Enterprise imaging: Threat or opportunity for radiology?

2018 03 05 21 43 1005 Oosterwijk Herman 400 Thumb

The majority of U.S. hospitals are looking for vendor-neutral archives (VNAs) to facilitate future PACS upgrades and/or changes in PACS vendors, as well as to allow different specialties to archive and manage their images across the enterprise. An additional advantage of the VNA is that it also becomes an access point for inter- and intraenterprise image access by nonradiology physicians.

Herman Oosterwijk of OTech.Herman Oosterwijk of OTech. The VNA, combined with the recent widespread implementation of electronic medical records (EMRs) facilitated by meaningful use incentives, can now provide easy access to imaging archives via EMR portals with a simple click of the mouse. Most radiology results used to be available only through transcribed reports, except for "heavy" imaging users such as surgery or orthopedics, but now the floodgates are open and images are available at basically every PC.

The scale of this level of image availability can be mind boggling. Take, for example, the Mayo Clinic Health System in Rochester, MN, which has close to 50,000 PCs that have this capability. The days are long gone in which physicians had to come to the radiology department to look at images, and image access has become ubiquitous by tying image archives into EMRs.

What is the impact for radiologists? They are no longer gatekeepers of imaging information, and their role needs to change if they want to keep their added value.

Here are some recommendations on how to deal with the advent of enterprise imaging -- and my suggestions for turning it into an opportunity:

1. Have input on workflow.

Make sure radiology's voice is heard and participate in planning meetings, as it is critical to design workflow upfront. Here are a few potential bottlenecks that can cause issues:

  • Determine when images are becoming available to the enterprise. It might be wise to make images available to physicians only after the radiology report is generated, assuming it does not involve emergency cases.

    Some large hospitals have a dedicated 3D lab for CT and MRI reconstructed views. Creating these additional images might also be a condition to have the images in a holding pattern until all data are ready to be reviewed.

  • Take into account how to handle image updates, deletions, and modifications. Imagine that all changes are made by a technologist, or in the case of a complicated fix by a PACS administrator at the departmental PACS, these must be communicated to the VNA. There could be a rare condition where some of the image fixes arrive at the VNA prior to the images. To avoid any conflicts, you might need middleware to buffer those changes until the images arrive.

  • Make sure the EMR viewer supports displaying the key images identified by a radiologist; you don't want your surgeon to have to scroll through a 3,000-slice whole-body CT. Instead, open up only the images that are relevant to the finding; for example, a lesion to be excised in the lung. In addition, make sure that Presentation States are supported as well to show annotations, window and level settings, and zoom/pan changes by the radiologist.

2. Consult with the specialties about the review and processing features of the EMR viewer.

Each specialty has its own workflow, especially if it is "encounter-based" and not used to scheduling formal orders, as is the case for most radiology departments, so that merging the patient demographics to the images could be challenging. Remember that radiology has probably at least a decade of experience with managing and viewing images, which can be invaluable to the deployment of image viewing across an enterprise.

There are many lessons learned that can benefit the decision-makers who are looking to make an investment in the enterprise imaging system. This does not apply only to the radiologist but also to the PACS administrator who will have a lot of experience in keeping the system up and running and taking care of the image and information integrity.

3. Change the role from gatekeeper to consultant.

Be proactive to make sure that physicians know they can access your expertise and ask questions about any findings. For many findings, there is a gray area in between benign and malignant, or pathology and normal, and having a conversation about these findings can be invaluable for physicians and, ultimately, patients.

4. Embrace the opportunity of additional access.

Enterprise imaging provides access for many more specialties other than radiology and cardiology, but the reverse is also true as well. A radiologist looking at a head CT scan can also view the images from the conebeam CT done by dentistry, look at potential head wounds and/or other image documentation done when the person was admitted to the emergency department, and correlate ophthalmology images with brain function that controls vision, as well as surgical notes if there was any brain surgery done. There is much to gain, especially if the PACS is driven by the EMR, providing access to notes, labs, allergies, patient family history, and much more.

Enterprise imaging also assumes access from outside your enterprise through standard communication protocols for image and information exchange such as XDS and access to a registry to find out if and where prior exams would be accessible. This is also a major advantage, as the headache of importing and exporting CDs with prior studies will be replaced with easy online access.


Enterprise imaging is an opportunity instead of a threat. It belongs in the "O-quadrant" of your strengths, weaknesses, opportunities, and threats (SWOT) analysis. Don't feel threatened by it: Embrace the opportunity for change. Radiologists, being the imaging experts, can make an impact by being part of the decision-making process for the next-generation imaging and informatics solutions.

Herman Oosterwijk, president of OTech, is a healthcare imaging and IT trainer/consultant for image management companies, specializing in PACS, DICOM, and HL7.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.

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