December 2015

Imaging Informatics: Image Governance
Drawing the Roadmap to Enterprise Utilization
By Jef Williams
Radiology Today
Vol. 16 No. 12 P. 10

Since hospitals already have a myriad of clinical images on file, it may seem counterintuitive to say an effective enterprise strategy should begin with setting governance policies first, but the truth is, without effective governance, all you're doing is storing images. To create an enterprise imaging strategy that works, health care organizations need a roadmap that shows them how to make the best use of the images they have stored. And to be most effective, this transformation requires not only the development of an innovative strategy but also the adoption of iterative phased steps.

Former imaging initiatives—PACS, PACS replacement, and peripheral system implementations—do not provide an effective roadmap for your enterprise imaging initiative as a whole. The complexity of enterprise imaging is much deeper and convoluted than departmental project work alone. Challenges related to system replacement, cross-specialty stakeholder buy-in, cost and budget models, chronology and project planning, and, ultimately, program and data governance require a detailed and thoughtful plan as well as the support and leadership of a strong governance entity.

This governance body cannot be just a figurehead committee that meets periodically to discuss updates. Governance of an enterprise imaging strategy, similar to an EHR program, requires a long-term, ongoing effort, with the EHR and imaging programs working in tandem for each to be considered both effective and meaningful to the care team. Therefore, deployment of an enterprise imaging initiative requires an engaged, informed, and empowered governance structure. There will be important decisions to be made throughout the entire project lifecycle, and many of these decisions will create conflict and pushback that requires skilled negotiation and compromise along the way.

Four of the most important decisions the governance body will need to take ownership of are departmental priority, workflow optimization, integration and interoperability, and the rules of engagement.

1. Departmental priority. The rollout of an enterprise system will include a timeline and chronology of events. Often there are competing interests within the organization, and the governance team will determine the best strategy for deploying technology by department or function, based on the organization's various needs and constraints.

2. Workflow optimization. There are as many workflow models as there are departments within an organization. The project's governance team must decide how to best fulfill each departmental need while maintaining enterprise standards. Representation from departments is, therefore, critical to fully informed decision-making by the governance team.

3. Integration and interoperability. As the number of systems participating in the enterprise imaging model grows, a complex set of data integrity assumptions—and ultimately, criteria—must be developed, understood, and internalized. Source of truth, custody of record, and many other important functions associated with updating and accurately contextualizing data are imperative. The details become absolutely crucial; the governance body must understand where data are created, stored, updated, and archived. In addition, those data must be kept in context over time and throughout the patient record.

4. Rules of engagement. An enterprise imaging initiative will encounter disparate systems that don't meet the enterprise clinical system's requirements for integration for a numerous reasons, including their age, design, or source code requirements, to name a few. These aged or outlier systems can be a sensitive topic. The governance body will have to weigh options when absorbing these information systems into the enterprise system. The governance body must also participate in any new system selection efforts to ensure that money is not wasted procuring departmental or specialty systems that cannot meet the enterprise requirements.

Important Considerations
Standards enable meaningful queries. Governance for an enterprise imaging strategy is entirely about creating standards that ensure the images that are presented to or integrated into the imaging solution fit agreed-upon criteria. Each image inside a vendor neutral archive (VNA), for example, must have the same metadata in the same format. This allows queries to produce meaningful data, yielding all the digital photos acquired on a patient with the last name of Smith, for example. The key is to ensure the integrity of the data associated with each image stored and managed within the enterprise imaging solution.

Meet licensing requirements in advance. Pay close attention to licensing requirements, which allow the producer of an image to assign patient demographics to the image as it is being acquired and allow those demographics to be routed along with the image as it enters and moves about the enterprise imaging solution. To enable ultrasound images to be archived in a VNA, for example, providers must have a DICOM modality worklist routing license in place, which should be accomplished before the image acquisition process.

— Jef Williams, chief operating officer at Ascendian Healthcare Consulting, is a frequent speaker and author on the people, processes, strategy, and technology involved in enterprise imaging. Contact him at