Global Health Informatics
The ACR RFS International Outreach Subcommittee at the 2015 ACR annual meeting presented several projects that students have worked on in various countries as part of global health elective months.
A recurring theme was the need for development in informatics because many of the institutions still rely on plain film radiography. A gentle conversion to digital technology can make a serious impact and is an achievable goal for many institutions.
The best analogy I have come across to help understand imaging informatics is the use of an iPhone or digital camera to capture photos. Just as you take photos with your iPhone and generate smart albums based on metadata in the photos, the Digital Imaging and Communications in Medicine (DICOM) standard governs storing, printing, and transferring medical imaging information. DICOM allows viewable patient images to be transferred between facilities regardless of equipment manufacturers and PACS.
Chest x-ray films are stored at Moi Teaching and Referral Hospital in Kenya
Courtesy Dr. Marc Kohli
Lean practices, which are designed to maximize available resources and sustainability, are critical when approaching global health radiology informatics. Projects that do not extend beyond their period of implementation can be wasteful and cause unnecessary disruption. One approach to making a project sustainable is to use open-source systems (software code that is available for modification under different licenses) to help run a lean system. Open-source software is provided free to use and modify, thus reducing licensing fees. Several open-source systems have a large community that builds new tools and offers support.
Not all components of a digital system may be applicable to each institution. Breaking a digital conversion into discrete tasks can allow for a smoother transition. That way, the transition can be carried out gradually as subsequent students become involved in the project.
The very first step is to understand the infrastructure available. This includes the imaging equipment and basic ideas of licensing. The local staff in most cases have little knowledge about licensing. A modular approach breaks the grand informatics challenge into small problems, including equipment and licensing, image management, radiation safety, order entry/management of referring physicians, personnel and training, cost and financing, and study interpretation.
I graduated from medical school in Kenya and trained in health informatics at Indiana University/Regenstrief Institute. I have developed and implemented multiple informatics projects in Kenya, Ethiopia, and South America. Below are pointers that have aided me as I work on global health initiatives.
• Find out the manufacturer of all equipment at the site you are visiting. Contact and make friends with company engineers that you can reach out to with technical questions. Locate manuals online or through your contacts (as most of the equipment will break down and reference manuals are rare).
• Image management involves a database for image storage (usually PACS), viewing, and processing. Several open-source PACS exist, including DCM4CHE and Orthanc. There are several open-source viewers available that connect to PACs, like Weasis for Windows, Horos, and Osirix for Mac users. Download software required before travel as most global health sites have poor Internet connectivity.
• Radiation safety remains a critical need. Assisting with protocols can save money and protect workers and patients. For example, most sites perform studies with and without contrast routinely and apply adult doses for imaging children.
• There are not enough radiologists in developing countries. Hence, always take the opportunity to teach medical students, medical officers, and any frontline health workers who are most likely to interpret the images.
Most of all keep an open mind, and always keep learning.
As they say in Kiswahili, Safari njema (Have a good trip)!
By Judy Wawira Gichoya, MD, radiology resident at Indiana University School of Medicine