Standardizing on One Enterprise Imaging System Yields Tremendous Benefits, Says Beverly Rosipko, Director of Radiology Informatics, University Hospitals of Cleveland

In this interview, Beverly Rosipko, Director of Radiology Informatics at University Hospitals of Cleveland, provides insight into her role overseeing radiology informatics and enterprise imaging. She explains the scale of imaging operations across 13 regional medical centers, 40+ ambulatory locations, and her team’s responsibility for managing over 1.5 million radiology exams and 2 million enterprise imaging exams annually. Rosipko highlights the collaborative work with IT teams across different specialties and how her team focuses on the long-term storage of medical images in a centralized system.

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Anthony: Welcome to healthsystemsCIO’s Interview with Beverly Rosipko, Director of Radiology Informatics at University Hospitals of Cleveland. I’m Anthony Guerra, Founder and Editor-in-Chief. Beverly, thanks for joining me.

Beverly: Thanks for having me.

Anthony: Very good. Beverly, do you want to start off by telling me a little bit about your organization and role?

Beverly: University Hospitals covers northeastern Ohio and we have 13 regional medical centers, our main campus in Cleveland, Ohio and 40+ ambulatory locations. Imaging wise, we perform roughly 1.5 million exams in radiology. For Enterprise Imaging, we’re upwards 2 million exams annually.

My role, I’m the Director for Radiology Informatics, that does include Enterprise Imaging when it comes to the storage and the image links presented out to the various systems for images from cardiology, vascular, GI, Digital Pathology, point of care ultrasounds, any type of medical imaging, we really try to keep them in a centralized system. I like to call it our EMR for images because it’s our central repository for those images.

Anthony: Very good. You mentioned 1.5 million in radiology, 2 million overall, again, we’re just talking general numbers here. That’s about half a million images that are outside of radiology and you mentioned a number of the areas where those 500,000 are taking place, correct?

Beverly: Correct.

Anthony: That’s basically what’s going on in the health systems and you are also in charge, to a certain degree, of those other 500,000, even though your title is Radiology Informatics. You also said you have overview of what’s going on with the rest of them.

Beverly: Sure. Me and my team, we work very collaboratively with those IT teams that are the main supporters for let’s say cardiology. We work very closely with them. We’re responsible for the oversight and management of the enterprise imaging system, where those images are stored long term.

There’s front end application sometimes like in cardiology, they leverage a front end system where the physicians are viewing them, reporting on them, but they’re not stored long term there. They’re locally there for a certain timeframe but ultimately, they are stored into the enterprise image management system. We’re not responsible for anything on the front end, we’re essentially responsible for the system on the back end where they’re stored long term. We work very closely with those teams. They’re really the experts in that area but then we’re the experts with the enterprise image application system.

Anthony: It’s fascinating, the different specialties. Does every specialty that you mentioned do quite a bit of imaging, do they all have embedded informaticists like yourself, each of the -ologies would have counterparts to your position?

Beverly: Not within the department. We’re structured a little bit differently. Me and my team report directly to the director of radiology, but again we follow all the IT guidelines, policies, procedures, attend meetings. It’s just really a reporting structure. But for those other areas, they typically fall under the IT umbrella. My team is more engaged in the operations perspective, it’s one of the differences between my teams and other teams – they’re involved in operations too but not to the extent of the radiology.

But if you think about it, in radiology specifically, images are what we do. That is our primary day in, day out, our systems, our radiologists can’t do what they need to do if our systems are not functioning, efficient workflows. That’s really how I look at it. We’re so ingrained in the department because as my recent boss, Jason Theodore, said, we’re the wheels on the bus.

Anthony: How would you describe your relationship and reporting structure with the central IT executives, Enterprise IT executives like the CIO and the CMIO?

Beverly: Sure. Our CMIO is a radiologist.

Anthony: That helps.

Beverly: Yes, Dr. Jeffrey Sunshine. He is my key mentor since getting into the informatics world about 20 years ago. He is heavily involved in any of those decisions and essentially I have a dotted line to him, direct line, probably both. I work with the CIO as needed. I really do have a dotted line to the Vice President for Clinical Applications and she includes me in all of her meetings with her directors. I’m part of that team, that is just a reporting thing on paper, if you will, following their processes, being involved in their meetings, their initiatives, following all of their guidelines.

Anthony: How would you describe what Enterprise Imaging means in the sense of what direction are you trying to move in? Is there a high level way to explain where you are trying to go overall? There are probably a million ways you can move, a million areas you can start and things you can try and do? But is there one way to describe the overarching goal that you’re trying to move towards?

Beverly: From my perspective, it’s really having that single repository where you can have the images accessible through your EMR, resolving those buckets of different repositories of ‘these images are sitting on this machine, there’s no redundancy, there’s no backup.’ Believe it or not we still see that, but not like we have in the past. We’ve really made a lot of progress with where we’re at today.

Recently, we came live on Epic EMR. With that go live some of that came to light, images living in little repositories, not that anybody’s fault, just areas that they’re not the image experts. For me, the future is really making sure those images are part of the patient’s medical record and making sure that they are appropriately available and part of that centralized medical record whether it be image link, embedded in the results, whatever the case might be. But a lot of times, because they are DICOM and the format of those images, you do need a separate system. But those two systems, your EMR and wherever you’re storing your images should be tightly integrated so those images can be available to patients, to providers taking care of the patients and providers outside the organization.

Anthony: Would you agree that a lot of people may share your vision but there could be a thousand ways to go about moving forward in that direction, a thousand areas to try and different strategies? For example, and I’d like to hear your opinion on this, I’ve interviewed CMIO types at different organizations who seemed to have at a high level chosen different paths to move in this direction.

One path might be to do some serious rationalization around PACS and reduce the number of PACS, because it’s better to have fewer systems. I’ve had others who said that’s extremely difficult to get users off of a system that they are comfortable with and enjoy, and I don’t want to go down that road because I see a lot of difficulty. They will deal with integration on the back end. One is more of an application reduction and the other one is more of an integration to keep the users happy. Do you see that as possible strategies to move in one direction or the other? What are your thoughts?

Beverly: I do. Obviously, I have one that I highly favor over the other. The one we’ve done is reduced the number of systems. We’ve acquired 6 different hospital systems over the last 10 years now, and one of our first goals was to eliminate their PAC system and bring them into our system because there’s so much complexity of having multiple systems and doing those integrations.

Honestly, from our perspective, from my perspective, having that single system has far more benefits for the end users, although it might be difficult moving away from the applications they’re used to now. It gets them into one viewer, it gets them into a really streamlined workflow that they’re familiar with.

Because if you have different integrations from different systems you need additional resources. You have different points of failure, you have different viewers that you have to manage. But I understand that it is difficult, it takes work, it can be expensive. But in my opinion, in the end where we’re headed, it makes sense that you work towards that goal, whether it’s one system this year, another system next year and for our patients and for our providers that are providing care.

I can see both definitely and everybody has different variables they have to consider, funds available, resources today. But again, the resources to maintain all those different systems, in the end, is it better to just move off of them. Change is always difficult – moving off of one system to another, that’s always difficult for our end users.

Anthony: Is your goal to get one PACS per ology and then to have all those PACS feed into a VNA that is integrated with Epic or is it much more complicated than that?

Beverly: It’s actually much simpler. We essentially have one enterprise image management system today and all of our various images are sent into that centralized system for storage and for presentation to EMR, presentation to MyChart. Cardiology is sending into the same system that radiology is sending into, vascular is sending into the same system, Digital Pathology, point of care ultrasound, ob-gyn, fertility imaging, all those images are feeding into the same system today. Essentially, you have one image record for those patients. If you log into the system, you can see images from any of those different areas today. It’s all one patient record.

The areas where we don’t store into that system are image capture like a digital photo. But those images are stored into the EMR. Those are not DICOM images, they’re tif or jpeg. Those are parts of the patient’s chart. Those are stored into the EMR which is still the same place where you can pull images from. Other areas that are not sent into that centralized location are some one offs, like it could be in the OR, could be an ultrasound machine sitting in somebody’s office.

We’re working to identify those and get them sent into the same system. We truly are, I would say 75% maybe higher of having all images into the same system. Those that aren’t sent into that system is because we haven’t discovered them.

Anthony: That’s a wonderful situation. It’s almost like you pick where you’re going to have your pain and suffering. You’re either going to have your pain and suffering on the migration side to get to that really nice architecture of one system or you’re going to have your pain and suffering on the integration side managing multiple systems. You decide where you’re going to have your pain and where you’re going to have your suffering but then you’re done with it.

Beverly: Right.

Anthony: It sounds like the biggest pain and suffering comes with the acquisition of a new health system, a new radiology group, and I don’t know if this is something you’re familiar with but would that come into discussions of acquisition? For example, you’re going to acquire a radiology group, you wouldn’t want to let them know ahead of time that they have to come off their PACS, their system, whatever they love, whatever they used, they are coming off it, if they come on board. It’s one of those big deal breakers you want to know ahead of time. Does that make sense?

Beverly: Yeah, it does. I’m not part of those discussions. But I can tell you from past experience, it is clearly defined what the goal is with all IT systems because it’s not just the PACS. Ours happen to be one of the first that we look to because we have a process and a way to do this in a very organized manner. We’ve done it so many times now and also our vendor that we use has the ability to accept a different MRN because that’s always the challenge. When you’re taking on another system and their records, they have a different MRN, that’s the first challenge. But it’s always clear in the contracting that will or won’t happen.

In all of our recent ones, it was part of the plan. It is upfront and they’re aware of it. Yeah, it is change for them but ultimately, hopefully, it’s a good change, bringing them more tools, better workflows, and also ultimately it’s best what’s for the patient. You don’t want to have to have some records in one system and records in another system because then – especially radiology, comparison images are detrimental. If you had a prior mammogram, a prior CT, you want your radiologist, you want them to see that. That’s another key lift, bringing on those systems if we have an acquisition.

Anthony: Let’s talk a little bit about migration because that’s what you do. When you acquire someone on a different system, you migrate them to your system of choice for a nice simple architecture and you don’t have to worry about integrations. But migration is hard. It’s harder in PACS and with images than it is around the EMR. Everybody knows that if an Epic health system acquires a hospital that’s on a different EMR, they’re coming off. No question about it.

But I think it’s a little more up in the air around images because there are some health systems, as I’ve mentioned, who I believe have decided ‘okay, we’ll figure it out on the backend. You can keep using what you’re using.’ Tell me about migration, tell me because it’s known as something that’s difficult which is why some people choose not to do it. These are very, very large files. If you keep the old system alive or sometimes there’s archived vendors where ‘we’re going to get everything out of the old system, we’re going to bring over a little bit to the new system, the rest is going to go to an archive.’ I don’t know. You tell me your thoughts on how you handle that kind of stuff.

Beverly: Sure. Having done this so many times, each time – yes, it’s hard but I would say our most recent one was in 2022 and I think if I recall correctly, we migrated that whole system within about 8 weeks.

Anthony: Wow.

Beverly: It was our smoothest. But again, we looked back to our first one, however many years ago, a lot of lessons learned. You’re right, a lot of times I think the most difficult thing is making sure that you have a vendor that can normalize the data. Another key is and I don’t know if all places do this, but we always migrate the orders. Because you really need the order there first before you send the images. We’re always doing an order migration first, get all those orders in the system and then migrating the images over.

Because essentially it’s a marriage, you need the order which is the exam information, and then the images can come in because those images belong to that exam, right. If you’re just sending images over and not those orders, I’m assuming it’s a standard that places do with migrations. But I can’t say because I’ve not been in another organization. Then the results, making sure the results are migrated too.

There’s always a file that didn’t migrate, there’s some manual review of those which the team does and then works with the vendor. It is difficult, once it gets going, making sure you get all the prep and you get all the information, that’s key because then that makes everything smoother.  We also have to consider the data that you’re moving, if it’s in bad shape, if it’s on tape drive, if it wasn’t properly identified to begin with, those are things that you have to consider.

Anthony: It sounds like if you didn’t have a lot of experience with this you need outside consulting help?

Beverly: We don’t use consultants, we use our PACS vendor that does the migrations for us. We have a third party for radiology migration but I know that there has been third parties used for other.

Anthony: Very good. When change comes to imaging in a health system, I’m curious as to who’s leading and who’s following. Our readers are going to be the CIOs and the CMIOs and I’m trying to educate them. The CMIO, especially if they’re radiologists, are going to know what’s going on but for those who didn’t come up through the clinical side, we want to educate them about what is possible and how things can be improved so that they can bring ideas to operations and not just wait to receive requests. We wanted to go both ways and I think one of the areas where IT executives can benefit from understanding what’s happening and what’s possible is around Enterprise Imaging.

In your experience, what are you seeing – when change bubbles up, when a new direction is requested, where is it coming from? Where’s the push coming from? What do you ultimately see as what’s your advice to the CIOs and the CMIOs as to how they can support this kind of change in their health systems?

Beverly: That the main drivers of change would be the providers, and I would say imaging is becoming more prevalent in the non-radiology space. We’ve seen such an increase in point of care ultrasound. I believe there is a lot of imaging occurring in the OR that’s not being captured. That definitely the providers and then of course, in radiology, they’re the image experts and they’re constantly pushing the envelope.

Right now, it’s all about AI in imaging and these AI algorithms, they’re helping to triage images. We have a shortage of radiologists so the lists are growing as far as things that need to be reported on. Most of the AI algorithms are helping them prioritize, those that need attention above others, but from a CIO perspective, I think looking to understand from the department, from radiology, even from outside of radiology, what are you looking to do from an AI perspective, saving the images comes back to billing too, if images aren’t saved that are being billed for, you can’t bill for them.

That’s another thing for a CIO, to work with their revenue team, making sure that we’re properly saving the images, do they have the tools to save the images, the avenues and again, the AI is just so prevalent right now, the different algorithms that are available. It doesn’t replace the radiologist, I don’t think it will ever replace the radiologist but it really does enhance their workflow and a key thing for a CIO is making sure that their workgroups, that the AI is implemented in a way that it enhances their workflow, it makes it better, it makes them more efficient and it provides value to the patients and to the provider for the imaging.

To me, those are things from a CIO perspective if I wanted to get ahead of the curve or at least make sure I have a clear understanding of what’s going on, those are areas I would focus on.

Anthony: It sounds like governance is so important, the request for functionality, even a bubble up from the users, from the radiologists, they’re going to say if they practice at different health systems, they’re going to have people to compare A to B. They’re going to say ‘well, over at A where I also practice, I can do this and this, and over here, I can’t do any of these and it makes my job harder.’

These things bubble up, you need to have the right governance in place to capture these things and then prioritize request. As you said, there’re going to be a million requests, which ones are we going forward. You have to make sure that that’s matching with the overall strategies of the organization and that you’re getting it right so that you can explain to your users here’s why we are doing A, B and C and not D, E and F, right. You’re picking the right things, working on the right things to satisfy your users as well as using your resources in the right places.

Again, that goes for every department because there are IT requests bubbling up from everywhere. Does that all make sense?

Beverly: Absolutely. We see that. We have a very concerted governance plan and we don’t move forward without an approved business plan, approval from the right people because you can have competing technology and we don’t want to have something in place that can be accomplished with two different technologies because then you’re back to A and B can do the same thing but Dr. A wants this.

I have to say our organization, it’s not easy and it’s not perfect, but really that systemizing, really having a clear decision that hey, we are a system, we want to have autonomy, but at the same time, we can’t have every solution possible implemented because there’s always users. They have different perspectives, different opinions. It can be a challenge but I would say that having that strong governance plan and support – because you can have a governance plan but if you don’t have the right support, your governance plan isn’t going to work. You got to support the CMIO, the CIO, the CEO.

Anthony: When you say support it’s here’s the strategy, here’s the plan, here’s the rule book, and support means that if someone goes outside that they are told to come back into the rule book.

Beverly: Yes, exactly. You nailed it.

Anthony: All right. As a final question, I think you said the next big picture thing you’re looking at is finding the images that are not sort of coming into that main system and getting that done. Finding those one-offs, those little pockets of things aren’t being captured and getting them into the fold, is that correct?

Beverly: Yes, that’s correct.

Anthony: All right. That will keep you busy for a little while?

Beverly: Yes, yes. Just a little while and then of course, new imaging technology, AI again is more and more – our list of AI solutions growing with imaging specifically. Then, we have a concerted process because again, that can get out of control too.

Anthony: I bet. You know I could talk to you for another half hour about AI and everything but we’ll leave that for our future conversation. I want to thank so much for your time, Beverly. It was wonderful.

Beverly: Thank you.