HIMSS/SIIM paper offers advice on enterprise image viewers

By Erik L. Ridley, AuntMinnie staff writer

August 4, 2016 -- Interested in adopting an enterprise viewer for reviewing images in the electronic health record (EHR)? There are some key issues to be aware of, according to a white paper jointly produced by the Healthcare Information and Management Systems Society (HIMSS) and the Society for Imaging Informatics in Medicine (SIIM).

For one thing, institutions need to grasp important technical considerations such as the software's performance and security. They also have to consider their requirements for advanced image processing as well as workflow-enhancing functions, according to the paper, which was published online July 29 in the Journal of Digital Imaging.

The white paper is part of a series on enterprise imaging topics produced by a HIMSS-SIIM workgroup and was authored by a subgroup focused on enterprise viewers.

Filling a gap

The subgroup defined an enterprise viewer as a "thin-client or zero-client application used on any off-the-shelf device to distribute, display, and manipulate multispecialty image, video, audio, and scanned documents stored in separate centralized archives through, or standalone from, the EHR."

Due to a variety of business and workflow needs, enterprise viewers are becoming popular options for facilitating image review in the EHR, according to the team led by Dr. Christopher Roth of Duke University.

"While specialty viewers will always be necessary to review high-complexity imaging for patient care and to handle some of the unique needs of diagnostic imaging specialties, overall their role as the backbone of imaging care within an enterprise may grow less common," the authors wrote.

Many healthcare enterprises are seeking to implement an enterprise imaging repository, enabling a single integration point for the EHR software to find images and facilitating a scalable central storage model, according to the group. However, images have traditionally been stored across many disparate clinical archives; each specialty may have its own archive or even multiple archives for storing images.

"Given that, enterprises have the option of interfacing their many legacy viewers into their EHR for widespread image accessibility or using a single enterprise viewer that can query federated archives," the authors wrote. "The latter is the common choice due to ease of support and the clinical satisfaction of a consistent application to manipulate all images, rather than forcing familiarity with many disparate location and specialty-specific viewers."

The authors said that enterprise viewers can allow hospitals to handle many gaps in clinical use cases:

  • Single-viewer access from the EHR, integrating clinical documentation with images stored in many storage archives
  • Integrating many forms of "nontraditional" clinical still image and video content not viewable in some traditional enterprise PACS today, such as from pathology, handheld cameras, and endoscopes
  • Diagnostic image interpretation by specialties and clinics without a dedicated PACS, using an application of high quality and often with some advanced image data manipulation functionality
  • Physician-to-physician collaboration, as some enterprise viewer applications offer teleconferencing capabilities while sharing the image viewer interface
  • Point-of-care secure mobile device image access for providers to review and discuss findings with patients and families in the hospital without being tied to a hardwired workstation
  • On-call provider image review in homes or offices
  • Patient portal image viewing
  • Referring physician or telehealth portal image viewing
  • Some medical learner education and research image viewing

Technical considerations

Most enterprise viewers today send imaging studies from the archive to a render server and/or short-term cache. From there, end users can access the data on their desktop, laptop, or mobile device, according to the authors. They noted that many enterprise viewers convert the image's original format to lossy or lossless non-DICOM formats, speeding up image access.

"After data transmission, many enterprise viewers reduce the resolution of the image on the server and send a rendition appropriate for the device and screen requesting the imaging, including to mobile devices," they wrote. "If the user zooms in on the image, the larger image is retrieved and rendered."

Because some providers view images in different environments than others, the enterprise viewer should, ideally, present images in the optimal state for the environment and user without requiring manual intervention.

"Enterprise viewer technology is developing quickly and toward having fewer client-side dependencies," the authors wrote. "Current iterations often do not require the plug-ins or runtime environments of older versions."

The group said that higher-functioning viewers require an HTML5-compatible web browser and can be used on most desktop and mobile operating systems.

"Compared to a full legacy PACS client, enterprise viewers often offer similar presentation of large sets of still image and video data with minimal latency and consistent playback frame rate, but fewer requirements on the local browser, RAM, and central processing unit," they wrote.

Security matters

Because devices can get lost, security is bolstered when the viewer does not require the transfer of composite DICOM data and metadata to the local device, according to the group.

"Some enterprise viewers today support client-side cache life-cycle management policies, deleting content immediately after its presentation and preventing image content from being retained on the device," the authors wrote. "Viewers should use secure connections and offer built-in encryption."

Enterprise viewers can be accessed either separately from the EHR via secure authentication or via existing EHR authentication. If access is provided only through the EHR, institutions can then enforce EHR access control policies. The authors also noted that enterprise viewers will often provide audit records.

"Even with these controls, however, with the ease of screen capture on today's devices, no enterprise viewer offers complete risk avoidance for losing medical imaging [protected health information]," they wrote.

In mulling over purchasing options, institutions need to consider issues such as the software's efficient usability, mobility, breadth of functionality for advanced and specialty toolsets, security, speed of full dataset presentation, and affordability, according to the authors. They also said that the differences in support and implementation costs between thin-client and zero-download browsers aren't substantial enough to be significant differentiating factors.

"Zero-download browser-based viewers may sacrifice slightly on speed, though the small difference may not be noticeable or relevant to end users," they wrote. "If speed is adequate, generally no-download applications are slightly preferable for end users with mobile devices because they do not require manual updating on personal devices."

Regulatory issues

Vendors typically pursue U.S. Food and Drug Administration (FDA) classification of their enterprise viewer mobile app offerings as either class I -- considered by the FDA to be of low risk of harm to use -- or as a class II device, which requires 510(k) clearance. Class I devices are generally cleared for image review, while class II devices -- including most specialty PACS viewers -- require more stringent controls for performance and design.

"With telemedicine growth internationally, many enterprise viewer mobile app vendors have sought diagnostic classifications similar to FDA class II outside of the U.S.," the authors wrote. "Outside of previously mentioned access controls, it is difficult for health organizations to predict how and when the enterprise viewer would be used for diagnosis and treatment, rather than image review, for research viewing, or for medical education. Thus, those viewer vendors with a broad spectrum of full and mobile version FDA class II and global clearances across the many imaging specialties and modalities may have a competitive advantage in that their solutions have been evaluated more intensively and may offer mitigated risk to the institution."

One size fits all?

Although specialty PACS viewers -- such as those used by radiologists during image interpretation -- and enterprise viewers may have similar technical requirements, they also have substantial clinical differences. Enterprise viewers can include some advanced features, but, in general, they are designed to meet the needs of image consumers rather than those specialties that produce diagnostic images.

"Thus, even with an enterprise viewer, most healthcare organizations should plan on having at least some specialized applications for more technically or clinically challenging diagnostic use cases," the authors wrote. "Note that higher-cost enterprise viewers often are more inclusive of advanced, specialty, and workflow toolset needs."

All enterprise viewers today include basic toolsets for image manipulation tasks, but many differ on their inclusion of advanced image processing functions such as surface rendering, volume rendering, centerline placement, multimodality image fusion, multiplanar reconstruction, bone removal, and maximal/minimal intensity projection, according to the group.

"Advanced tools often permit easy manipulation of large DICOM datasets of content to gather new perspectives and conclusions," the authors wrote. "These tools are often the primary differentiators across vendors providing enterprise image viewers."

These advanced features are typically used by the imaging service that generated the image, as well as by specialties that utilize imaging to plan surgical interventions. Primary care physicians would only infrequently use these capabilities.

"As functionality becomes more widespread across vendor solutions and across clinical user bases, advanced tools grow to become increasingly basic and commoditized, such as enterprise viewers more and more commonly offering multiplanar reconstructions of coronal and sagittal views from isotropic axial datasets," they wrote.

Specialty toolsets

Specialty toolsets -- image data manipulation features typically required only by the specialty generating the image -- are not often included on enterprise viewers, according to the authors.

"Modality vendors develop new diagnostic image data-capture technology and physiologic calculation tools regularly and often require a dedicated same-vendor proprietary specialty viewer in early development," they wrote. "Promising capabilities in imaging deep learning and computer vision will likely be piloted in specialty toolsets and grow more widespread over time toward enterprise viewer use."

In addition, "enterprise viewer capabilities in specialty toolsets are being developed quickly and with broad physician input and prioritization," the authors wrote.

Enterprise viewers may also vary significantly in their inclusion of features that can aid daily operations of an imaging enterprise or communication of imaging findings.

"Some enterprise viewers incorporate provider-to-provider real-time text and video chat or teleconferencing for synchronous imaging study collaboration; these collaboration tools may be only within an organization or may be configured with image sharing capabilities outside the organization," they wrote. "Workflow tools tied to specialty PACS or enterprise viewers may also include integrations for voice dictation and structured data passage to downstream systems."

When choosing an enterprise viewer for EHR image review, it's important to include a multispecialty provider evaluation as well as provide adequate oversight, according to the group.

"Further enterprise viewer expansion is expected to cover the broad needs of provider, nonprovider staff, and patient image access and viewing in coming years," the authors concluded.

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