oriented Architecture)SOA (Service Oriented Architecture)ESB (Enterprise Service Bus)ESB (Enterprise Service Bus)BPM (Business Process Management)BPM (Business Process Management)EDI (Electronic Data Interchange)EDI (Electronic Data Interchange)A Rose by any other nameA Rose by any other name– $6.3 Billion dollar market 2005 (Aberdeen)$6.3 Billion dollar market 2005 (Aberdeen)

http://www.eaiindustry.org/docs/member%20docs/Fallhttp://www.eaiindustry.org/docs/member%20docs/Fall%202003%20Enterprise%20Integration%20Software%20Piece%202003%20Enterprise%20Integration%20Software%20Piece%20-%20BCF.pdf%20-%20BCF.pdf

EAI EnablesEAI Enables

Supply chain managementSupply chain management

Just in time inventoryJust in time inventory

B2B Business to businessB2B Business to business

CRM Customer relations managementCRM Customer relations management

The internet economyThe internet economy

Nobody does it all anywhere.Nobody does it all anywhere.

Goal is the sameGoal is the same

Loosely coupled systems where the end Loosely coupled systems where the end user doesn’t know where they are being user doesn’t know where they are being run.run.

Make process transparent to end users Make process transparent to end users (customers)(customers)– Fedex package trackingFedex package tracking

In medicine we call it IHEIn medicine we call it IHE

Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise

Gartner GroupGartner Group

Predicted that by 2005, 90% of basic Predicted that by 2005, 90% of basic functionality between PACS vendors functionality between PACS vendors would be converged would be converged (window/level/pan/zoom).(window/level/pan/zoom).

The major differentiator between vendors The major differentiator between vendors would be in their ability to integrate with would be in their ability to integrate with other vendors.other vendors.

Diffusion of innovationDiffusion of innovation

Innovator phaseInnovator phase

Early adopter phaseEarly adopter phase

We are in year 6We are in year 6

How many years did it take for DICOM to How many years did it take for DICOM to reach path dependence?reach path dependence?– ACR NEMA 1 & 2ACR NEMA 1 & 2– DICOM 3.0 is Version (3) of the ACR standardDICOM 3.0 is Version (3) of the ACR standard

Diffusion of innovation modelDiffusion of innovation model1943 model of Iowa farmers adoption of hybrid seeds1943 model of Iowa farmers adoption of hybrid seeds

Five personality and socioeconomic categoriesFive personality and socioeconomic categories

Time

Innovators

Early Adopters

Early Majority Late

Majority

Traditionalists

B. Reiner, E. Siegel “Psychological factors affecting the adoption of PACS” Applied Radiology Volume: 31 Number: 4 April 2002

Technology Lifetime Technology Lifetime

Standards (DICOM, HL7, IHE, SNIA…) 25- 50 years

Infrastructure (IP, SAN,…) 10- 20 years

Programming Languages (PL/1, Pascal, C, C++, Java, …) 5-10 years

Software (data formats, compatibility, …)2-5 years

Hardware (Network cards, video cards, processors, …) 1-2 years

Shapiro, IBM

Obstacles you will need to hurdleObstacles you will need to hurdle

#1. Modality Integration Study#1. Modality Integration Study

101 Modalities101 Modalities

C-Store 100%C-Store 100%

Modality worklist was above 90%, Modality worklist was above 90%,

MPPS and storage commitment 30%MPPS and storage commitment 30%

The simultaneous support of all of Q/R The simultaneous support of all of Q/R SCU/SCP, MPPS, print SCU, verification SCU/SCP, MPPS, print SCU, verification SCU/SCP, Worklist SCU, and Storage SCU/SCP, Worklist SCU, and Storage commitment on 3 modalitiescommitment on 3 modalities

A Gavain, SCAR 2004, To be published (University of Montreal)

#2. Asking for “none of the above” #2. Asking for “none of the above” from the vendorsfrom the vendors

A. Proprietary vendor integrationB. Vendor provided APIC. Customized DICOM InterfacingD. Custom HL7 InterfacingE. None of the above

Write in: IHE Integration

X

#3. Swing of single source#3. Swing of single source

One vendor can not solve all your One vendor can not solve all your problems. Sooner or later you will need to problems. Sooner or later you will need to integrate.integrate.IHE enables Best of BreedIHE enables Best of BreedForces continued competitive pricing Forces continued competitive pricing innovation from your vendor down the innovation from your vendor down the road.road.What incentive does a single source What incentive does a single source vendor really have to listen to you? vendor really have to listen to you?

Lifecycle of RIS is longer than the Lifecycle of RIS is longer than the PACSPACS

RIS has a 10 year life spanRIS has a 10 year life span

PACS has 5 year life spanPACS has 5 year life span

Unidirectional RIS interfacesUnidirectional RIS interfaces

#4. Price per interface#4. Price per interface

How many interfaces is scheduled How many interfaces is scheduled workflow(Only the first integration profile)? workflow(Only the first integration profile)? – Dicom C-StoreDicom C-Store– Dicom Storage CommitmentDicom Storage Commitment– Dicom Modality WorklistDicom Modality Worklist– Dicom Modality Performed Procedure Step (In Dicom Modality Performed Procedure Step (In

Progress)Progress)– Dicom Modality Performed Procedure Step Dicom Modality Performed Procedure Step

(Completed)(Completed)

If you pay 20k per interface. Do you have to pay If you pay 20k per interface. Do you have to pay 100k per modality to get IHE?100k per modality to get IHE?

The cost of interfacesThe cost of interfaces

The cost of interfaces to the vendor is for the The cost of interfaces to the vendor is for the very reason that DICOM or HL7 were not plug very reason that DICOM or HL7 were not plug and play.and play.They took a lot of integration testingThey took a lot of integration testingOn-site service engineeringOn-site service engineeringThe whole point of IHE is to bring down that The whole point of IHE is to bring down that complexity integration by having the complexity integration by having the connectathon.connectathon. Vendors need to change their pricing models to Vendors need to change their pricing models to reflect the real work it takes to integrate now.reflect the real work it takes to integrate now.

#5. 1#5. 1stst step is the hardest step is the hardest

Scheduled workflow if the biggest stepScheduled workflow if the biggest step

Involves (RIS, PACS, & Modalities)Involves (RIS, PACS, & Modalities)

#6. Educated users#6. Educated users

I’ve got DICOM, why do I need IHEI’ve got DICOM, why do I need IHE

DICOM 3.0 is 11 years old. Become very DICOM 3.0 is 11 years old. Become very flexible. Not plug and play.flexible. Not plug and play.

Too technocratic, hard to directly address Too technocratic, hard to directly address business needs of an organization. It’s the business needs of an organization. It’s the building blocks.building blocks.

IHE is how you need to use those blocksIHE is how you need to use those blocks

#7. Planning goes against the #7. Planning goes against the medical ideologymedical ideology

Organic evolution and responding to Organic evolution and responding to clinical drivers instead of systematic clinical drivers instead of systematic approach towards a technology vision.approach towards a technology vision.

“People don’t plan to fail, they fail to plan”

#8. Technical Leadership#8. Technical Leadership

CTO is focused on the use of technology in CTO is focused on the use of technology in products developed by the company and products developed by the company and technology delivered to external customers. technology delivered to external customers. CTOs are typically more technical than CIOs. CTOs are typically more technical than CIOs.

A CIO is more concerned with keeping systems A CIO is more concerned with keeping systems running day-to-day and uptime. CIOs are running day-to-day and uptime. CIOs are typically more managerial than CTOs. typically more managerial than CTOs.

http://www.monster-isp.com/glossary/CTO.htmlhttp://www.monster-isp.com/glossary/CTO.html

Defining the complementary job Defining the complementary job roles of the CTO and CIOroles of the CTO and CIO

As the right hand of the CIO, the CTO is As the right hand of the CIO, the CTO is responsible for designing and recommending the responsible for designing and recommending the appropriate technology solutions to support the appropriate technology solutions to support the policies and directives issued by the CIO. In so policies and directives issued by the CIO. In so doing, the CIO is able to marry the doing, the CIO is able to marry the recommended technologies to the strategic recommended technologies to the strategic business objectives of the company. This business objectives of the company. This approach establishes the CTO as the technology approach establishes the CTO as the technology specialist. specialist. http://techrepublic.com.com/5100-6299-http://techrepublic.com.com/5100-6299-5030390.html5030390.html

Getting over the humpGetting over the hump

IHE is a marriage between business IHE is a marriage between business objectives and technical architectural objectives and technical architectural policies.policies.

IHE needs to be in the contractIHE needs to be in the contract

Shall languageShall language

Continued cost of licenses for growthContinued cost of licenses for growth

Penalties associated with non Penalties associated with non conformanceconformance

Learning CurveLearning Curve

Learn how to use the MESA/CTN toolkit Learn how to use the MESA/CTN toolkit developed by the Mallinkrodt Electronics developed by the Mallinkrodt Electronics Radiology Laboratory. Freely Radiology Laboratory. Freely downloaded.downloaded.

This tool is what the vendors use at the This tool is what the vendors use at the connectathon for validation.connectathon for validation.

Do you want to be an early Do you want to be an early adopter?adopter?

Subsidize the development cost of IHE Subsidize the development cost of IHE with the vendors.with the vendors.

A. You pay for it one way or anotherA. You pay for it one way or another– Vendors have already done it Vendors have already done it – 5 years from now you will be kicking yourself5 years from now you will be kicking yourself– Migration costsMigration costs– Not achieve the workflow benefits of PACS Not achieve the workflow benefits of PACS

that everyone assumes will magically happen.that everyone assumes will magically happen.

ConclusionsConclusions

Is IHE Ready for Prime time?Is IHE Ready for Prime time?– Yes, but some assembly is requiredYes, but some assembly is required

IHE is a critical indicator of when PACS IHE is a critical indicator of when PACS hits the majority phase of technology hits the majority phase of technology maturity and cost effectiveness.maturity and cost effectiveness.Break the catch 22Break the catch 22Vendors don’t offer it because customers Vendors don’t offer it because customers don’t ask for it. Customers don’t ask for it don’t ask for it. Customers don’t ask for it because vendors don’t offer it.because vendors don’t offer it.

IHE is just entering the early adoption IHE is just entering the early adoption phase of technology diffusion and there is phase of technology diffusion and there is still some assembly required.still some assembly required.

Most hospitals do not have the strategic Most hospitals do not have the strategic vision to appreciate the benefits of IHEvision to appreciate the benefits of IHE– Next to zero CTO’s in healthcareNext to zero CTO’s in healthcare

Many vendors are taking a wait and see Many vendors are taking a wait and see attitudeattitude