1. Overcoming IHE Implementation Hurdles Paul Nagy, PhD Director, Quality and Informatics Research Department of Radiology University of Maryland School of Medicine

2. Outline 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

3. 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.

5. 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%2 0Enterprise%20Integration%20Software%20Piece%20- %20BCF.pdf

6. EAI Enables Supply chain management Just in time inventory B2B Business to business CRM Customer relations management The internet economy Nobody does it all anywhere.

7. Goal is the same Loosely coupled systems where the end user doesnt know where they are being run. Make processes transparent to end users (customers) Fedex package tracking Buying goods through Amazon

8. In medicine we call it IHE Integrating the Healthcare Enterprise A standard way to use the standards

9. IOM Model of Service Safety Effectiveness Patient centeredness Timeliness Efficiency Equity Source: Institute of Medicine, Crossing the Chasm Align to the patient

10. Rules 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

11. Diffusion of innovation model 1943 model of Iowa farmers adoption of hybrid seeds Five 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

12. Obstacles you will need to hurdle Top ten excuses for not doing IHE from hospitals

13. #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)

14. #2. Asking for none of the above A. A. Proprietary vendor integration B. B. Vendor provided API C. C. Customized DICOM Interfacing D. D. Custom HL7 Interfacing E. E. None of the above Write in: IHE Integration X

15. #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

16. #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

17. #5. Price per interface How 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.

18. #6. 1 st step is the hardest Scheduled workflow and Patient Information Reconciliation are the biggest steps Involves (RIS, PACS, & Modalities) Involves the most number of transactions

19. #7. Goes against medical ideology Organic evolution and responding to clinical drivers instead of systematic approach towards a technology vision. People dont plan to fail, they fail to plan

20. Technical 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

21. #8. Educated users Ive 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. Its 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

22. #9 IHE isnt always enough PSA – Patient Synchronized Applications Keeps app synched to patient But doesnt synch to Study ID A RIS cant drive the PACS without adding extra functionality.

23. IHE 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.

24. #10 Dont 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.

25. Getting over the hump IHE is a marriage between business objectives and technical architectural policies. Making all the domains of healthcare transparent to the patient and the bedside.

26. Steps 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 RFPs for new equipment and information systems Gain some first hand knowledge of integration testing with DVTK SIIM 2008 Learning Labs

27. 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

28. In 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?

29. Best 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

30. 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

31. Conclusions IHE is now a reality. Yes, but some assembly is required Need more CTOs (leadership) in healthcare