1. IHE Implementation Hurdles Paul Nagy, PhD pnagy@umm.edu University of Maryland Maryland Institute for Medical Imaging Informatics (MIMII)

2. Learning Objectives 1. What other industries call IHE. 2. Understanding the role of diffusion of innovation 3. Top five obstacles when implementing IHE 4. Getting over the hump

3. What does your technology strategy look like? Each department solving its own internal problems. To get data from the department you need to go down to it.

5. IT Revolution Allows the role to be turned inside out and to be patient driven. Makes the process more transparent to identify delays in care and errors.

6. Integration for Healthcare MPI CPOE (EMR) Physician Portal Data Level Business Layer Presentation Layer Meta Data Key Images, Annotations Single Signon, Results reporting Images (PACS) Results (RIS)

7. 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%20 Enterprise%20Integration%20Software%20Piece%20-%20BCF.pdf

8. 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.

9. Goal is the same Loosely coupled systems where the end user doesn’t know where they are being run. Make process transparent to end users (customers) –Fedex package tracking

10. In medicine we call it IHE Integrating the Healthcare Enterprise

11. Gartner Group Predicted that by 2005, 90% of basic functionality between PACS vendors would be converged (window/level/pan/zoom). The major differentiator between vendors would be in their ability to integrate with other vendors.

12. Diffusion of innovation Innovator phase Early adopter phase We are in year 6 How many years did it take for DICOM to reach path dependence? –ACR NEMA 1 & 2 –DICOM 3.0 is Version (3) of the ACR standard

13. 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

14. 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

15. Obstacles you will need to hurdle

16. #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 Gavain, SCAR 2004, To be published (University of Montreal)

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

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

19. Lifecycle of RIS is longer than the PACS RIS has a 10 year life span PACS has 5 year life span Unidirectional RIS interfaces

20. #4. 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?

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

22. #5. 1 st step is the hardest Scheduled workflow if the biggest step Involves (RIS, PACS, & Modalities)

23. #6. Educated users I’ve got DICOM, why do I need IHE DICOM 3.0 is 11 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

24. #7. Planning goes against the 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”

25. #8. 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

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

27. Getting over the hump IHE is a marriage between business objectives and technical architectural policies.

28. IHE needs to be in the contract Shall language Continued cost of licenses for growth Penalties associated with non conformance

29. Learning Curve Learn how to use the MESA/CTN toolkit developed by the Mallinkrodt Electronics Radiology Laboratory. Freely downloaded. This tool is what the vendors use at the connectathon for validation.

30. Do you want to be an 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.

31. Conclusions Is IHE Ready for Prime time? –Yes, but some assembly is required IHE is a critical indicator of when PACS hits the majority phase of technology maturity and cost effectiveness. Break the catch 22 Vendors don’t offer it because customers don’t ask for it. Customers don’t ask for it because vendors don’t offer it.

32. IHE is just entering the early adoption phase of technology diffusion and there is still some assembly required. Most hospitals do not have the strategic vision to appreciate the benefits of IHE –Next to zero CTO’s in healthcare Many vendors are taking a wait and see attitude