"Despite widespread implementation of electronic health records, many patients and doctors find the majority of their clinical images lie in poorly integrated silos," said Dr. Christopher Roth, in comments made during a March 1 session on understanding the challenges of enterprise imaging at the Healthcare Imaging and Information Management Systems Society (HIMSS) meeting in Las Vegas.
The silos may be comprised of still or video images, scanned clinical documents and reports, or charts such as electrocardiogram (ECG) strips. They may support a differential diagnosis or confirm a clinical suspicion. Others may -- optically or through a radiological modality -- indicate key elements of a procedure before, during, or after its completion.
Evidential images, spanning the range from optical to radiological, demonstrate the current status of the patient; for example, a skull with multiple fractures, chickenpox on the skin of a pediatric patient, or video taken through an endoscope. Reports incorporate multiple images used as illustrations for textual explanations.
Their exchange and sharing serve a range of purposes from diagnostic to consultative. They may underlie the transfer of emergency patients from one facility to another, support consultations on trauma or burn patients, or satisfy a patient request for a second opinion. The recent wave of consolidation that has washed over the healthcare landscape has added to these challenges.
"In today's environment, you have hospitals buying up other hospitals, which all operate their own [electronic medical records (EMRs)] and PACS," said Don Dennison, a member of the board of directors of the Society for Imaging Informatics in Medicine (SIIM) and chair of the American College of Radiology (ACR) Connect Committee.
Meeting the challenge of sharing
Sharing images and documents across departments and facilities can be difficult within and outside of the enterprise. But it is being done daily. IT platforms and vendor-neutral archives (VNAs) developed initially for DICOM-based images are being adapted to handle non-DICOM photos and documents.
Some platform-based solutions span the enterprise, constructing a single patient record that includes images as well as textual data. With these products, image sharing is achieved using the same rules-based engine that orchestrates workflow.
Another kind of solution is exemplified by an offering from Fujifilm Medical Systems USA, which uses its VNA as the means for sharing images and documents across departments.
"The VNA serves as the organizational layer for content management," said Bill Lacy, Fuji's division vice president of informatics marketing and enterprise sales. "Putting [content] in a VNA immediately gives you sharing capability."
The company's VNA, obtained in the spring of 2015 through the acquisition of TeraMedica, complements its Synapse 5 PACS software. Integrated with an EMR system, the VNA interfaces with PACS -- either its own or ones from other vendors -- to provide interdepartmental connections that might be leveraged through a single, enterprise viewer that launches from the EMR.
Fuji has expertise in the development of such interfaces, as it offers not just PACS and a VNA but also a zero-footprint, browser-based viewer, as well as interfaces to endoscopes and point-of-care ultrasound in its product portfolio.
Mach7 Technologies provides yet another kind of hybrid, one that combines a platform- and VNA-based approach, utilizing an IT backbone for sharing images. The company describes its enterprise imaging platform as supporting an "ecosystem" of best-of-breed information technologies that correlate and share images across various -ologies and other departments within an enterprise.
"Our platform really focuses on the 'A' and 'C' of PACS," said Eric Rice, Mach7's chief technology officer. "The communications capabilities of the platform are where we provide the workflow exchange and (image) sharing, moving images between departments and sites."
Broward Health Medical Center in Broward County, FL, uses the Mach7 platform to integrate, access, and share images across its more than 50 healthcare facilities. Similarly, Sentara Healthcare in Norfolk, VA, uses the platform to share images residing on eight different PACS across more than 100 sites in Virginia and northeastern North Carolina. Among the Sentara facilities are 12 acute care hospitals, nursing and assisted-living centers, and outpatient campuses.
Images are embedded in the resident EMR using any of several "recipes." These recipes prescribe how the Mach 7 platform interacts with the EMR. Workflow is tailored to the individual institution.
Rice explains that the supplier of an EMR, for example, "might have a workflow that is great for dermatology, but the wound care physicians might want a different solution," Rice said. Consequently, Mach 7 tailors the IT infrastructure "so that anything that goes into the EMR can flow into our platform," he said. "This provides a unified repository for all the unstructured clinical data."
The chief information officer and other members of the hospital C-suite want this kind of flexibility, according to Rice.
Often the healthcare enterprise has installed one or several PACS, subsequently implements an EMR system, and thus seeks to image-enable its network by combining and extending the two types of IT systems.
"We integrate really with any imaging vendor that our customer chooses," said Eric Helsher, vice president of client success at Epic, a leading provider of EMR systems. "We use standards-based integration with the PACS or VNA, take its images, and display them on a viewer that is launched directly from Epic."
There are many possible options and approaches to image-enabling the enterprise, Helsher said. In addition to expanding on the PACS and VNA, a customer may implement a document management system to handle reports and specialty charts such as ECGs. In an Epic-based, image-enabled enterprise, these non-DICOM images would be displayed as well as DICOM images on the viewer, which could be a best-of-breed product.
"I could click a link and launch the viewer to see a scanned document, a DICOM image, or a non-DICOM image, such as the digital photograph of a wound," he said. "The idea here is that Epic provides a single view. We want to keep providers within the system so they can access any image."
Healthcare providers in the enterprise may not be the only ones who need or want access to medical images. Many IT companies provide portals through which patients can view their own images or through which they can assign providers outside the enterprise the right to view their images.
Despite the availability of these portals, sharing images among facilities, particularly ones in different enterprises, may depend on burning images to CDs, DVDs, and USBs. In these cases, patients may be pressed into service as couriers. This practice is not only expensive, as it entails the use of media, there can be problems reading the images, resulting in patient management delays.
LifeImage claims to have the solution: an instant and secure image exchange that bears the name of the company. This technology, adopted by dozens of high-profile users, among them Beth Israel Deaconess Medical Center, the Medical University of South Carolina, and Baylor Health Care System, reduces the need to burn images on media, according to Jim Phillips, LifeImage's senior vice president of client services. It also supports the transfer of data using these media.
Even digital-savvy hospitals receive images burned on media, he said. These may come from patients referred to a hospital from outside the state, or they may come from providers in a regional health system that simply does not want to exchange images electronically.
"Even today our best customers still see 20% of their outside exams on CDs," he said.
This is why LifeImage has developed its system to support both the electronic- and media-based transmission of images. Regardless of their source -- or type (LifeImage manages DICOM and non-DICOM images) -- images are handled using the same software and toolset. This allows the "exact same workflow," Phillips said.
Images may be transferred electronically over a secure connection using the Internet. Or they may be transferred in a Dropbox-like way. In the latter method, the recipient receives an email that states an image is available for transfer and includes an email-embedded link. First timers register for receipt of the image and then complete the download.
Currently, many of the image transfers among facilities are ad hoc. But this is going to change, according to Phillips, who envisions the evolution of a centralized registry of images that allows participating facilities to index exams so that images are easily and immediately available.
In the image-enabled enterprise, image sharing touches all aspects of patient management, from the practical to the incongruous, speeding consultation and engaging patients in their care. How these images are used depends heavily on how they are displayed.
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