Ram Chadalavada, MD, Vice Chair of Radiology Informatics, University of Cincinnati & UC Health
In this interview, Dr. Ram Chadalavada, Vice Chair of Radiology Informatics at the University of Cincinnati & UC Health, discusses the evolving field of enterprise imaging. He explains his role in managing imaging data across various medical specialties, emphasizing the importance of consolidating imaging data from different departments, such as radiology, cardiology, and pathology. Dr. Chadalavada highlights the benefits of seamless data integration for both clinicians and patients, improving communication and patient care. He also underscores the need for standardized imaging systems, advocating for leadership in informatics within departments to facilitate collaboration and enhance the overall healthcare ecosystem. The discussion touches on the complexity of transitioning healthcare systems toward unified, organization-wide imaging strategies.
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Anthony: Welcome to healthsystemsCIO’s Interview with Dr. Ram Chadalavada, Vice Chair of Radiology Informatics at the University of Cincinnati & UC Health. I’m Anthony Guerra, Founder and Editor-in-Chief. Dr. Chadalavada, thanks for joining me.
Dr. Chadalavada: Anthony, thank you so much for having me. It’s a privilege and a great opportunity to speak with you and colleagues everywhere.
Anthony: Excellent. Thank you very much. Let’s start off. Do you want to tell me a little bit about your organization and your role or your roles?
Dr. Chadalavada: Absolutely. I think having some context, clinically, what I do is also very relevant to this conversation. I’m a vascular interventional radiologist. I serve as a Vice Chair of Radiology and Informatics. At an institutional level, I work very closely with Dr. Frank Fernandez, the Chief Medical Information Officer, who also refers to our Chief Health Digital Officer Umberto Tachinardi. Umberto works with the hospital system and is from the University of Cincinnati & UC Health where I practice clinical medicine. He also serves in an informatics role.
Anthony: Very good. You’re with both the University of Cincinnati & UC Health?
Dr. Chadalavada: That’s correct. The hospital system is recognized as UC Health. The academic entity is University of Cincinnati. We’re a robust academic center with residency, fellowship programs in various specialties, a college of medicine, training medical students and biomedical engineering from the undergraduate level. This is a very robust ecosystem here.
Anthony: Excellent. We’re going to talk about enterprise imaging today. What I’m hearing is more of a journey and a direction rather than a final end state. For example, if you’re implementing Epic there are real milestones where you’re done, like stages but there’s definitely hard milestones.
Enterprise imaging seems to be more of many different ways people are trying to get there, almost different strategies, different goals for the journey. But there probably are some co-modalities on what people are trying to achieve. If you want to give me your vision about what we mean when we say enterprise imaging as opposed to where we’ve come from.
Dr. Chadalavada: I think a very simplistic approach to enterprise imaging – basically, radiology is one of the biggest gorillas related to enterprise imaging or imaging. But the way I see it is more data, it’s our ability to consolidate imaging data from various sources across the health system and any of the various entities that practice utilizing imaging. We have radiology which is a big gorilla but we have cardiology, pathology, dermatology, ophthalmology, gastroenterology. Various sectors throughout the health system play an important role.
To me, if there’s a picture involved, whether it includes light pictures or direct visualization pictures or x-ray based pictures, I see them as the same when it comes to imaging data and how to organize those. I think this is really important because the enterprise imaging model – there’s two primary entities that play a role. You have the clinical faculty, the staff and then you have the patients.
Having the seamless integration of imaging data across the various departments whether it’s radiology, pathology, it’s just better for us to communicate as clinicians and coordinate care. Think of the situation of a multi-disciplinary conference where you have the oncologist, the radiologist, the pathologist, all there and in order for them to work, you also need to work together in the imaging infrastructure as well.
That same thing applies to patients. Patients want to be able to integrate through their imaging because they might have a GI scope where they can see the visualization of their endoscopy, and then that leads to a pathologist evaluating a specimen that they may have gotten a biopsy of. It’s improved patient care. There are efficiencies in workflow from day to day but also from a system level, and then just overall, better utilization of our resources.
Anthony: Very good. How do we move forward in this? You mentioned all the different-ologies and I guess we can use the term PACs for the system that holds the images. That’s sort of step 1. I understand it at a high level – I’m trying to learn this stuff, high level understanding. But it’s like from the modality to the PACs.
Now, you talked about the different -ologies. There could be different PAC systems within an -ology, right?
Dr. Chadalavada: Yup.
Anthony: Do we think of this as, step 1, let’s try and standardize within the -ologies on one PACs. Instead of having 3 in radiology and 4 in cardiology and 2 in dermatology, or whatever the case maybe, let’s see if we can shrink that down. We standardized more per -ology. Then maybe after we standardized on one per -ology, what’s the next level of bringing images together? Some people say it’s a VNA.
Then, if we get everything into a VNA, ultimately what do we want to do? We want to make sure the VNA is integrated with EMR so that patients can get everything or different clinicians can. That’s my high level understanding on some of the ways to go forward. Tell me if that makes any sense or what your thoughts are?
Dr. Chadalavada: Anthony, I think you’re right on. We haven’t undergone acquisitions but there’s a lot of transitions happening in the healthcare ecosystem, from city to city, small town to small town and just regionally as well, whether it’s southeast United States, the Mid West, there’s a lot of transitions happening within healthcare. I think these affect the day to day -ologies and the day to day operations. For example, I think one of the key things, your transition of having the different variance PACs, the different departments, I think it starts with representation.
First of all, just knowing who the folks are, typically the department of radiology has identified informatics people and they’re the leaders in most healthcare systems. I think they’ve been a decade ahead of most of the other departments in identifying an individual. Once we have a, not necessarily a spokesperson, but a doer, an actionable person, somebody who has the background knowledge in this armamentarium, I think is really important.
For example, in our institution, I represent radiology and Dr. Mary Mahoney was very early on in identifying a Vice Chair of Informatics. This is my 10th year at University of Cincinnati. I’ve been functioning this role though my titles have probably changed due to funding and other reasons, but I’ve been serving the same role under her leadership for 10 years. I think other departments have recognized that. So I think at a chair level, our cardiologists are recognizing the need for an informatics person they can go to.
I actually help supplement that quite a bit because of how our management system is organized on the IT side. We’ve actually recruited an informatics person in our department of pathology. Identifying those individuals, I think is really important. I’m kind of a people first person and just knowing who they are helps develop currency. It helps identify some leadership within those silos so they can come together. Then, I think you have to, in some ways, go to the organization. In our case, we do that. We want to implement an organization-wide imaging strategy related to the -ologies and related to these other components.
I think that’s something that we think about and we organized around and so that we can make those kind of fundamental transitions and decisions.
Anthony: Right. That’s almost a step 1 in your mind is make sure you have somebody dedicated to the informatics in each -ology to be in there, embedded, thinking about image sharing and facilitating that. That’s sort of a step 1 and then you can go from there. Is that correct?
Dr. Chadalavada: I think so. First of all, identifying the individual and then how these individual’s function. I’m in a very collaborative state of mind and invited kind of role. I like meeting with our pathologist who has recently joined in informatics. Actually, our chairs helped us introduce each other which is great. I’m looking forward to meeting the dermatology person that’s identified in this role and the ophthalmology person in this role.
I think this also gives us the opportunity to say ‘hey, you know there’s already collaboration happening between radiology and pathology.’ I think these are examples that you can cite to IT leadership or hospital administration. I know I’m using these terms just very generically but there would be individuals, like in my case, a Frank Fernandez. He’s the CMIO. He would be persons that I would engage with and have a quarterly meeting with, as our teams work together.
In our institution, we’re working on reorganizing our informatics teams, just kind of an evolution of things. Before it was very EMR centric but we realized it needs to be more at different institute levels. We need to be at an outpatient level, inpatient level, having different partners in each of those things. I think just as importantly, the other stakeholders I bring in, Anthony – I think the vendor partners are also really important to this. Some of us have really good and on-going relationships with them. They have examples from other institutions that they can bring, other successful projects and maybe even projects that didn’t go as smoothly that we can also learn from.
Anthony: You mentioned identifying informatics folks. Do you feel like it’s best to create the position and then hire for it or you think it works well when someone who is currently practicing as a clinician that has an interest in informatics is a better fit?
Dr. Chadalavada: Anthony, this is a great question. I think it’s a two-pronged approach and I tell you this because I think it kind of becomes your resources, your location, what you have access to. I’ll tell you a little bit about my pathway. I trained at University of Pennsylvania, or HUP Penn Radiology. I was a diagnostic resident there. I also did my interventional radiology fellowship there. But as an integrated program in my fourth year, I also did an informatics fellowship under the tutelage of Dr. Tessa Cook.
Informatics was an important part of our ecosystem at Penn and I feel like I was at the right place, the right time. That program, I’m the first graduates of that fellowship program. Since then, there have been a number of folks who have infiltrated across the country, whether it’s clinics or some are private practice programs, Emory, you name it, they’re everywhere.
I think having individuals who have been sub specialized, trained, certified, SIP certified, SIM and ABBI provided, means and resources, so people had that right mentorship and who have been shown the pathway and opportunities are excellent resources. But there are not that many of them. There’s a supply and demand issue. Demand is high, supply is somewhat limited. If you have the opportunity to recruit such individual, not only do they compliment a clinical need you might have but even if your clinical need may not be high, but that informatics need is there, it’s a good strategy to secure those resources in your department, into your institution.
I say this in the most humble way, but I think my colleagues and peers will say “they’re not that many Rams that are in interventional radiology, that are patient facing, that are integrated with our referring physicians all across the institution and also in the informatics systems. You kind of understand the dynamics of the providers, also understand the dynamics of our patients. You don’t have to be an interventional radiologist who does informatics, there are other great clinical folks who also do informatics. I think having that kind of training and experience is huge.
However, if you don’t have that, I think first it starts with the local leadership, recognizing the importance and the need. I had the privilege of attending, SCARD which is the Society of Radiology Chairs Association. It’s a wonderful group of amazingly talented, gifted folks who recognize this is an area that needs informatics in their specialty. I can tell you a number of departments need it, want it. They are recruiting hard in this space but sometimes they have to identify folks locally who may have shown an early interest.
I don’t think it’s one of those things where you’re just going to point it and do it. It has to come with some infrastructure. Understanding probably just starts with reading some of the basic text in informatics, just understanding your local ecosystem – when did we move to the EMR, who are we, what did we have. When I got here in 2015, even though I had this formal training, I had a lot to learn about this environment. If you have somebody that’s vested and understands it and is willing to put in the time and the resources and effort at a department level and institutional level, to groom and grow. I personally think it’s a 5-year process to take somebody that hasn’t had some of the formal mechanisms or prior experiences to groom into that potential role.
Anthony: Very good. One of the biggest issues in this area seems to be having a number of different PACs in a particular -ology. Ultimately, there’s two opinions that I’ve encountered. One is let people continue to use what they’ve been using because they like it very much and it’s very hard to get people to give these things up. That’s an extremely user friendly approach but it may be more onerous on the back end, the technologies of it and to keep all those integrations going.
The other end is almost like an EMR approach which is let’s consolidate on one platform, let’s get everybody moved over and then we have nothing to worry about. It may be a nightmare, make everyone miserable, get people want to quit but once we do it, everyone’s happy and we’re beautiful and life goes on.
You’re a user. You know how connected you can get to a particular PAC system, the comfort level. I mean, you’re doing clinical things here, you’re viewing, you want a level of comfort here. What are your thoughts around that dynamic? Ultimately, if you do have to tell a particular set of radiologists that they’re going to be moving off a system they’re using – do you have any thoughts on how to do that successfully and get them to buy into that kind of change?
Dr. Chadalavada: Anthony, great question. I think one of the caveats we mentioned when I started is that I have not personally been involved in any transition in the health system for UC Health because we haven’t done any mergers/acquisitions. But just as I started in 2015, our two hospitals, Westchester Hospital and UCMC came together. They kind of functioned as independent hospitals so I kind of saw a flavor of it.
There’s a technical and informatics component to this and then there’s a people component to this. Most institutions and a lot of departments just see this as a technical change or IT change and I think this is where having the clinical background of somebody like me is really important to facilitate and understand the process. I have observed through several of these transitions that regional hospitals nationwide and also several of my colleagues who have acquired different practices, in private practice so I keep a pulse throughout the country.
Knowing where you are as an institution and the march of these acquisitions and transitions, are you in kind of early phase, more is coming and what kind of research and infrastructure have we done and what kind of research and infrastructure input have we sought from our practicing radiologists. What’s working, what’s not, what have we made, there’s some kind of last mile things that you have to do, whether you’re going to stick with one mechanism or others.
For example, if we’re going to let people keep the different systems, you have to first understand the people side of things, right. Are there people merging from a different practice that are joining your practice? You might have to include a transition period for that to come. Do you have a cross over, cross coverage of people being assigned to different areas and different hospital systems so they’re using different PACs? Maybe is there an opportunity to see the best of that versus the best of this or the worst of each. Depending on where you are in the march of transitions and acquisitions, you might be taking that approach where you might be thinking about the 2 different systems or if it’s more of a hostile situation, you might need to be the person that’s softening those transition. Often times, the informatics in IT can be the early integrators of those.
As a health system or a practice has marched on, and they are more established or they’ve done the infrastructure or they’ve done it before and they’ve implemented it and they’ve had successes, they know the value of following in a checklist of do this first, do that first. Let’s also think about the people, how we organize and assign them to their assignments. Do we have a buddy system? Do we have a paired system? Is there clinical intensity in one location paired with their technical utilization? Are there EMRs? Are there logins?
I think it’s possible to do either but I think more and more infrastructures and institutions are kind of simplifying their situations so that they can merge and bring people on. But I think it’s so important if you go with the latter which is you have a system, we want to bring everybody on to this that we implemented and understand the people’s process, the training process. Do we have enough staff to train and on-board? All those surrounding infrastructure needs need to be understood.
Anthony: Right. If we go with the we’re all coming on to a consolidated system, and we acquire a new radiology practice and it’s part of the deal that they’re going to come on to your system, I think what you’re saying is you better know what you’re doing with that transition and experience helps.
I did interview one institution where yes, this was their policy, everybody comes on to their platform and the sentiment was expressed that yeah, it was hard at the beginning but we’ve done so many now that it’s smooth, right. We learned the process and as you said, we got our checklist, we know how to do this. But it’s probably not easy to learn that. Those are learnings that come painfully over time.
Dr. Chadalavada: Yeah, absolutely. Also just as important, is there a person that’s involved in operations? I recently met a Vice Chair of Communications at the University of Wisconsin – they’re a champion and leader for being a communicator within their department, especially as new members come in or new faculty are acquired or hired. There’s the people side of things that I stress quite a bit on.
Anthony: It makes me think of governance here. How important do you think governance is in this situation?
Dr. Chadalavada: Governance and ownership are kind of aligned with me, for me, because I think governance helps identify who the stakeholders are and who’s owning certain aspects and how do we all collaborate. Because at the end of the day, governance is the fundamental collaboration between the imaging folks as clinicians and the enterprise level IT executives. I think it’s really important. I think it’s also making sure that all the right people invited. It’s okay to maybe invite the wrong folks but you cannot miss the must haves. That’s one of the key things.
It can kind of blacklist you a little bit if you don’t have all the key stakeholders identified. Again, identify all the clinicians and then all the enterprise level IT executive. The creation of governance structures is really important because it allows shared ownership of this so-called enterprise imaging initiative. Who is involved, how are we going to get there, this can be committees that include both the clinicians and IT folks to develop the strategy. But I think you also need them when you’re in the heart of it but also even on the back end, right.
Let’s say you made this governance plan, you tried to implement it, this same group of people and system is also going to be there for your troubleshooting, and also future progress. I think it’s a really, really important system.
Anthony: You mentioned the word collaborate a few times. We talked about governance. It’s important to get the key people involved. We also know that especially in academic health systems things can move slowly when you want consensus, you want everyone to agree, you want everyone to be happy and feel heard.
How do we make sure we keep moving things forward and that we’re not constantly tabling things to the next meeting? Is that a problem?
Dr. Chadalavada: No, Anthony, I think it’s the so-called the stall effect or the let’s revisit this. This happens in lots of domains. I don’t think it’s exclusive to academic medicine. So I’ll look out for us in that way, but I do know this happens in many different industries, many different arenas. But yes, it definitely also happens in academic medicine. But actually, you know I tend to focus on some of the background infrastructure on leadership.
For me, leadership is very important in this infrastructure, their leadership, their organization, their vision. I am the type of person who looks to our leaders, to have a good depth and breadth, have a checklist, have timelines that are in place. Then, they’re the ones that help lead and a lot of the work has to happen, not at the meeting but it’s kind of, it it’s a meeting that’s happening, it’s got to be a work meeting with decisions and actual items in between.
I can tell you this from my own local experiences, whether it’s on the clinical side or whether it’s on the informatics side. I tend to follow the same policies and mechanisms and I shouldn’t say policies but same working patterns. We’re going to hear the objectives, we declare in the email, the night before I send out – here are the things that we’re trying to accomplish, we hope that you made some progress since the last meeting and then here’s what we’re going to address.
In those meetings, we try to go through a checklist. Time management is very important because sometimes things take much longer than anticipated or they actually deserve it. Being organized in that fashion and then closing the loop and kind of sometimes being a concluder, be like okay, this is where we stand at this, why. Well, we have, it could be a 9:1 but it might be something we need all 10 people, to be on board. Let’s investigate, find out what it is, are they not at the meetings. All those kinds of things are really good.
I think leadership is really important to me. Also, the minutes that follow, for me, I’m not the type of person that sends out the minutes just before the next meeting. Actually, the minutes should follow immediately of the current meeting that happened so that people know what the summary is. If they have any discrepancy as to what’s happening there, and what were the actionable items, who was doing what, I think needs to be dictated.
It fundamentally comes down to the leadership, the culture and kind of the expected timelines that should be set out.
Anthony: Yeah and hold the people accountable, right?
Dr. Chadalavada: Absolutely.
Anthony: We’re just about out of time. I just want to ask you a final question. As I said, most of our readers are going to be the CIOs and the CMIOs, and I want to help them with these interviews. For the CIOs that don’t have imaging front and center on their radar, I want to help them to be thinking along certain lines.
What would your best piece of advice be to the CIOs and the CMIOs, your best piece of advice on how they need to think about working with the departments around imaging?
Dr. Chadalavada: People first is one of the things that I always focus on. I think what I would tell our CIO peers and colleagues is there’s a need for leadership, effective management or change management and also the people part of this is focus on the collaboration between the clinical teams and include all the key stakeholder departments, make sure no one is left out and then IT, to successfully implement enterprise imaging aspects or the infrastructure.
For our CIOs I would presume one of the main goals is to enhance the patient care. They want to make sure the operations are streamlined, that it’s smooth. It’s also accounting for the retrospect or the history of that institution but also forward thinking, setting up for success and then just leveraging the technologies we have currently or that are coming to make sure we improve our patient experiences, our clinical outcomes and address the two key parties here, the clinical teams. Obviously, the IT teams but also ultimately the patients. I think if that is the perspective or the mindset, I think they are off on their great trajectory.
Anthony: This absolutely should be on their radar, right. They should be thinking about imaging. Would you say that?
Dr. Chadalavada: Yeah. Imaging is growing and utilization, it’s growing. Obviously, it has a huge contribution from economics to the institution. It’s also important for patient care, patient decisions. I rarely have met a patient that does not have an imaging infrastructure or imaging test in their jacket. It is an important part of what they are, no matter what specialty it is and imaging is very centric to a pillar that they function around.
Anthony: Excellent, Dr. Chadalavada. I really appreciate your time today and I hope you have a great day. Thank you.
Dr. Chadalavada: Thank you, Anthony. I had a wonderful time speaking with you and this is a very important topic and near and dear to me so thank you for this opportunity.
Anthony: Take care.
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