Dr. Shrestha is Vice President, Medical Information
Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and
Medical Director, Interoperability & Imaging Informatics,
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?
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.
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
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
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
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
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.
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?
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.
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
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.
- Shrestha RB . Guide to replacement PACS, version 2012. Applied Radiology. 2012;41:4.
- Shrestha RB. Blinded by buzzwords. Enterprise Imaging Blog. Applied Radiology,
June 1, 2012.
Accessed October 14, 2012.
- Shrestha RB. Mobility in healthcare and imaging: Challenges and opportunities. Applied Radiology. 2012;42:9.
- Marion J Enterprise Imaging Catching On? Healthcare Informatics. [Online]
March 14, 2012.
Accessed October 10, 2012.
- Shrestha RB. Imaging on the cloud. Applied Radiology. 2011;40:5.
- Langer S. Issues surrounding PACS archiving to external, third-party DICOM archives. Digit Imaging. 2009;22:48-52.
- Mendelson DS, et al. Image Exchange: IHE and the evolution of image sharing. Radiographics. 2008;28:1817-1833.