Overcoming IHE Implementation Overcoming IHE Implementation HurdlesHurdles

Paul Nagy, PhDPaul Nagy, PhD

Director, Quality and Informatics ResearchDirector, Quality and Informatics Research

Department of RadiologyDepartment of Radiology

University of Maryland School of MedicineUniversity of Maryland School of Medicine

OutlineOutline

1. What other industries call IHE

2. IOM and the redesign of healthcare

3. Obstacles when implementing IHE

4. Steps to implementing IHE

5. Building a strategic vision

What is your technology strategy?What is your technology strategy?

Each department solving its own internal problems.

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

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

EAI (Enterprise Application Integration)

SOA (Service Oriented Architecture)

ESB (Enterprise Service Bus)

BPM (Business Process Management)

EDI (Electronic Data Interchange)

A Rose by any other name $6.3 Billion dollar market 2005 (Aberdeen)

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

EAI EnablesEAI Enables

Supply chain management

Just in time inventory

B2B Business to business

CRM Customer relations management

The internet economy

Nobody does it all anywhere.

Goal is the sameGoal is the same

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

Make processes transparent to end users (customers) Fedex package tracking Buying goods through Amazon

In medicine we call it IHEIn medicine we call it IHE

Integrating the Healthcare Enterprise

A standard way to use the standards

IOM Model of ServiceIOM Model of Service

Safety

Effectiveness

Patient centeredness

Timeliness

Efficiency

Equity

Source: Institute of Medicine, Crossing the Chasm

Align to the patient

Rules of system redesign by IOMRules of system redesign by IOM

4. Share knowledge and let information flow freely

6. Safety is a system property not a function of vigilance

7. Become transparent

10 Foster cooperation among clinicians

Berwick D. Escape Fire. Jossey-Bass, San Francisco 2004

Obstacles you will need to hurdleObstacles you will need to hurdle

Top ten excuses for not doing IHE from hospitals

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

101 Modalities

C-Store 100%

Modality worklist was above 90%,

MPPS and Storage Commitment 30%

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

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

#2. Asking for “none of the above”#2. Asking for “none of the above”

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

Write in: IHE Integration

X

#3. Internalizing IHE#3. Internalizing IHE

IHE describes the interface only

You can comply with IHE and do little or nothing with the messages.

(MPPS completed message on a RIS)

Internalizing the message is the real value to the end user.

When a vendor says they conform to IHE they at the very least set the expectation with the end user about internalization

#4 Lifecycle of RIS > PACS#4 Lifecycle of RIS > PACS

RIS has a 10 year life span

Legacy systems

PACS has 5 year life span

Higher churn rate as computer industry moves forward.

Unidirectional RIS interfaces

#5. Price per interface#5. Price per interfaceHow many interfaces is scheduled workflow(Only the first integration profile)? Dicom C-Store Dicom Storage Commitment Dicom Modality Worklist Dicom Modality Performed Procedure Step (In Progress) Dicom Modality Performed Procedure Step (Completed)

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

The cost of interfaces to the vendor is for the very reason that DICOM or HL7 were not plug and play.

The whole point of IHE is to bring down that complexity integration by having the connectathon.

#6. 1#6. 1stst step is the hardest step is the hardest

Scheduled workflow and Patient Information Reconciliation are the biggest steps

Involves (RIS, PACS, & Modalities)

Involves the most number of transactions

#7. Goes against medical ideology#7. Goes against medical ideology

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

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

Technical LeadershipTechnical Leadership

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

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

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

#8. Educated users#8. Educated users

I’ve got DICOM, why do I need IHE

DICOM 3.0 is 14 years old. Become very flexible. Not plug and play.

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

IHE is how you need to use those blocks

DICOM gets you lost in the trees

DICOM is point to point IHE is about workflow

#9 IHE isn’t always enough#9 IHE isn’t always enough

PSA – Patient Synchronized Applications

Keeps app synched to patient

But doesn’t synch to Study ID

A RIS can’t drive the PACS without adding extra functionality.

IHE is still evolvingIHE is still evolving

New profiles are coming out each year.

IHE is now 9 years old

The first profiles are just as valid now as they were 9 years ago.

#10 Don’t want to be early adopter#10 Don’t want to be early adopter

Subsidize the development cost of IHE with the vendors.

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

everyone assumes will magically happen.

Getting over the humpGetting over the humpIHE is a marriage between business

objectives and technical architectural policies.

Making all the domains of healthcare transparent to the patient and the bedside.

Steps to getting IHESteps to getting IHE

Read IHE profiles, see which profiles mean the most to your organization

Create a 5 year vision document for your department

Put the IHE into your RFP’s for new equipment and information systems

Gain some first hand knowledge of integration testing with DVTK SIIM 2008 Learning Labs

Strategy - Wikipedia “a long term plan of action designed to achieve a

particular goal, most often "winning". Strategy is differentiated from tactics or immediate actions”

In 5 years where will you beIn 5 years where will you be

Will you be able to integrate with other clinical systems?

Will you be forced down a dead end and need to start over?

Will you have archaic computers running your system?

Will you have to buy your data back from the vendor?

Best of Breed StrategyBest of Breed Strategy

Healthcare IT is a turbulent industry.

Best of breed strategy.

Remain flexible to changes in companies, products, and technology.

Competition is the best guarantee to cost protection

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

ConclusionsConclusions

IHE is now a reality. Yes, but some assembly is required

Need more CTO’s (leadership) in healthcare