Mrs. Robinson…Coo Coo ca choo

Ms. PACS:

Guys love to watch coming of age movies because they are usually about how a boy becomes a man - just watch The Graduate for the 10th time to get my drift. As an adult, you reminisce about the golden days of your youth, but at the time they were really days of confusion.

Well, here’s another coming of age story – starring PACS. This is not about its adolescence but undoubtedly it is facing another stage of maturity - something the PACSman, at times, must come to grips with as well. PACS is well beyond the age of imaging silos that separated radiology and cardiology, has become an integral part of the oncology experience, continues to cross all of the ‘ologies,’ and more recently has absorbed pathology. But before medical imaging can conquer the healthcare enterprise in its entirety, PACS will be restructured as a data management solution that feeds into an image-enabled electronic medical record (EMR).

At the HIMSS 2009 annual conference, a few industry leaders spearheaded this movement toward the image-enabled EMR. Both GE and Agfa rolled out centralized image management archives for all images - DICOM and non-DICOM - as enterprise imaging solutions. These archives are standards-based and help manage patient and image data. In the words of GE’s marketing speak: “The end result is a multi-departmental imaging repository that enables an enterprise to create a longitudinal, single patient jacket for users across a region that includes multiple hospitals and imaging centers.”

The EMRs are designed to consolidate patient data from existing multivendor PACS into the EMR system. GE calls its solution “Centricity Enterprise Archive” and Agfa bequeathed the name “Enterprise Visualization” on theirs. Agfa’s is powered by both IMPAX Data Center and IMPAX Mobility, which take independent PACS and clinical data into a comprehensive enterprise solution. Plus, both the GE and Agfa systems have a single enterprise viewer. According to Agfa, this is “the foundation for the true multi-media Electronic Health Record (EHR).”

Obviously, the viewer in the EMR is not diagnostic quality, or at least not yet, so PACS will remain the specialty platform for radiology. But what does change is the workflow. In this scenario, radiology PACS will not be the train conductor but just another driver of medical images, that feeds the EMR.

I know change is hard, but these are no more than adolescent growing pains because what an image-enabled EMR can do for radiology is enhance referrals and the overall value of radiology. Now, or at least in theory, clinicians will be able to use a viewer to see the imaging exams not just as part of the final report but also at the point-of-care. The value of radiology services will augment, confirming the relevance of imaging exams as an essential element in today’s complete medical record. This will take radiology where PACS up to now has not. So, if EMR is the older mistress, then its time for PACS and EMR to jump in the sack.


PACSman:

And here’s to you, Mrs. Robinson,
Jesus loves you more than you will know.
God bless you, please Mrs. Robinson.
Heaven holds a place for those who pray,
Hey, hey, hey….

Ms. PACS likes to think that men love the fantasy of an older woman seducing a 15 year old boy, but let me tell you, I have both a 15 year old (16 this week) and 17.5 year old sons here and if Mrs. Robinson tried to seduce them they would both say “Eww. That is just so gross. She is so OLD!” Now, know that I wouldn’t have kicked Anne Bancroft out of bed for eating crackers, but when The Graduate came out in 1967 I was a mere baby of 12 and still an altar boy. Kids still think that engaging in “the act” ends at age 25 or when you have kids, whichever comes first.

Now kids do impact both the quantity and quality of coo coo ca choo moments for sure…but much to their chagrin those moments still do happen, as gross as that may seem.

We’d like to know a little bit about you for our files
We’d like to help you learn to help yourself.
Look around you all you see are sympathetic eyes,
Stroll around the grounds until you feel at home.

PACS came of age years ago, so I’m not quite sure where Ms. P is coming from. It sounds more like an evolution than a revolution to me though. PACS hasn’t aged or grown or absorbed anyone or anything. It’s gone well beyond Mrs. Robinson and evolved into Jerry McGuire - show me the money and the money is in EHR these days, not PACS. With an average $5.7M Medicare stimulus package dangling over the typical 250 bed hospital’s head to implement an EHR, who in their right mind is going to buy a standalone PACS? PACS somehow needs to be carefully gift-wrapped into the new EHR. Tie in a common archive, add an “ology” or 3 for good measure and…viola - instant EHR.

Data from the HIMSS Analytics Database, which tracks IT adoption milestones from 5,166 non-governmental U.S. hospitals, reveal that 67% of these hospitals need to add only one or two healthcare IT applications to be compliant. The applications include computerized physician order entry, clinical documentation, clinical decision support, and/or major auxiliary department information systems. Stage 7 (a paperless system and the ability to share interoperable patient data and analyze clinical data for performance, improvements and clinical decision support) is the ultimate goal yet only 2 hospital groups in the country are stage 7’s -12 Kaiser hospitals in CA and three NorthShore University Health system, based in Evanston, IL and none were there until the middle of 2008 so we have a very long way to go. Still, that’s where the money is long term so….

According to yet another HIMSS Analytics report published in December 2008, based on an eight-stage EMR implementation process:
- 31.2% of hospitals are at Stage 2 and have implemented a clinical data repository that contains and facilitates physician review of orders, lab results, radiology images and reports, and prescription drug information.
- 35.7% are at Stage 3 and have also implemented nursing documentation capabilities in at least one unit of the hospital and have clinical decision-support systems to support nursing procedures.
- 6% have advanced EMR capabilities such as computerized practitioner order entry, physician documentation, data warehousing and mining capabilities, and full radiology PACS.

Sitting on a sofa on a Sunday afternoon.
Going to the candidate’s debate.
Laugh about it, shout about it
When you’ve got to choose
Every way you look at it you lose.

So with everyone buying EHR’s will anyone be happy buying “just” PACS. Well, look on the bright side- “full radiology PACS” is considered an advanced EMR capability so…I sure hope so. It is fascinating that of the big six PACS vendors only McKesson (at 14,.4%) and Siemens (9.5%) are listed in the top five of EHR vendors with Meditech #1 at 26.6%; GE and Agfa didn’t even make the top 10.

PACS needs to be in the drivers seat when it comes to radiology operations for sure, but will it take precedence over IT’s other choices? That is the $50,000.00 question.

A 4/8/09 article in Healthcare IT news reported the following:
“The hard part is doing something with it,” said Dave Garets, the session’s moderator and president and chief executive officer of HIMSS Analytics. “At a Stage 7, you have everything, what are you going to do with it?”…..

The interfaces to legacy systems are also more numerous, complex and expensive than one might think, said Andrew Wiesenthal, M.D., SM, associate executive director of The Permanente Federation.

“You won’t have advantages until you have everyone up and running on the system,” said Thomas Smith, chief information officer of the NorthShore University Health System.
Smith said NorthShore did a few things wrong the first time. Having a backup data center is important, he said, because ongoing user engagement is a priority and order sets should be taken care of.

“Surprises” in implementing an EMR in the three organizations included the amount of training needed, complexity and cost of a truly redundant information center, whether it’s worth getting rid of all paper documents, and the legal reaction to an EMR.

“The simple stuff can bite you,” Wiesenthal said. “If you strive for perfection, you won’t get anything but.”

So yes, Ms. P, change is hard, but then hard is what Mrs. Robinson ultimately strived for wasn’t it? She gave new meaning to the term adolescent growing pains.

Is the “older woman” in the form of EMR able to do anything more for PACS than the teenage prom queen can? While she brings more to the table in terms of experience and money…that’s about all. Benjamin was merely a play toy after all. After all that teasing she did to poor, poor Benjamin, Mrs. Robinson ended up spending the next 38 years happily married to none other than….. Mel Brooks….









Photos: UA/Embassy © 1978 Bob Willoughby - Image courtesy mptvimages.com