The document discusses the challenges of enterprise medical imaging in Zambia and opportunities for improvement. It finds that there is a critical shortage of radiologists in Zambia and limited use of modern medical imaging practices. A case study of University Teaching Hospitals in Zambia showed inefficient workflows due to a lack of imaging systems. The authors propose implementing enterprise imaging techniques to help address these challenges by improving how medical images are acquired, managed, and analyzed. A SWOT analysis identified strengths like trained staff but also weaknesses like outdated equipment and a lack of IT infrastructure. The study aims to better understand current workflows and help automate processes through new imaging systems.

1. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Enterprise Medical Imaging in
the Global South: Challenges
and Opportunities
Ernest ZULU1
and Lighton PHIRI2
1
Adult Hospital, University Teaching Hospitals
2
The University of Zambia
Zambia

2. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Radiological Examination Process

3. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Motivation, Problem Area
Two fundamental challenges affecting effectiveness
and efficiency of radiological services in the global
south:
• Critical shortage of radiologists
• Limited use of modern medical imaging practices
Potential solution to address the second challenge:
• Implementation of Enterprise Imaging
(EI)—techniques and workflows for
– Acquiring
– Indexing
– Managing
– Storing
– Analysing ….clinical images

4. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Research Objectives
To:
• Highlight challenges that adversely affect effective
interpretation of medical images
• Explore the opportunities associated with the
implementation and adoption of EI strategies in
order to enhance medical imaging interpretation in
Zambia

5. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Research Approach, Methodology
Study approach
• Mixed method approach
– Case study at University Teaching Hospitals
– Meta-analysis
Methodology
• Strengths‐Weaknesses‐Opportunities‐Threats
(SWOT) analysis
– Records analysis
– Personal observations
• Enterprise Medical Imaging Meta-analysis

6. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results (1/2)
• 2815 health
facilities in Zambia
• Owned by
– Government of the
republic of Zambia
(GRZ)
– Military
– Non-Governmental
Organisations (NGO)
– Private
• Our work focused
on public health
facilities (GRZ)

7. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results (2/2)
• 151 facilities
classified as Level 1,
2 or 3 Hospitals
– Majority owned by
GRZ
• Radiologically
equipped according
to level in GRZ
facilities
• Only 8 GRZ
Radiologists,
operating in 5
facilities

8. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results: UTH Case Study (1/2)
Workflow challenges
• No Radiology Information System (RIS) or Hospital
Information Service (HIS)
– Inadequate request forms
– Repetitive entries of patient details
– Uncollected final reports
– Tedious annual returns report generation
• No Picture Archiving and Communication System
(PACS)
– No systematic storage of images and reports
– Manual reporting
– Multiple registration of same patient
– Use of non-DICOM image acquisition
• Long report turnaround time
– Few Radiologists
– Heavy workload

9. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results: UTH Case Study (2/2)
• Total examinations: 92, 599
• Majority of modalities are X-rays and Ultrasound,
mostly done in lower-level hospitals

10. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results: EMI Analysis (1/2)
Challenges affecting EMI implementation
• Challenges of integration of various clinical imaging
disciplines into unified EI
– Differences in workflows (e.g. ordering of an imaging
exam)
– Challenging patient identification in non-DICOM images
– Differing image qualities and standards (measurements,
image colour, patient positioning)
– Linking of all patients’ images and reports in the EMI
viewer to the patients’ EHR
– Lack of EMI-specific ontology and standard nomenclature
– Medico-legal concerns
– Use of mobile devices for image acquisition and personal
privacy

11. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Major Outcomes/Results: EMI Analysis (2/2)
Additional challenges facing EI implementation in the
global south
• Substantial cost and ongoing investment for
maintenance
• Requirement for good Information and
Communication Technology (ICT) support service,
• Training of users and requirement for a good
understanding of complexities involved in EI
implementation

12. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
SWOT Analysis: Strengths
• Well-trained radiologists
• Organised existing imaging stakeholder
departments
– Well-established administrators
– Standard Operating Procedures (SOP)
– Manual workflows in place, could be incorporated in
EI-centric ecosystem
– Fairly equipped imaging ecosystem at all levels (level 1, 2
and 3), DICOM-compatible machines
• Ongoing mobilisation of Teleradiology equipment

13. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
SWOT Analysis: Weaknesses
• Subsidiary departmental imaging services not
integrated into mainstream clinical imaging
• Continued use of analog imaging in some modalities
• Use of visible light based image capturing
equipment in some subsidiary services
• Poorly-serviced equipment with frequent and long
downtimes
• Lack of good ICT infrastructure

14. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
SWOT Analysis: Opportunities
• Developing EHR system (SmartCare)
• Pre-existing e-Government services for internet
connectivity

15. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
SWOT Analysis: Threats
• Unreliable internet connectivity
• Uncertain acceptability of EI

16. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Conclusion and Outlook
• SWOT analysis was conducted; highlighted the
challenges and opportunities of implementing
successful EI strategies
– Motivation for implementation of EI strategies
• Meta-analysis conducted to consolidate information
on general challenges of EI implementation against
local challenges
• Ongoing: Pilot study to fully understand current
imaging workflows with expected outcome of
automation of the workflows
• In pipeline: Implementation of
– PACS and RIS
– Machine learning models
• Further research required in exploration of
automatic radiology report generation

17. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Bibliography
[1] O. Bwanga, J. M. Sichone, P. N. Sichone, and Y. B. Kazuma, ‘Image
Interpretation and Reporting by Radiographers in Africa: Findings
from the Literature Review and their Application to Zambia’, Med. J.
Zambia, vol. 48, no. 2, pp. 125–135, Aug. 2021 [Online]. Available:
https://mjz.co.zm/index.php/mjz/article/view/877
[2] D. A. Clunie, D. K. Dennison, D. Cram, K. R. Persons, M. D. Bronkalla,
and H. ‘rik’ Primo, ‘Technical Challenges of Enterprise Imaging:
HIMSS-SIIM Collaborative White Paper’, J. Digit. Imaging, vol. 29, no.
5, pp. 583–614, Aug. 2016, doi: 10.1007/s10278-016-9899-4. [Online].
Available: https://doi.org/10.1007/s10278-016-9899-4.
[3] C. A. Petersilge, ‘The Enterprise Imaging Value Proposition’, J. Digit.
Imaging, vol. 33, no. 1, pp. 37–48, Nov. 2019, doi:
10.1007/s10278-019-00293-1. [Online]. Available:
https://doi.org/10.1007/s10278-019-00293-1.
[4] C. J. Roth, L. M. Lannum, and K. R. Persons, ‘A Foundation for
Enterprise Imaging: HIMSS-SIIM Collaborative White Paper’, J. Digit.
Imaging, vol. 29, no. 5, pp. 530–538, Oct. 2016, doi:
10.1007/s10278-016-9882-0. [Online]. Available:
https://doi.org/10.1007/s10278-016-9882-0

18. 16 - 20 May 2022 IST-Africa 2022 Copyright 2022 Authors
Enterprise Medical Imaging in
the Global South: Challenges
and Opportunities
Ernest ZULU1
and Lighton PHIRI2
1
Adult Hospital, University Teaching Hospitals
2
The University of Zambia
Zambia