By Greg Freiherr, AuntMinnie.com contributing writer

March 3, 2016 -- LAS VEGAS - PACS is fading, as enterprise imaging steps into the spotlight. But there are serious challenges -- both technological and cultural -- to the adoption of what some believe may be the inevitable extension of a once purely radiological application.

At this week's Healthcare Information and Management Systems Society (HIMSS) meeting, three radiology thought leaders described the challenges that threaten enterprise imaging and the forces that are compelling the medical community to embrace it. In an hour-long session, radiologists Dr. Christopher Roth and Dr. Alexander Towbin, led by healthcare strategist Kim Garriott, described the difficulties of coping with the different types of workflow that drive the various disciplines of medicine. They also discussed the challenges in effectively sharing and retrieving images and displaying medical images as part of the electronic medical record.

The advance of consumer technologies -- particularly mobile devices such as smartphones and tablets -- combined with the widening bandwidth for data transmission are forcing healthcare's hand. Physicians today are already capturing and sending digital images ad hoc to their colleagues, according to Towbin, a pediatric radiologist and chair of radiology informatics at Cincinnati Children's Hospital.

This practice poses serious risks to patient privacy, he said. It also introduces gross inefficiencies into the system. Images may be all but impossible to archive and retrieve, even by the physician taking them, as these images are stored on isolated computers or smartphones.

"These images tend to stay in [the physician's] photo library," he said. "Another problem is that they are being sent to colleagues. It's being done. We need to do it in a safe way."

Roth, vice chair of radiology IT and clinical informatics at Duke Health, advocated a planned, strategized approach to implementing enterprise imaging, one that begins with an understanding of what enterprise imaging entails. Integral to this definition, he said, is the management of all clinically relevant content, including imaging and multimedia. This is done with a singular purpose of enhancing the electronic health record, as it relates to diagnostic imaging, planning for procedures, recording evidence (e.g., the extent of a fracture), and as part of image-based reports.

Methods for image capture, indexing, management, storage, retrieval, viewing, and exchange, as well as analytics, are all based on the specific workflows used in different departments and by different specialties.

Images must be easily shared regardless of their type or how they are captured, Towbin said. The trick is in tying these images to the patient. While this is easy for radiology and cardiology, thanks to DICOM, it is anything but for other specialties. Radiology is driven by worklists compiled from medical orders, whereas many other disciplines are encounter-based. A dermatologist, for example, may decide on the spur of the moment to photograph a skin condition, leading to problems later on in identifying the patient.

One way to address this problem is to faithfully bracket each picture with digital photos of identifying information. But slipping up just once, either before or after the patient photo, will jumble images together. Pasting a barcode sticker in the photo's field-of-view might work in some cases, but it won't for endoscopy, just as it would be impossible to anonymize the image for presentation at a scientific conference, for example, Towbin noted.

Today, image sharing among providers is often accomplished using CDs, according to Garriott, principal consultant for healthcare strategies at Logicalis. Because the CDs are often carried by the patient, this can delay viewing and, consequently, planning or action by the medical team receiving the images. In a worst-case scenario, the CDs are not compatible with readers at the other facility. This can be particularly problematic for emergency cases, such as those referred by a community hospital to a level I trauma center, she said.

Organizations have to be looked at holistically, "so whatever solutions are purchased can be used across the organization rather than having departmental silos of technology," Garriott said.

Similar challenges regarding ease of use and interoperability relate to display technology. Viewers should be "zero-footprint," Towbin said, so they can work on a wide variety of devices, including desktops and smartphones. Having a zero footprint means that the image is rendered at the server and streamed to the remote device.

These viewers are often referred to as universal -- but they definitely are not, he said. These are really more akin to "enterprise viewers." Designed with a limited set of tools, such as pan and zoom, they are intended to satisfy the basic needs of most physicians. They fall far short of the mark for specialists, such as radiologists, cardiologists, or orthopedists, who depend on advanced processing to make diagnoses or plan interventions.

"These specialists need viewers with the functionality that fits their specific needs," Towbin said.

C-suite considerations were not presented during the session as being among the challenges facing enterprise imaging. They could, however, be among the most difficult to address.

Two speakers told AuntMinnie.com that the argument for adoption is more difficult to make for image-enabling the enterprise than for PACS. The rationale for enabling wide availability of medical images is not as obvious as moving from analog to digital images was for radiology, according to Garriott.

"People at different levels of the organization have different views," she said. "Some don't think that clinicians should have access to all of the images."

Similarly, enterprise imaging can't deliver the same increase in efficiency and cost savings as PACS.

"You have to look at it in a completely different way," Roth said. "You have to look at the soft costs [of not image-enabling the enterprise]. These are the costs imposed by nonstandardization and by confusion among clinical providers," costs that are woven into today's delivery of healthcare.

While image-enabling the enterprise will not replace an inefficient methodology, it will increase the availability of images to physicians who would otherwise go without, he said.

The advance of technology makes it all but certain that enterprise imaging will be pursued, just as technological progress is fundamentally changing the nature of PACS, Roth told AuntMinnie.com, noting how each letter in this acronym has recently taken on new meaning.

"Picture" no longer refers to just radiological images but also to optical ones, both static and video, he said. "Archive" is now part of increasingly popular vendor-neutral solutions. And "communication" is accomplished daily by hundreds of millions of individuals around the world using the Internet.

"There will always be a need [in radiology] to do archiving and indexing and viewing," Roth said.

Increasingly, in the future, this need will be more widely shared.

In the coming weeks, AuntMinnie.com will examine how the three key challenges facing enterprise imaging -- workflow, image sharing, and display -- can be addressed with technology that is now commercially available or nearing the market.


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