April 15, 2016 -- The viewer can enable enterprise imaging -- or doom it to failure. It can bring medical disciplines together or keep them apart.
Launched from the electronic medical record (EMR), the enterprise -- sometimes called "universal" -- viewer should ideally display images from and for all medical disciplines: MRI and CT scans from radiology, digital photographs from dermatology, videos from endoscopy, electrocardiograms from cardiology, and PDFs and other documents from just about anywhere.
Making these images widely available encourages collaboration, which may improve patient management, according to Dr. Shafiq Rab, vice president and chief information officer for Hackensack University Medical Center in New Jersey.
"How do we do the right thing by the patient?" he asked, quickly answering his own question. "We do that by making [healthcare] easy. We put everything in one place. It is that simple."
Breaking down barriers
The need to break down barriers between "-ologies" will push enterprise imaging beyond the DICOM-based PACS that preceded it, Rab said. Enterprise imaging must store and distribute images of many different kinds, as image viewing is democratized across the enterprise.
But the diversity of users in the typical healthcare enterprise presents a challenge to the viewers charged with displaying the images. This calls into question the premise of a truly "universal" viewer, particularly one that can meet the diverse needs of dermatologists, pathologists, radiologists, and others.
"Today, there is not a viewer that can universally handle all different workflows," said Dawn Cram, manager of application systems development for enterprise imaging at the University of Miami. "So [in that respect] the 'universal viewer' is a misnomer."
In recognition of this, vendors are coming to favor the term "enterprise" rather than "universal" when referring to their viewers. The most basic of these serve the lowest common denominator of medical practice, displaying the basic image and allowing simple functions such as pan and zoom. Disciplines reaping the most benefit from basic enterprise viewers are those whose images had not been previously allowed -- dermatologists, pathologists, and the like.
Yuma Regional Medical Center, located in the Arizona desert, uses a clinical viewer from Mach7 Technologies for simple viewing of images and another, the eUnity software from Client Outlook, for its go-to diagnostic viewer. As the medical center expands its vendor-neutral archive (VNA) to support images from its many departments -- a process now underway and expected to continue for the next several years -- other viewers will be plugged into the Mach7 ecosystem.
"If we wanted to have 10 different types of viewers, all we have to do is connect them," said Brian White, PACS administrator for Yuma Regional.
White is orchestrating the implementation of a VNA that within five years could host images created by every specialty in the medical center and its sprawling network of clinics. He is open to the inclusion of just about any viewer, an approach made possible by an IT backbone from Mach7 that allows a best-of-breed ecosystem of technologies.
"We are saying, 'Hey, use what you want to use to read your images,' " he said.
Forcing physicians to use a specific viewer is a sure route to trouble, said Rab from Hackensack University Medical Center. Radiologists from the hospital, for example, often use the viewer built into their PACS from Agfa HealthCare, which serves as the backbone for the interpretation of images. But they and other physicians across the enterprise have the option to use VitreaView from Vital Images.
Vital has designed VitreaView for access to simple tools, while also providing the option to access more advanced toolsets through a series of well-placed clicks along the inside rails of the imaging frame. In this way, VitreaView can be many things to many physicians.
The enterprise imaging world is populated by myriad viewers, the most advanced of which evolved from thin-client servers that were developed as adjuncts to PACS. VitreaView is one of these. Others come from TeraRecon, whose viewers evolved from the front ends of thin-client servers designed initially more than a decade ago as advanced visualization options to PACS.
Images should flow easily throughout the network, Rab said. But practical and technological challenges have gotten in the way at the University of Miami.
To maximize bandwidth and accelerate the transmission and display of images, the IT staff at the university restricts access to images on a need-to-use basis, according to Cram.
"Do you actually need to query all these sources, if the specialty doesn't call for it?" she asked. "If your enterprise viewer is calling out to a data source that is really slow, it is going to make your enterprise viewer slow."
In planning to image-enable the university health enterprise, it installed a VNA that is being loaded initially with multimedia images. These now include everything from digital photographs of patient skin to endoscopic videos. An enterprise viewer, developed by IBM's Merge Healthcare unit, launches from the electronic medical record to display those non-DICOM images. Meanwhile, radiology maintains its own PACS; cardiology four of its own PACS, each suited to a specific type of image. Cardiologists and radiologists use viewers they choose.
The goal behind image-enabling the University of Miami was to promote efficiency and collaboration. But doing so at a large academic teaching enterprise in the northeastern U.S. (whose policies require it to remain anonymous) did little to bring radiologists any more into the medical fold than they were before. Recently, the network administrator heard from a radiologist that his first inkling that enterprise-wide imaging was possible came when a referring physician called to ask about an image.
"The radiologist wouldn't have even known [enterprise imaging was in place] if a clinician hadn't called and said, 'I'm looking at this patient from X hospital,' " the administrator told AuntMinnie.com. "He didn't even know it existed."
Hackensack University Medical Center hopes to avoid this by providing common ground for all enterprise physicians seeking access to images. While specialists may use a high-functioning and specialized PACS viewer, they all have access to VitreaView, which is embedded in the medical center's Epic EMR system.
"We believe everything has to be in the patient health record, so we are using VitreaView in its full capacity so all physicians and all providers can have full access to everything at any time," Rab said.
Constrained by budgets and prevailing practice patterns, administrators may resist the urge to try to enable the entire enterprise in short order. They may, instead, opt for a phased approach that image-enables pieces of the enterprise by priority.
Dermatology is often an early choice because it allows the capture and sharing of images that describe a condition better than can be done with words. These images, for example, might capture the initial appearance of a rash or wound and later depict its response to treatment. The ad hoc use of digital cameras -- especially ones built into smartphones -- has added a sense of urgency to efforts to add dermatology to the image-enabled enterprise.
Alternatively, enterprises may be image-enabled by connecting individuals rather than brick-and-mortar departments and clinics. As part of an effort to improve the efficiency of its physicians, Sheridan Healthcare is deconstructing the components in the Merge PACS in its teleradiology service and deploying a VNA to store radiology images -- as well as ones from office-based ob/gyns.
"We're deploying our own technology that will sit on top of hospitals' PACS or replace their PACS," said Dr. Glenn Kaplan, chief of comprehensive teleradiology solutions at Sheridan Health, which he described as the largest hospital-based practice in the country. Sheridan Health provides radiology services, as well as anesthesiology, neonatology, and emergency medicine to hospitals and medical facilities nationwide.
Images are being displayed using a TeraRecon viewer capable of handling the range of radiological and ob/gyn images and the complexity of their diagnostic interpretation.
Just as image enablement can change the practice of a profession, it can also change the profession itself. Long accustomed to operating within their own world of PACS, radiologists at Yuma Regional Medical Center are growing accustomed to working within the patient medical record.
Workflow at Yuma stems from Clario, a worklist-driven engine from Clario Medical Imaging that integrates with the Yuma PACS, dictation system, and the medical center's evolving VNA. Radiologists interpret images in the context of the EMR from Epic Systems, which launches alongside the dedicated PACS viewer.
Like pushing desks together in a classroom, image-enabling the enterprise can bring specialties together. Hackensack University Medical Center is trying to do exactly that.
"We started by bringing radiology and cardiology into our VNA, then we turned to maternal medicine echoes," said Jeremy Marut, Hackensack's director of enterprise architecture. "Dermatology is coming in next; we'll follow with dental and then different areas."
Enterprise imaging increases collaboration, Rab said. But there's a catch -- a big one. It only happens "if physicians like each other," he said with a laugh.
But he's not kidding.
Technology can only do so much, Rab and Marut agree. Like the VNAs, networks, and servers that drive them, viewers must support the needs of physicians and the institutions where they work.
The administrators who determine the policy underlying these devices and the staff who implement and use them determine whether and how much these technologies will benefit the patient. Making it work for the patient, Rab said, is the highest purpose of enterprise imaging.
"The most important person in this entire dialogue is the patient," he said.