Bringing Imaging Informatics Education to Nepal: Joining the RAD-AID Initiative to Improve Healthcare in Low- and Middle-Income Countries

Imaging informatics is a field that is rapidly transforming healthcare worldwide. It involves the use of technology and information management to improve the efficiency and quality of medical imaging. Unfortunately, many low- and middle-income countries (LMICs) lack the infrastructure and knowledge needed to properly leverage these tools. This can have serious consequences for patients and healthcare providers in these areas.

I am excited to announce that I will be participating in a RAD-AID initiative to help provide imaging informatics education to the Tribhuvan University Teaching Hospital in Nepal! This hospital recently had an Ambra PACS installed, and hospital staff would benefit from an overview of imaging informatics workflow. I am thrilled to be able to provide this education and share my knowledge, as I was fortunate enough to participate in a Rad Aid experience in 2018 in which I helped implement a radiology information system in Ghana.
The lack of imaging informatics infrastructure and knowledge in LMICs is a significant challenge. The World Health Organization reports that about two-thirds of the world’s population lacks access to basic radiology services, and this issue is particularly acute in LMICs. In addition, many healthcare providers in these areas lack the knowledge and skills needed to effectively use imaging informatics tools.

The consequences of this lack of access to imaging informatics can be severe. Patients may have to travel long distances to receive imaging exams, which can delay diagnosis and treatment. Healthcare providers may struggle to manage large volumes of images and data, leading to errors and delays in care. Without access to tools like picture archiving and communication systems (PACS) and radiology information systems (RIS), healthcare providers may struggle to collaborate and share information with one another.
Through initiatives like the one I will be participating in, organizations like RAD-AID can help address these challenges. By providing training on the use of PACS and RIS, healthcare providers in LMICs can better manage and share imaging data. Implementing these tools can improve the efficiency of hospitals and clinics and reduce the likelihood of errors and delays in care.

It is exciting to travel to Nepal and share knowledge of imaging informatics with healthcare providers in need. This initiative will undoubtedly make a meaningful impact on the lives of patients and healthcare providers in the region. I will be sharing updates related to my trip, so stay tuned to learn more about this important work.
In conclusion, providing imaging informatics assistance to those in need is critical to improving healthcare outcomes in LMICs. Through education and the implementation of imaging informatics tools, healthcare providers can more effectively manage imaging data and improve patient care. Initiatives like the Rad Aid initiative in Nepal are essential to addressing this issue, and I am proud to be a part of this work.

In conclusion, providing imaging informatics assistance to those in need is critical to improving healthcare outcomes in LMICs. Through education and the implementation of imaging informatics tools, healthcare providers can more effectively manage imaging data and improve patient care. Initiatives like the Rad Aid initiative in Nepal are essential to addressing this issue, and I am proud to be a part of this work.


Welcome Back

Welcome back to our blog! It’s been a while since we last posted, but we’re excited to start sharing content with you again.

First and foremost, we wanted to let you know about some exciting news – we have recently launched Nagels Consulting, a company focused on providing top-tier imaging informatics training.
With the increasing reliance on electronic medical records and the growing volume of medical images being produced, there is a high demand for professionals with expertise in imaging informatics.

At Nagels Consulting, the goal is to provide comprehensive and practical training that helps professionals stay up-to-date on the latest technologies and best practices in the field. We believe that through our training, we can help professionals advance their careers and make a meaningful impact on patient care. Our training programs are designed to cater to the needs of various professionals, including radiologists, technologists, and IT professionals. We offer both in-person and online courses, allowing participants to choose the option that best fits their schedule and needs.

In addition to our training programs, we also offer consulting services to organizations looking to optimize their imaging informatics systems and processes. Our team of experts has a wealth of experience in this field and can provide valuable insights and recommendations to help organizations achieve their goals.

We hope you’ll join us on this exciting journey as we work to provide top-tier imaging informatics training and consulting services. We look forward to sharing more updates and insights with you through our regular blog posts.


The Countdown to Ghana!

In 2017, RAD-AID and SIIM teamed up to create the SIIM Global Ambassador program. During the first year of the program, two SIIM Global Ambassadors – Starla Longfellow and David Marichal – traveled to Laos and Nicaragua, countries in which RAD-AID had recently installed PACS. Starla and David were recently on SIIMCast, in which they sat down for an interview about their experiences participating in the program.

If you would like to listen, the interview is embedded below:

When I heard about the opportunity to support our global imaging informatics community, I was immediatley interested. I applied earlier this year and am excited and honoured to have been selected as one of the 2018 SIIM Global Abassadors.

In less than a month, on September 29th, I will be flying out to Ghana, to lend a helping hand with Imaging Informatics at Korle Bu Teaching Hospital in Accra. I will be in Accra for 2 weeks and plan on regularly tweeting, and hopefully posting to the blog while there.

Below is a terrfic video that demonstrates the positive impact that RAD-AID has had in Ghana.

Stay tuned for more updates. If anyone has tips for the trip, feel free to post a comment below.

– J

Imaging, Standards and Interoperability

Let’s hop into the Delorean and travel back in time…

The date is November 8, 1895 and a 50 year old bearded man named Wilhelm Roentgen is testing the results of passing electric current through a combination of low pressure gases.  Working in complete darkness, he notices a screen across the room become bright fluorescent as the electric currents pass through discharge tube.

This is the moment Wilhelm discovers X-rays.

Wilhelm starts experimenting, capturing images of different sized objects in the X-rays’ path. He calls to his wife, and creates the first ‘x-ray’ by developing the image of his wife’s hand.

It doesn’t take long for manufacturers to start building technology to satisfy the demand for this new technology. The year following Roentgen’s discovery, the world’s first radiology department is launched in the Glasgow Royal Infirmary in 1896.

From this point on, diagnostic imaging continues to evolve. Skip ahead to the late 1940’s and we see ultrasound imaging being used for diagnosis. In the mid-1960’s, the Egan Method for capturing mammography imaging is used. In the decade that gave us disco and punk-rock, we are introduced to the CT scanner and MRI imaging.

With the 1980’s, the adoption of information technology increases and ‘PACS’ is introduced in order to exchange diagnostic imaging digitally. This drives the need for standardization across the industry. Thus DICOM is born and the eventual creation of the IHE framework we rely on today for standardization.

The timeline below demonstrates how far we’ve come, from the discovery of different imaging methods, to our reliance on standards.


  • Wilhelm Roentgen discovers X-Rays.

    Wilhelm Roentgen discovers X-Rays.

     Captures the first x-ray of his wife’s hand.

  • First Commercial X-Ray Machines

    First Commercial X-Ray Machines

    GE and Siemens develop electrical equipment for production of X-Ray.    

  • World’s First Radiology Department

    World’s First Radiology Department

    Glasgow Royal Infirmary starts first radiology department.

  • First Annual RSNA meeting

    First Annual RSNA meeting

    The first  Annual RSNA meeting held at Hotel Sherman in Downtown Chicago

  • Ultrasound Imaging

    Ultrasound Imaging

    Ultrasound is used as a Diagnostic tool used in USA in late 1940’s

  • The Egan Technique

    The Egan Technique

    Robert Egan publishes book called ’Mammography’. The “Egan technique”, as it became known, enabled physicians to detect calcification in breast tissue.

  • Computed Tomography Imaging

    Computed Tomography Imaging

    Computed Tomography (CT) scan invented by Godfrey Houndsfield. These early CT scanners took several hours to acquire the raw data for a single  slice and took days to reconstruct a single image.

  • Magnetic Resonance Imaging

    Magnetic Resonance Imaging

    Magnetic Resonance Imaging is used as a medical diagnostic technique to create images of the human body using the principle of nuclear magnetic resonance.

  • HL7


    Precursor activities begin in 1979, that would eventually result in HL7 as a standards development organization.

  • PACS


    The first large-scale PACS installation is implemented at the University of Kansas.



    ACR and NEMA join forces and form a standards committee that would eventually be known as DICOM.

  • IHE


    Integrating the Health Exchange (IHE) created to identify workflow scenarios and document how to use established standards to solve workflow challenges.

(This timeline demonstrates how far we’ve come from the discovery of different imaging methods, to our reliance on standards. Standards are essential for interoperability.)


Now that we’re all caught up to the present day, we can hop out of the Delorian and explore the idea of interoperability.

Interoperability doesn’t have to be an abstract concept related to exchanging information across computer systems. We experience social interoperability on a daily basis. Marriage is an example of interoperability. In marriage, two separate parties attempt to come together and achieve a common goal. Most likely, both partners speak the same language, but may have different ways of interpreting delivered messages, with different communication protocols.

In our Imaging IT world, there are always ways to find non-standard workarounds to achieve desired results in specific use cases; however without standards it can be near-impossible to replicate those results.

A little over a decade ago, the goal to see ‘one patient, one record’ across Canada was established. In order to achieve ‘one patient, one record’ from a diagnostic imaging (DI) perspective, the need was identified that outside DI studies and reports should seamlessly integrate directly into local PACS. In Canada, the method of sharing outside imaging directly into the local PACS became known as ‘foreign exam management’ (see linked journal entry for more on this topic).

Providing a local PACS with the ability to ingest and manage foreign exams is an interoperability challenge. Unfortunately there was no defined standard or framework for foreign exam management. This resulted in regions across Canada rolling out different degrees and variations of implementations that supported this function. Many of these implementations relied on unique and custom built proxy boxes.

Over the past year I’ve been fortunate enough to sit on the IHE Radiology Planning and Technical Committees and witness the development the profile, Import and Display of External Priors. This is a profile that intends to address the use-cases related to foreign exam management.

It’s been quite an experience to see the development of an IHE profile, from the initial identified need addressed with multiple custom workarounds, to the development of an IHE profile that will rely on mature established standards.

Roentgen wouldn’t have been able to imagine what imaging would be like today. The word interoperability didn’t even exist back then.

It’s hard to predict what the future will look like as imaging continues to evolve and new tools emerge to manage our changing needs. One thing can be certain, as technology moves forward, so will our standards.

Keep it going… /What are your thoughts?

A few final thoughts before closing this post off.

  • If there is anything on the timeline that you think would be useful to add, leave a comment and let me know. It would be great to see this timeline continue to grow with feedback from our Imaging IT community.
  • I’ve had a fun time being involved and watching the development of an IHE profile. Feel free to get involved and participate! IHE relies on vendor and customer participation to keep our standards moving forward.




Plans for SIIM17

In just over 3 weeks from now, attendees of this year’s SIIM conference will arrive in Pittsburgh: The city that  brought us Heinz Ketchup and Andy Warhol, and a city that apparently has more bridges than Venice. Pittsburgh’s city planners seemed to have rubbed off on the SIIM planning committee as this year’s theme is ‘Bridging the Transformation to a New Era of Medicine’.  It’s an appropriate theme when the City of Bridges is hosting the event.

Here’s a few of the key sessions that I’m excited about for SIIM17.

Day 1:

Opening Session: Harnessing Artificial Intelligence: Medical Imaging’s Next Frontier

This is a topic that keeps growing in interest to our community – I’m interested to hear how the session touches on harnessing the power of AI rather than being fearful of AI making us irrelevant.

9:45 am – 10:45 am: Order Entry CDS: From Implementation to Positive Outcomes

IHE profiles such as Guideline Appropriate Ordering (GAO) and Order Appropriate Tracking (OAT) are helping shape the actions of CDS.  I’m interested to see how CDS can be used as a tool to report when repeat imaging is prevented due to appropriateness checks.

1:15 pm – 2:45 pm: Rad-Path Diagnostics: Rethinking Imaging Informatics

Now that the FDA has approved Phillips to Market their Intellisite Pathology Solution for Whole Slide Imaging for digital pathology, this is just the beginning. It will be interesting to see how the FDA’s approval affects consumer interest in adopting digital pathology. I’ve written in the past about the disconnect between standards development and vendor solutions for non-radiology imaging. This should be an interesting discussion.

In the evening I hope to grab a sandwich at Primanti Brothers and find a local Pittsburgh craft beer to wash it down with. (If anyone has any suggestions on local Pittsburgh craft beer, I’m all ears)


Day 2:

9:45am – 10:45am – Educators Toolkit for Imaging Informatics: From Basic Education to Advanced Learning

Education and effective knowledge transfer affect us all. Without effective training, our teams will be weak, adoption low and our patients and customs will suffer. 

1:15pm – 2:45pm: Carnegie Mellon Showcase: Technologies that Will Help Propel Key Aspects of Imaging Informatics
3:00 pm – 3:30 pm: Data Interoperability With, and Access For, External Referring Physicians
4:15pm – 5:15pm Radiation Dose Metrics: Current & Future Considerations

Friday evening is the only night that the Andy Warhol Museum doesn’t close at 5pm. We often talk about wanting to achieve creativity and innovation within our industry.  Andy Warhol is a good example of someone that was able to find creativity in everyday common place items.  It takes a special way to look at the world to see a soup can and figure out a way to make it art.

Campbell’s Soup Cans – Andy Warhol

Day 3:

8am – 9:30am: Image Retention: Help Us Develop an Image Retention Policy that Makes Sense
9:45am – 10:45am: The Business of Imaging: Ruthlessly Quantifying Your Value Metrics
11:30am – 12:30pm: Role of Artificial Intelligence in the Future of Medical Imaging – What Do Vendors Think?
1:15pm – 2:45pm: Improvement Stories for Informatics Professionals
Closing Session: Weaving the Fabric of Trust: Security, Privacy, Resilience, and Accountability

Over the past year, there have been many reports of hospitals being victim to cyber-attacks, including ransom ware attacks. This should be a great closing session.

I look forward to seeing​ you at SIIM17.



The User Adoption Process

Imagine if you will…

You’ve just wrapped up a lengthy project, in which you’ve implemented a new solution at a hospital or clinic. Now that the venture is complete, we can relax, pat ourselves on the back and watch user adoption just roll in.

Seems like a fantasy? In reality we typically see something quite different…

Regardless of how well a project is run, and despite how beneficial the implemented solution is for the end-user; any time a solution involves changing current behavior, without a well thought out change management plan, it remains a challenge to drive user adoption. It’s not uncommon to see well-designed, robust solutions fail, due to a lack of effort to implement proper change management.


Successful user adoption is not accomplished in a short sprint, but rather, it occurs over time and it increases with stakeholder’s effort. As demonstrated in the graphic below, user adoption is a gradual process, with several steps to take towards full user acceptance and commitment.

image source: Erica Toelle – Create Your End User Adoption Strategy

These steps are building blocks, in which you ideally start out early in the project, making all stakeholders aware of the new solution. Once the stakeholders are aware of the general solution, further effort is required to ensure users have a thorough understanding of the solution’s functionality. Understanding the solution must develop into commitment and buy-in from the user-base, which will leads to successful adoption.

This begs the question, what efforts can we apply to achieve success across these building blocks?


The following are 3 key actions that should be part of the overall adoption strategy:

1.What is the baseline and what is the target?

If you are trying to improve user adoption on an existing solution that is currently available to your users, first ask yourself, where are you today and how many active users are currently using the solution?

Understanding the baseline creates realistic adoption targets. The targets should be time bound. For example, ‘over the quarter we hope to improve user adoption by 5%.’  Additionally, reviewing the existing user base may help to identify any highly active users. Active users can work as cheerleaders to ‘advertise’ the solution to their colleagues. Determining realistic targets may also require outside input from subject matter experts, or pulling data from past experiences.

The adoption rates will vary depending on the solution – for example, if the new functionality is required as part of the user’s job, the expectation would be 100% adoption. If the solution is a value add and improves the user’s work experience, but is not required functionality, it may be useful to look at adoption targets for previous comparable projects.

2. Build Awareness and Make the Solution Known

This can be as simple as trying to build a conversation related to the solution. One easy and inexpensive way to build awareness and stir up conversation is creating a poster campaign that highlights key events in the adoption process, from the launch and ongoing training, to helpful how-tos and usage success stories. A simple lunch-n-learn that provides the users with top user tips and a relaxed atmosphere for a Q&A session can be very effective.

Look at the opportunity of providing awareness to indirect stakeholders. If the primary users are physicians, is it possible to build awareness of the functionality to the patients? This might not always be possible, but if the solution is something that directly impacts the patients, they may be able to become a cheerleader for the solution.


3. Training, Training, Training….

Continuing from where we left on building awareness, effective training is an essential part of the adoption process. Implementing a training plan can be a bit of challenge when training isn’t your official role. Often training is just one of the hats you wear,  and your department doesn’t have access to the tools (i.e. eLearning authoring software, Learning Management Systems, etc.) that a formal training department would  have access to. Stay tuned for a follow-up post that provides some tips to help implement an effective training strategy, and what cheap or free tools are out there that can be leveraged.

The main thing I’ll mention here, as it relates to adoption, is that training is an ongoing process. Regardless of which training method you use (face-to-face, webinar, self-paced eLearning, blended style), it can not be assumed that once a user has received training, they then  have sufficient knowledge to commit to regularly using the solution. Cheat sheets and/or ‘short to the point’ eLearning modules can be beneficial to users so they can easily reference key steps if they ever feel stuck.  Again, I’ll elaborate on best practices for training in a future post.


These are just some of the options available for successful user adoption. I’d love to hear what successes (and pain points) you have found when trying to implement adoption strategies. Feel free to share in the comments section.




To wrap or not to wrap? That is the question…

It’s been a busy 2016! Here’s a December post to cap off the year!

One of the initiatives that I’ve been involved in the past few months, is investigating the opportunity of integrating non-radiology imaging in the Diagnostic Imaging world.  Some of these non-radiology image types could include, but are not limited to:

  • Wound Care
  • Dermatology
  • Ophthalmology
  • Non-DICOM Cardiology
  • and …. Pathology

Let’s spend some time on last, but by no means the least significant item on the list – Digital Pathology. As you are most likely aware, Digital Pathology is extremely large in volume and size.

If we look at this strictly from a formatting/standards perspective, it becomes an interesting exercise. There are two distinct camps on how Digital Pathology should be handled. Just like other opposing groups that we are familiar with (ie. The Montagues vs the Capulets, the Jets vs the Sharks, or Biggie Vs. Tupac, etc.) -these two imaging camps have their own moniker:

DICOM vs. Native Format

DICOM has been around for a little over 30 years and is a proven standard that’s provided interoperability between disparate imaging vendors.

nema-dicom ACR/NEMA 300, version 1.0, released in 1985.

Fast forward to 2016, and this standardized interoperability makes it possible to exchange and share patient’s diagnostic imaging. Additionally this standards-based approach provides customers the possibility (and freedom) of migrating their imaging data to another PACS vendor at any point. The customer isn’t restricted to using only systems that support a ‘proprietary’ imaging format.

Considering all the pros and history of DICOM as a standard for image transfer, it would only make sense for non-Radiology imaging to follow the same approach and to adopt DICOM as an imaging format, right? Well that answer is a bit unclear.

Let’s look at Pathology for example: A lot of effort has been put into DICOM Working Group 26, which is focused on a DICOM based approach to handling Digital Pathology. Not to mention the IHE domain, PaLM (Pathology and Laboratory Medicine), which has coordinated activities and joint meetings with DICOM Working Group 26.

When we compare the work being accomplished in the standards committees to what vendors are doing in real life, we see quite a gap. I recently had a Digital Pathology vendor provide a demo of their product. They touted all the “benefits” of not relying on DICOM and using a proprietary format. According to this vendor, using a proprietary imaging format, provided ‘more flexibility and better performance’. To me that sounds a bit too much like a sales pitch. I’m curious if a customer decides to change vendors at a point in the future,  how difficult will it be to migrate/convert the proprietary imaging format so that it’s acceptable for the new vendor.

It appears that this particular vendor isn’t unique with this behavior. My very informal investigation related to this, has discovered that it’s hard to find a digital pathology vendor that isn’t using a proprietary imaging format.

This leaves us with a bit of a disconnect between the focus of Standards Committees and how vendors are building their solutions for the real world.

After all, these are ‘just’ standards. By definition the purpose of a standard is to reach a certain level of quality or attainment. Standards are not requirements, and the only thing that will drive the vendors to create change is through consumer action.

I would love to hear from others on their experience with integrating Enterprise Imaging in their environment and what you have found from a DICOM vs. Native format perspective. Feel free to comment below.






7 Tips for Patient-Centered Care


It was only 2 weeks ago that SIIM 2016 was kicking off, but it feels like it’s far off in the rear-view mirror now. There were so many great sessions – and I’m already looking forward to see what SIIM17 has in store.

One of the presentations that I find replaying in my mind is the Opening session, ‘Leveraging Innovation to Drive Patient Centered Care’, by Rasu Shrestha.

In the presentation he laid out 7 tips for Patient-Centered Care.

They are as follows with a few comments I’ve added below some of the items.

  1. Forget what you know – Challenge the status quo
  2. Humanize care – Understand that on the other end of the screen is a patient
  3. Embrace design thinking – We replicated the analog world instead of embracing new tech opportunity
  4. Tame the data beast – Connect big data to big insights
  5. Focus on simplicity – We don’t want to just add things, we want to make sure we’re also taking things away.
  6. Fear less – Embrace failure
  7. Aim for behavior change – Innovation at the end of the day is about behavior change

Of the 7 points, the three that really connected with me were the following:

Forget what you know:

This reminds of the concept of ‘Beginner’s Mind’ in Zen practice. There’s a saying that goes, “In the beginner’s mind there are many possibilities, in the expert’s mind there are few.”

Humanize care:

Of all the points listed, this is the one that hit me the most. I see this often with vendors and Healthcare IT professionals stuck in the mindset of building or fixing IT solutions. It’s easy to forget that the whole purpose behind the solution we’re providing is to serve the patient.

Fear less – embrace failure:

Simply put failure can be an amazing tool. The idea of embracing failure reminded me of this quote by Bill Gates: “It is fine to celebrate success, but it is more important to heed the lessons of failure.”

Once again – Thanks to all for putting on a great conference this year at SIIM16.


Jason N

Reflecting on 11th MIIT

This past Friday, I was fortunate enough to attend the 11th annual Medical Imaging Informatics and Teleradiology Conference (MIIT).


All of the sessions were very information and, based on what I saw this year, I would highly recommend you make an effort to attend next year’s 12th annual MIIT.

For the purpose of this Blog Post, I’ve decided to comment in particular on Brad Erickson’s presentation on Deep Learning. I’m really interested in how AI will fit into our future.

Deep Learning is something most of us access multiple times a day. Anyone using Siri, Google, Facebook, Twitter, Skype and the list goes on…, is witnessing the power of Deep Learning. Here  is an article from WIRED on how AI is changing Google Searches. The article reinforces what Brad Erickson’s presentation stated on the power of systems that can ‘learn’. Here’s one quote from the article:

“Google’s search engine was always driven by algorithms that automatically generate a response to each query. But these algorithms amounted to a set of definite rules. Google engineers could readily ch ange and refine these rules. And unlike neural nets, these algorithms didn’t learn on their own. As Lau put it: “Rule-based scoring metrics, while still complex, provide a greater opportunity for engineers to directly tweak weights in specific situations.”


Something as common-place as searching for the best Thai restaurant in your neighborhood has been positively impacted by AI.  What will the impact be to Imaging Informatics?

It’s been 5 years since Watson won Jeopardy and since then we have watched IBM improve Watson and prepare ‘it’ for healthcare. It seems likely that in 15-20 years (or quite a bit earlier) most diagnostic imaging will been ‘seen’ by a deep learning solution. What will it take for the culture to change for us to feel comfortable with a computer performing the primary read on our diagnostic imaging?

I think there’s an analogy between self-driving cars and AI in radiology. We have Tesla’s that can drive us to work, but it’s illegal for us to sleep at the wheel. Regardless of the fact that Google’s self-driving cars had driven over 1.3 million miles before causing its first accident, many people felt like this accident emphasized why we shouldn’t have self-driving cars.

Imagine the Public’s reaction on a system’s first misdiagnosed read that caused a negative impact to patient care. Even if AI makes the odds of accidents low, it feels more natural to have humans cause accidents rather than computers.

Moore’s Law may state that computing power will approximately double every 18 months –  but can the general public’s comfort level with technology keep up with this pace?

This talk really whet my appetite for the SIIM 2016’s closing talk ‘Peering Into the Future through the Looking Glass of Artificial Intelligence’.

Hope to see you there in Portland.


Feel free to share your comments below on how you think AI will fit into radiology, and how the ‘court of public opinion’ will impact the technology moving forward.