Applied Radiology

Dr. Shrestha is Vice President, Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.

Disclosures: Dr. Shrestha is on the Medical Advisory Boards of Nuance Inc. and Vital Images, Inc., as well as on the Editorial Board of Applied Radiology, and the Advisory Board of KLAS Research.

As healthcare networks continue to deploy electronic health records, driven, amongst other things, by the successful carrot-stick approach of Meaningful Use regulations, we have the opportunity to define and embrace true enterprise imaging, and to build a more functional cohesion between electronic medical records and imaging systems. With the maturing of the picture archiving and communications systems (PACS) market¹ and the emerging needs of imaging in other clinical areas, we are seeing a need to approach enterprise imaging more inclusively, from acquisition and viewing images over a universal viewer to storage and image exchange. Image-enabling the electronic medical record (EMR) and soon, perhaps, health information exchanges (HIE), may not be optional down the line. Staying ahead of the curve is critical, as some legacy solutions may not fully embrace the standards needed for true interoperability and content exchange.

What truly is enterprise imaging?

Many do not bother to ask this question, choosing instead the easier route of believing the myths and fallacies spun by the marketing gurus we have aplenty today. Every chief information officer (CIO), director, or radiology chair that attends any healthcare or imaging-focused conference knows the need to address the burning demands of his or her institution for enterprise imaging. Unfortunately, most are getting blinded by buzzwords² and do not fully comprehend the notion of enterprise imaging as a singular concept.

Some think that enterprise imaging consists of enabling a cloud-based image exchange application that helps to get rid of CDs and DVDs and to streamline image exchange. Others believe that enabling a zero-footprint viewer so that images can be viewed across multiple platforms constitutes “enterprise imaging.” Some insist that the ultimate enabler of enterprise imaging really is mobility³ – freeing images from the confines of the workstation and making them available anywhere. Many PACS have ‘clinical viewers’ that allow referring clinicians to view images and reports remotely, and noble attempts are being made to tightly integrate these light viewers directly into EMRs. Perhaps this is enterprise imaging; after all, we’re hitting the needs of enterprise users. Yet others approach enterprise imaging from the bottom up, looking at image archiving as the linchpin of true enterprise enablement, and exploring the myths and realities of Vendor Neutral Archives (VNAs).⁴

While all these applications and functions contribute to true enterprise image enablement, none on their own truly address the overall requirements demanded by true enterprise imaging. Cloud-based image exchange⁵ is a marvel of innovation that leverages today’s technologies to address remarkably important workflow needs around image transfer and retrieval. Zero-footprint viewers were unheard of until just a few years ago, and several in the industry today truly require zero install and are entirely HTML-5-based. Images can be viewed literally from any browser or device, and launched from any application, such as an EMR. This is a significant move toward enabling enterprise imaging. While the concept of the VNA has been around for a while, the industry buy-in that it has garnered today is remarkable, and efforts to rethink enterprise- image archiving truly have merit.

Cohesion, not another singular application

The reality of true enterprise imaging, however, is that cohesion is king. It’s sometimes baffling to see that, as the industry tries to chomp away at the challenges of enterprise imaging in bits, what we truly need is an interoperable way to tackle the problems, to truly get us past the finish line.

The need for interoperability seems to raise its head toward a certain part of the spin-cycle in every significant electronic health technology revolution. As we started reaping the benefits of going digital in radiology, and started deploying disparate PACS, radiological imaging systems (RIS), and advanced visualization and reporting systems, we saw a desperate plea for more integration of these applications. We have seen the emergence of integrated RIS-PACS workflows and advanced PACS with integrated 3-dimensional (3D) functionalities. This call for cohesion and interoperability was also seen in the EMR world. As healthcare institutions continue to roll out EMRs and focus on computerized physician order entry (CPOE) and clinical decision support (CDS), we’re seeing a greater need for interoperability amongst these applications, resulting in a much more patient-centric view across the longitudinal care record, and the ability to aggregate, organize, and semantically harmonize discrete data elements, such as medications, allergies, problems, and diagnoses stored in disparate systems.

Sure enough, this cohesion is exactly what we need across the wave of enterprise-image-enabling technologies that are emerging above the horizon. Herein lie both tremendous challenges and remarkable opportunities. Much like the emergence of PACS, RIS, advanced visualization, and reporting in their own quadrants—with each application flourishing in functionality and complexity—we’re seeing the emergence of innovative approaches in enterprise imaging flourishing in their individual areas; and this time perhaps in more of a triad, in cloud-based image exchange, mobility, and VNAs. While it is essential for each of these 3 applications to grow, mature, and truly address the many complexities and challenges in their individual areas, failing to see the forest for the trees would be foolish. The key to unlocking the potential of enterprise imaging is to define and build a more cohesive and interoperable approach to the needs of the enterprise at large while ensuring that they complement and aid in the demands of individual departmental workflows.

It is refreshing that some in the industry are already starting to march in this direction. We are seeing vendor-neutral archives that are leveraging zero-footprint viewers to permit image launching from any platform, on any device, and across any application, including EMRs. We’re also seeing cloud-based image exchange push in the other direction—leveraging mobility and enabling the zero footprint viewers to drive workflow across the clinical domains.

Decoupling the PACS from the archive?

The traditional approach to deploying PACS has been to ensure a tight coupling of the actual workflow and application layer to the archive, ensuring optimal performance. However, as systems mature, and ecosystems of various applications start to flourish, we see needs emerging around scalability, optimization, and patient-centric workflow. As healthcare institutions start maturing, they are seeing needs driven either by acquisition or growth, toward workflows that entail more than one PACS. CIOs are witnessing the growing adoption of digitization in other “-ologies,” such as pathology, dermatology, ophthalmology, oncology, and otolaryngology. Of course, cardiology has always been a close counterpart to radiology, but CIOs are facing the daunting task of addressing the storage and workflow needs across the cardiology horizontals of echo, cath, and nuclear cardiology.

A novel approach to managing these needs is to decouple the PACS from the archive—and create a cohesive middleware layer between the storage and workflow layers to optimize workflow and system performance. This approach perhaps best leverages the potential of a VNA and mitigates the need to constantly migrate from one legacy archive to another, or to deal with waves of obsolete technologies.⁶ Proprietary storage or compression formats are always daunting challenges, but enterprise imaging is seeing a massive adoption of industry standards beyond DICOM and HL7 (such as IHE⁷ profiles including XDS.b and XDS-I). At the end of the day, this will enable true interoperability across the “-ologies.”

It’s the workflow, stupid

Imaging truly is the life blood of a healthcare organization. Most patients, at some point in their encounter with a healthcare organization, undergo an imaging study or two. Whether a trauma patient that needs an urgent computed tomography scan of the head and neck, or an ambulatory patient that gets seen by a PCP for a nagging headache and eventually ends up receiving a neurologist-ordered magnetic resonance image of the head, imaging is an established and essential part of clinical decision making across the enterprise. Hence, effective and efficient imaging management streamlines clinical workflows. It allows for a patient-centric approach to care versus an image- or application-centric approach. It allows for the possibility of true collaboration among care teams, which would bring the value of imagers back into the spotlight. It allows for true anytime, anywhere workflow, enabling a resident to postprocess a 3-dimensional reconstruction and share the key snapshots with his attending, who can then restore the saved presentation anywhere and immediately share the surgical roadmap with colleagues in his own clinic or operating room.

At the end of the day, this truly is about continuing to evolve, mature, and enable the most streamlined and patient-centric workflows across the enterprise.

References

1. Shrestha RB . Guide to replacement PACS, version 2012. Applied Radiology. 2012;41:4.
2. Shrestha RB. Blinded by buzzwords. Enterprise Imaging Blog. Applied Radiology, June 1, 2012. www.appliedradiology.com/blog_comment.aspx?id=27711&blogid=201402&blogid=201402. Accessed October 14, 2012.
3. Shrestha RB. Mobility in healthcare and imaging: Challenges and opportunities. Applied Radiology. 2012;42:9.
4. Marion J Enterprise Imaging Catching On? Healthcare Informatics. [Online] March 14, 2012. http://www.healthcare-informatics.com/blogs/joe-marion/enterprise-imaging-catching. Accessed October 10, 2012.
5. Shrestha RB. Imaging on the cloud. Applied Radiology. 2011;40:5.
6. Langer S. Issues surrounding PACS archiving to external, third-party DICOM archives. Digit Imaging. 2009;22:48-52.
7. Mendelson DS, et al. Image Exchange: IHE and the evolution of image sharing. Radiographics. 2008;28:1817-1833.