Enterprise Imaging Guidebook 2022
A Comprehensive Guide to Developing an Enterprise Imaging Strategy

Where Are Findings from the 2022 Summit?

While many of the findings in this guidebook come from previous summits, ongoing KLAS studies continue to validate the importance and relevance of the key findings and themes, which are foundational to the discussion summary from the 2022 summit. Additionally, recent insights are interspersed throughout the summaries from the previous summits. To jump directly to insights from the 2022 summit, click here.

What Is Enterprise Imaging?

KLAS defines enterprise imaging as the ability to store and/or view images across the enterprise from more than one service line, PACS, or long-term storage solution. Organizations that have adopted such a strategy feel that the ability to consolidate critical patient images and integrate them into the clinician workflow has the potential to revolutionize patient care across the continuum. While an enterprise imaging strategy can encompass many technologies, such as workflow solutions and document management tools, providers feel that at the heart of enterprise imaging are three primary technologies: vendor neutral archives (VNAs), universal viewers, and image exchange solutions (with PACS solutions playing a role in diagnostic viewing for the bulk of their studies). Some organizations are new to using these solutions for enterprise imaging and are working to fit these solutions into a meaningful strategy. See the 2016 Enterprise Imaging report for more information.

Post-Purchase: Creating a Strong Foundation & Bringing Your Strategy to Life

At the 2020 summit, provider thought leaders, imaging vendors, and EMR vendors discussed best practices for helping organizations set themselves up for success in enterprise imaging. They determined that provider organizations should consider the following as they develop a deployment strategy:

• Properly inform C-suite and IT stakeholders about enterprise imaging’s breadth and the complications and challenges that are inherent in deepening EI adoption. This will help align support and resources and is best accomplished by associating EI goals with what is important to these key groups (i.e., security and cost control).
• Mindfully plan for a virtual environment, focusing on what the process will look like (e.g., schedule time differently to avoid having too many people on-site at once). Consider whether the locations where the trainings or go-live will be facilitated have the necessary software installed (e.g., join early for test run).
• Provide good structure and documentation in advance so all stakeholders know what to expect when and why. People want to have the correct equipment and processes in place.
• Reduce barriers to support, especially in a virtual environment. Being able to click a button that is already in their workflow is much easier for providers than having to remember and call a phone number.

In addition to the advice mentioned above, there are three primary areas in which provider and vendor stakeholders can work together to secure success: workflow, governance, and vendor delivery. Provider organizations who have seen success say a focus on these areas is highly important.

Workflow: Standardizing Approach to Visible-Light Images, Encounter-Based Imaging, and Image Exchange Yields Significant Benefits

Ensuring that clinicians have access to patient images in the EMR is essential to increasing physician collaboration around patient care. In fact, when asked what outcomes they are achieving, organizations with EMR integration are quick to note that it has been integral to their success: “[Our viewer] is fully integrated with our EMR, and that has improved outcomes in many ways. I even think that integration has increased system adoption by our referring physicians. [Our viewer] is easy to use, so most of the referring physicians are able to navigate the two systems with few problems if any” (PACS administrator).

Providers and vendors who attended the 2018 enterprise imaging summit identified several areas in which workflow improvements could be made. Three stood out as the most impactful:

• First, it was made clear that organizations need to standardize the capture, upload, and workflow for visible-light images.
• Second, attendees identified the importance of standardizing for encounter-based imaging across all specialties. At the time, the need for encounter-based imaging was frequently mentioned in KLAS’ research interviews with provider organizations, and a notable number of organizations did not have plans to deploy such capabilities (though some progress has been made since 2018).
• Provide good structure and documentation in advance so all stakeholders know what to expect when and why. People want to have the correct equipment and processes in place.

Another main takeaway from the provider and vendor discussion on workflow was the need to standardize the metadata included with captured visible-light images. The 2018 summit group identified the following metadata elements as the three most critical: the relevant body part, patient information (e.g., name and ID), and reason for the encounter (e.g., diagnosis, primary complaint).

Governance: Clinical/IT Collaboration, Internal Alignment, and Clear Road Map Are Foundational for Success

While the importance of governance may seem obvious to some, a surprisingly large number of provider organizations doing enterprise imaging do not have clear governance in place. Even among those who do, governance may live at the department level and lack participation and input from the greater organization. In these cases, the lack of governance hampers success. A chief of cardiology noted, “We are the barrier to wider implementation of the VNA because we don’t have any governance or initiatives within our organization to implement it.”

As governance progresses—from being nonexistent to departmentally focused and then to organizationally focused—the number of reported outcomes increases. Because each provider organization’s goals and structure are unique, the specifics of governance can vary across organizations. However, 2018 summit attendees identified several guiding principles and questions that can help create successful governance regardless of context:

• The first guiding principle identified was the need for close collaboration between clinicians and IT staff.Suggestions for improvement in this area include:
  • Creating a common vision among stakeholders
  • Using IT rounding to better understand enterprise imaging
  • Involving C-level individuals responsible for technology
• The second was the need to create greater alignment within provider organizations.Here, providers and vendors suggest several best practices:
  • Getting C-level, medical director, and specialty buy-in
  • Aligning purchasing and funding strategies
  • Forming a strong steering committee
• Third, a clearly defined road map is key. This includes setting targets, goals, and finish lines to celebrate along the way.

To successfully implement the governance principles listed above, organizations must form effective steering committees. KLAS has found that organizations with a unified, executive-supported, multidisciplinary enterprise imaging committee are often the furthest along with their EI strategy. Though these committees look different across organizations, there are common best practices. At KLAS’ 2020 summit, a panel of providers with advanced EI strategies shared what they have learned when it comes to creating this committee, as seen on the following page.

Governance committees should establish a wide net of influence, from the executive level down to departmental stakeholders. Individuals who can also speak to the patient experience perspective (i.e., clinical operations) are also important to involve. It is a good practice to incorporate stakeholders who have historically supported advanced EI as well as those who are invested in future progress.

Incorporate all types of image users, even those who may have been sub-users in the past (e.g., ED ultrasound, ophthalmology). This can be done by inclusive sub–work groups or establishing channels through which all can submit ideas and engage in the EI strategy.

The committee can expand and contract based on situational needs for subject matter expertise (e.g., enterprise architects). However, there should be continuity in a core group of individuals who are staying abreast of the latest technology and strategies and sharing what they hear from peers.

IT should have a continued presence on the committee to interpret vendor messages and relay what the technology can do. Keeping IT continually engaged facilitates a collaborative relationship.

Establish C-suite buy-in by aligning EI initiatives and goals with major strategic initiatives. This is done optimally when EI goals are able to be easily articulated and their value is understood (e.g., patients being able to access images on mobile devices, giving referring physicians centralized image access, creating imaging specialist workflow).

It is essential to create vision and scope statements to create a foundation on which to build the program. These statements will act as guiding principles to maintain internal consistency in times of conflict and should be regularly reevaluated and revised as needed.

Maintain organizational momentum for EI by socializing wins, engaging correct stakeholder/physician champions, and continually focusing on priorities. This can be accelerated in the beginning by focusing on one problem (e.g., enabling POCUS, getting rid of CDs).

As appropriate, imaging vendors should be involved on the committee to better understand organizational priorities and challenges. This will help optimize solutions for EI, not just specialty imaging.

Vendor Delivery: Partner with Vendors That Facilitate Governance Conversations, Identify Problems and Goals, and Engage Proactively

“Delivery” refers to a vendor’s operational practices that are ultimately tied to customer success. The delivery principles that lead to customer success in imaging also apply across healthcare IT in general. Provider organizations can help support their vendors by communicating clearly and often and being open to hard discussions that will benefit both parties in the long run.

During the 2018 summit discussion, attendees repeatedly stressed the importance of strong partnerships as key to successful delivery. Several of the most impactful ways this can be achieved are as follows:

• First, providers and vendors should focus jointly on outcomes. This provides a common vision that helps facilitate additional conversations about governance, deployment plans, implementation, and so forth.
• Second, providers and vendors should develop a clear understanding of the problem they are trying to solve. This includes communicating the problem to all stakeholders within the provider organization (e.g., C-level, IT, and individual departments).
• Third, vendors need to provide strong executive sponsorship and regular touchpoints to drive collaboration and foster deeper partnerships.

Elements of a Strong Provider/Vendor Partnership

In addition to the suggestions listed above, broader KLAS research identified several important elements for strong provider/vendor partnerships and delivery. These insights were gleaned from confidential interviews conducted with 50 vendors in 2016 to understand how they approached sales, training, and support. When respondents’ answers were correlated with their customers’ satisfaction, several best practices and guiding success principles emerged.

Prescriptive Selling

A top indicator of customer satisfaction is how a vendor sells to their customers. There are three primary types of selling: à la carte, packaged, and prescriptive. In an à la carte model, customers can pick and choose the modules, support level, training, and other product aspects they wish to purchase, regardless of how their choices may limit their success. In a packaged approach, vendors build packaged options for customers to choose from, helping to narrow their options.

The third model is prescriptive selling. Vendors who sell prescriptively have a deep understanding of each customer and a clear view of what success looks like. This allows them to prescribe the modules, interfaces, training, services, and other elements that they know will lead to a customer’s success. Beyond simply prescribing the recipe for success, prescriptive vendors are principle driven and are willing to walk away from a potential customer if they cannot foresee success. Customer satisfaction ratings for vendors who sell this way tend to be a full 12 points higher (on a 100-point scale) than those who sell à la carte.

Strong Implementation and Training

Training is another highly influential factor that affects customer success. Many vendors offer training as part of an initial install, but vendors who consistently drive high customer satisfaction prescribe rigorous ongoing training focused on driving usability and deep adoption. This ongoing training ensures that as the use of a product or product suite expands, all new users make full use of the available functionality and use the tools in the optimal way to achieve outcomes. It also ensures that the organization is receiving their money’s worth.

The importance of strong training is reinforced by KLAS’ Arch Collaborative research, which looks specifically at end-user EMR satisfaction. This research shows that excellent training focused on personalizing a solution for users’ unique workflows significantly improves customer satisfaction.

While vendors are responsible for providing training options, the Arch Collaborative research shows that provider organizations can also improve their experience themselves by ensuring that training is a priority for end users. Some examples of how organizations can emphasize the importance of training include requiring users to complete a proficiency test, requiring clinicians to complete a certain amount of training, and incorporating training into departmental meetings.

In a world where remote work is the new normal, provider organizations and vendors have been forced to reevaluate their deployment and training strategies. Rolling out technology with a remote or hybrid workforce can be daunting, but 2020 summit attendees had several pieces of advice:

• Training needs to be done in small, focused groups. This encourages more accountability and engagement among participants and allows trainers to customize the training to specific groups’ needs. Record trainings for those who cannot attend.
• Present information in a short, dense format to reduce participants’ urge to multitask. If possible, information should be centralized and shared within existing workflows (e.g., logging in to the EMR).
• A warning—email is better for IT staff than clinical staff, and long messages are rarely read in their entirety.
• Vendors need to be flexible and available for trainings and go-lives; one provider said their organization had established 24/7 virtual SWAT rooms with remote-in capabilities to help users whenever problems arose. Quick responses to calls for help are even more critical in a virtual environment.

Account Management

Another key to success is a strong relationship. While most vendors and provider organizations agree that strong, positive relationships are important, the majority of the HIT vendors that KLAS measures do not achieve scores that indicate the presence of a strong relationship. One tool that service-oriented vendors use to drive customer success is account management. Provider organizations, particularly those working in complex spaces such as enterprise imaging, benefit tremendously from having contacts that understand their organization’s structure as well as their goals. In this year’s enterprise imaging research, several respondents were quick to praise their vendor account manager for help setting up their strategy and overcoming challenges.

It should be noted, however, that not all account management is created equal. For account management to truly drive satisfaction, and ultimately outcomes, account managers and other supporting staff must be empowered to break down barriers for their customers. Provider organizations are looking to partner with vendors whose account managers will make them a priority and give them the help they need.

Beyond Technology Solutions, What Contributes to Success in Enterprise Imaging?

Keeping Sensitive Images Safe in an Enterprise Imaging Environment

At KLAS’ 2022 enterprise imaging summit, one highly mentioned topic was managing sensitive images (i.e., images with nude, gruesome, or personal content that can cause shock, embarrassment, grief, or emotional distress). As images become more accessible to more providers via technology, the potential for security breaches and staff members using the images inappropriately increases. Keynote speaker Dr. Alex Towbin from Cincinnati Children’s Hospital Medical Center shared examples of how some organizations’ failure to secure sensitive images has impacted their reputations and caused serious harm to patients and their families.

In the 2022 pre-summit survey, just over half of provider attendees said they currently do not have procedures in place for storing and accessing sensitive images. Providers who do have procedures in place said the most common methods are to restrict access to images deemed sensitive and to use standard labeling for sensitive images. For organizations who do not yet have procedures in place, conversations about developing these procedures are still in the early stages, and procedure development is generally not being pursued.

2022 summit attendees engaged in small-group discussions to (1) identify common barriers to developing effective procedures for managing sensitive images, (2) share tips for getting organizational buy-in, and (3) list other best practices for successfully managing sensitive images. Across all eight discussion groups, the general sentiment was that while the industry still has foundational EI issues to solve, failing to have early discussions about the management of sensitive images could potentially cause both ethical and legal problems down the line.

Common Barriers to Developing Procedures for Sensitive-Image Management

• The industry needs a standard approach to labeling, though it is unclear who (i.e., provider organizations, vendors, or the government) should be driving progress.
• Reaching a consensus on best practices within your organization can be difficult, particularly outside of cases that involve abuse.
• Implementing procedures solves only part of the problem—storing images securely on devices and workstations is critical.

Tips for Obtaining Organizational Buy-In for Sensitive-Image Management

• Legal departments can serve as partners to make sensitive-image management an organizational priority (though both provider and vendor attendees noted that without strong governance and policy input from providers, too much data may be restricted).
• Education needs to take place at all levels and in all departments (e.g., organizations can help radiologists understand why clicks are being added or help nurses think about how images can be used).
• Technology vendors can serve as a hub for learnings and best practices across their customer bases. They can share examples of the challenges provider organizations may encounter if they lack effective sensitive-image management procedures.

Other Best Practices for Successfully Managing Sensitive Images

• EMR vendors have a critical role to play, especially when it comes to tagging functionality. Provider organizations can engage their EMR vendor in imaging discussions to help drive progress around sensitive-image management.
• Focus on visible-light image capture, as this area is where much of the vulnerability exists today.
• AI has the potential to help, but until the industry standardizes body part names and labels, AI’s utility is limited. Organizations should be wary of relying too much on AI when developing procedures for sensitive-image management.
• Cases of sexual assault and abuse are critical starting places for governance, policy, education, and standards.
• We can learn from other industries and use cases—for example, how does Google manage sensitive images in searches, or how do behavioral health departments manage sensitive information?

Navigating Enterprise Imaging Post-Pandemic

Coming out of the height of the pandemic, both provider and vendor attendees say their enterprise imaging strategies have shifted somewhat. While most respondents to the 2022 pre-summit survey haven’t made significant changes (see chart below), several mentioned adjusting some areas to address emerging problems and leverage new technology.

Remote Work and Image Exchange Are Top Technology Investments to Bolster Enterprise Imaging Strategies

Unsurprisingly, one of the top areas for additional technology investment is remote work. One provider organization shared that they invested a significant amount into virtual care and adopted mobile technology to facilitate real-time consulting sessions between radiologists and physicians. Provider organizations also mentioned investing in cloud technology, workstations, collaboration tools, and other tools to drive efficiency in the face of staffing shortages.

Another frequently mentioned area of investment is image exchange to support patient care in a remote environment (e.g., patients who are seen virtually cannot bring physical copies of CDs to their appointment). Adoption of image exchange solutions was accelerated by COVID-19, but for many provider organizations, other methods—like HIEs, burned CDs, and VPNs—are still a critical part of imaging interoperability.

Amid Imaging IT Budget Cuts, Provider Organizations Point to Tools That Offer Much-Needed ROI

Diminished funding for enterprise imaging is hampering organizations’ ability to address the evolving care and work landscape. Provider attendees shared that their margins in departments like cardiology and radiology are shrinking significantly and that there is more departmental competition for limited funds. Because of the increased scrutiny of IT purchases, it is critical for organizations to make investments that will drive value. In the group discussions, providers often highlighted the following technologies as driving the biggest ROI outside of the VNA, the universal viewer, and organizations’ work-from-home infrastructure:

• Health data exchanges and other interoperability tools
• Image exchange solutions to eliminate the use of CDs
• AI tools or worklist-orchestration tools that target efficiency
• Point-of-care ultrasound deployment across multiple departments (though this can lead to large amounts of new billing)
• Clinician collaboration tools

How Can Provider Organizations Mitigate the Impact of Staffing Shortages?

No organization is immune to the difficulties of managing staffing structure, turnover, and labor shortages. Many 2022 summit participants shared their struggles and turned to their peers for suggestions. The following approaches were frequently mentioned:

• Use contractors to build out the capabilities of ground-level IT analysts, and invest in outside training sources to supplement knowledge replacement after experiencing turnover. Contractors are best to use when the knowledge is easily transferrable, and full-time staff should be reserved for activities that require more strategic knowledge.
• Find ways to cut technology costs to retain staff (e.g., hold on to perpetual software licenses when possible)
• Plan to address clinical and IT staff gaps jointly rather than separately; this reduces churn and maximizes the time both groups spend on optimization and planning.
• Simultaneously redesign IT and workflows to quickly gain efficiencies that boost imaging volumes.
• Build a culture of effective remote communication to retain clinical quality.
• Standardize IT solutions where possible.

Functionality Appendix

Vertical 1: Capture

Vertical 2: Storage

Vertical 3: Viewing

Vertical 4: Interoperability/Image Exchange

Vertical 5: Analytics