lessons learned during stanford children’s outside image
TRANSCRIPT
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Lessons Learned During Stanford Children’s Outside Image Management Journey
Session 288, March 9, 2018
Safwan S. Halabi, M.D., Medical Director of Radiology Informatics,
Stanford Children’s Health
Lisa Grisim RN, MSN, VP & Associate CIO
Stanford Children’s Health
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Safwan S. Halabi, M.D.Medical Director of Radiology Informatics, Stanford Children’s Health
Lisa Grisim RN, MSNVP & Associate CIO, Stanford Children’s Health
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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Agenda
• Speaker Introduction
• Challenges Across the Network
• Clinical & IT Perspectives
• Movement to the Cloud
• Key Outcomes
• Lessons Learned
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Learning Objectives
• Identify IT governance, personnel, and technical requirements needed to successfully implement an outside image management (OIM) policy
• Discuss how outside image management (OIM) solutions are essential for tertiary academic centers of excellence in delivering quality care
• Analyze the cost savings and care benefits to the health institutions and to patients by utilizing an outside image management (OIM) system
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Speaker Introduction
Dr. Safwan S. HalabiMedical Director Radiology Informatics,
Stanford Children's Health
• Dr. Safwan S. Halabi is a board certified radiologist with
additional fellowship training and certification in Pediatric
Radiology and Clinical Informatics.
• Dr. Halabi currently practices Pediatric Radiology and
Maternal/Fetal imaging at Lucile Packard Children's Hospital at
Stanford.
• He is the Medical Director of Radiology Informatics for Stanford
Children’s Health.
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• Lisa Grisim has been at Stanford University Medical Center in various positions
for over 30 years.
• Her most recent EMR implementation resulted in Stanford Children's Health
(SCH) & Lucile Packard Children’s Hospital Stanford attaining the prestigious
HIMSS Analytics Stage 7 of the EMR Adoption Model (EMRAM).
• She held positions as Project Manager for the implementation of Stanford adult
hospital's first EMR followed by being the Project Director for Lucile Packard
Children's Hospital Stanford’s first EMR implementation.
Speaker Introduction
Lisa Grisim RN, MSN VP & Associate CIO,
Stanford Children’s Health
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Stanford Children’s Health
• Exclusively dedicated to pediatric and obstetric care.
• Provides high levels of expertise across
San Francisco Bay Area and to other local hospital
locations worldwide.
• Stanford Children’s is expanding their network to
bring care to the patient closer to home.
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Challenges Across the Network
• COORDINATION among various care
providers and subspecialties including a
current outside study ingestion volume of
over 1,000 studies per month.
• DOSE MANAGEMENT in pediatric population.
• NETWORK GROWTH - sending imaging
studies generated at the hospital back out
to referring facilities at an expected volume
of about 6,000 per year.
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Imaging & Pediatric Populations
• Pediatric patients are more radiosensitive than adults (i.e., the cancer
risk per unit dose of ionizing radiation is higher).
• Pediatric patients have a longer expected lifetime, putting them at
higher risk of cancer from the effects of radiation exposure.
• Avoiding duplicate imaging in transfer or trauma patients can
eliminate risks.
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Avoiding Duplicate Imaging
OR TRAUMA TRANSFER
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Legacy Outside Image Management Strategy
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CD delivered to SCH
CD Imported
(Film, Reports, etc.)
Patient Lookup to EMR
Order Created in EMR
Demographic Data from
EMR Injected to
Outside DICOM Images
Data Imported to
Local Enterprise
Data Available within
Local Enterprise SystemsData Viewed in EMR
Data Diagnostically
Reviewed in PACS System
Disc Returned to Patient
Results/Images Available
to Referring Provider
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Clinical & IT Perspectives
IT
• Workflow and data architecture
challenges with manual matching
of patient data from CD to RIS.
• Extra PACS storage costs as
imaging had to be ingested from
external sources for viewing within
the hospital
Clinical
• Unnecessary delays with
delivery of care when the patient
would sometimes arrive for a
specialty consult ahead of when
their prior imaging could be
accessed.
• Quality and dose management
concerns when prior imaging CDs
could not be located or had errors
and imaging had to be repeated.
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Workflow Goal
RIS
EMR
VNA
Clinical
(DICOM)Radiology *ology
Clinical
(Non-DICOM)
Enterprise
Image Viewer
Cardiology
MetaData
Image DataImage RoutingOutside
Images
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Solution Selection Process
Clinical Requirements
• Electronically receive, ingest, and view diagnostic imaging in
less than 5 minutes from CD inserted to first image available
in EMR viewer
• Access to all connected SCH campuses via EMR
• Simple means to upload CDs when needed
• View imaging on hardware and viewing configurations
• Perform side-by-side comparisons
• Easily send exams and results to referring providers
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Technical Requirements
• Cloud architecture
• DICOM conformance statement
• Non-DICOM and non-image data capabilities
• Secure
• EMR integration capabilities
• Workstation requirements & built in viewer
Solution Selection Process
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Outside Image Management (OIM) Implementation
RFI Process Vendor Selected
Fall 2014 YE 2014 !Q 2015 2Q 2015 !H 2016 2H 2016 1H 2017 2H 2017
Image Exchange Inventory COMPLETED:
o John Muir Health
o Renown
o El Camino Hospital
POTENTIAL FUTURE PROJECTS (FY18):
o Sutter (PAMF & CPMC)
o Kaiser
o Sequoia Hospital
Multiple Sites Live
w/OIM
CD Ingestion Inventory COMPLETED:
o Specialty Services Los Gatos
o 730 Welch (incl. Ortho)
o OB/PDC @ El Camino Hospital
POTENTIAL FUTURE PROJECTS (FY18):
o Emeryville (+Ortho)
o Walnut Creek (+Ortho)
o Specialty Services @ CPMC (+Ortho)
o Stanford Transfer Center
o 770 Welch
o Sunnyvale
John Muir live
730 Welch (incl. Ortho) live
Project Kick-off Live Pilot Project Restart Image Exchange Live CD Ingestion Live
Major
Turnover on
Internal
Project
Team
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Stanford Children’s Health Diagnostic Outside Image Management Technical Schematic and Workflow Diagram
SCH
OIM Cloud(Temporary study retention site)
Source-site specific folders
Nominate-to-PACS request process.
NOTE: Studies purge after 30 days
Lucile Packard
Children’s
Hospital
Stanford
Faculty
Practice
Organization
(FPO) clinics
Packard
Children’s
Health Alliance
(PCHA) clinics
Stanford ED/
Transfer
Center
El Camino
Hospital
Sequoia
Hospital
AFILLIATED ENTITIES
John Muir
(Sectra
IEP)
Sutter
CPMC/PAMFRenown
JOINT VENTURES
Dayton
Children’
s
OTHER SOURCES
SHC Image
Store
SCH
SCH Radiology
Departments
LPCH Image Library (Radiology Department,
gatekeeper for PACS)
SCH & SCH PACS(permanent non-echo
diagnostic study storage site)
CD Ingestion
-upload study to Cloud
-submit Order in SCH EMR
OR request via Cloud
vendor
VPN tunnel
(custom)
Renown
OIM
Solution
Dayton
OIM
Solution
PACS
(echocardiograms)
Radiology (PDC
ultrasounds)
SCH Ultrasound
Modalities
(multiple
specialties)
SCH Cardiology
Secure
Transfer
Solution
echocardiograms
DICOM upload
Cath
images
SHC Digital Solutions Group SCH user
downloads study to PC > SHC user
normalizes, uploads to SHC Image Store, and
further uploads to SHC Cath Lab PACS
DICOM upload - PDC
DICOM
upload
(non-
PDC)
Studies pushed
manually
to OIM Cloud
VendorStudies promoted to PACS
VPN to
PACSGEA
R
SCH provider
access to patient
chart DICOM
Interface
Submit Digitize
Request (as
needed)
View studies In
PACS Linked to
MRN
DICOM upload
Upload
Study
EMR Order request
to digitize study
Link approved studies
to MRN (silent schedule
and create Order as
needed)
View studies in
PACS linked to
MRN
DICOM
interface
?
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Project Challenges
STAFFINGDEPLOYMENT
& TRAININGSECURITY
AGREEMENTS
& POLICIES
Retrained staff with
help of vendor.
Alignment workshop,
“train the trainer” to get up
and running fast.
Some institutions’ policies
still dictated that images
be shared only via
CD/DVD vs. uploading to
the cloud.
Legacy arrangements
around OIM had to be
turned off in favor of the
new cloud suite.
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Staffing
• Staffing proved to be a challenge
– Encountered mid-way when implementing outside image
management (OIM) at Stanford Children’s
– Several key IT resources left the organization, along with the
deep system knowledge that had been built up.
– Meant a re-start on project goals and knowledge transfer.
• Close partnership with the vendor was key
– Vendor assisted to re-train the new project team assigned,
facilitated knowledge transfer.
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Deployment & Training
• Training had to be factored into the mix
– Particularly when expanding the use of cloud OIM to providers
outside of radiology, other imaging specialties
• Leadership had to staff the team
– Time commitment needed to allow them to focus on expanding
the network for outside image management
• Technical skills required at a referring site
– When Stanford wanted to have a cloud PACS gateway
established to automate sending of high image volume
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Security
• Education around cloud security
– Needed to take place across healthcare providers
– Some institutions’ policies still dictated that images be shared only
via CD/DVD vs. uploading to the cloud
• Special solution configuration needed
– To meet specific security requirements of different roles across network
• All data transferred over secure sockets layer (SSL) encryption
– TLS v1 256-bit, industry-leading standard for high quality encryption
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Agreements & Policies
• Agreements and policies with existing partner organizations
– Variety of barriers had to be overcome related to BAAs
– Legacy arrangements around OIM had to be turned off in
favor of the new cloud suite
• Newly created partnerships
– Standard OIM solution offering had to be crafted
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Key Outcomes
• With browser-based CD uploading,
staff upload studies in 1-5 mins (max)
• Study becomes available for network
wide viewing immediately. Previously,
could take from days to hours as
referring physicians mailed in CDs.
STUDY UPLOAD TIME
IMPROVED 3-5X
• SCH able to send studies to
outside organizations through
secure link or some auto-routed
• Using Ambra Health, SCH has
shared over 16,000 studies with
outside sites to date
SEAMLESS IMAGE
EXCHANGE/SHARING
Imaging is available through
the entire network, including
on mobile devices and any
computer with a browser.
NETWORK WIDE
VIEWING
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1. Reduction in duplicate imaging
2. Able to share a copy of imaging with
patients electronically
3. Improved time-to-care delivery
Improved Patient Care
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Lessons Learned
Must have strong collaboration and buy-
in across the institution– especially at
leadership levels– and all subspecialty
departments utilizing imaging.
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Lessons Learned
Factor in interoperability requirements across
systems, particularly EHR, right from the start
in selecting a system and vendor for outside
image management (OIM).
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Lessons Learned
Don’t underestimate the work effort around
agreements and policies with external
facilities.
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Future Goals– EHR Image Enablement
• Desired outcome: single sign-on
– Between EMR and cloud vendor with
all patient information mapped to a study.
– Required thinking through order integration and
patient matching criteria in order to automate study
upload workflow.
• Had to address if image-enabling the EHR means extending
imaging access to patients via EMR patient portal (MyChart).
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Future Goals– Made Possible with Cloud Image Management Platform
DEEP LEARNING,
AI INITIATIVES
CLINICAL TRIAL
COLLABORATIONIMAGE ENABLED
PATIENT PORTAL
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Questions?
Dr. Safwan S. HalabiMedical Director Radiology Informatics,
Stanford Children's Health
Lisa Grisim RN, MSNVP & Associate CIO,
Stanford Children’s Health
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