Dr. Shrestha is Vice President, Medical Information
Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and
Medical Director, Interoperability & Imaging Informatics,
An effective image-sharing framework is essential to truly functional
and clinically meaningful electronic health record (EHR) deployments.
your clinical images and associated reports from the clutches of your
legacy systems and clinical information silos will enable a much
broader, patient-centric health delivery paradigm. The good news is that
today’s challenge is less about technological limitations and more
about defining priorities. How do you meet the mandates of Meaningful
Use, prepare for ICD-10, and take on countless other priorities—all
while pushing ahead with image exchange as a core strategy?
Clinical data exchange
we take a step back and look at our illustrious journey toward
embracing the EHR, we realize that while moving from analog to digital,
paper to paperless, and film to filmless were all critical points on the
trip, these systems become so much more valuable if they can “talk” to
one another. That is when the true value to clinical workflow can be
exponentially realized. The ability to effectively integrate disparate
clinical information systems and enable them to exchange clinical data
sets the stage for truly patient-centric workflow, as opposed to merely
So the battle is not just about
moving from analog to digital but about integrating health information
systems.That will facilitate access to and retrieval of valuable
clinical data, and streamline a robust workflow focused on a broader,
longitudinal care record. Such clinical data exchanges could potentially
reduce medical errors and lower costs through improved care
coordination among all stakeholders— providers, care teams, payers, and
Cloud-based image exchange
computing is often misunderstood and, particularly of late, over-hyped.
However, it offers dynamic scalability, better performance, and economic
sense. The availability of different cost models, including
pay-per-usage models, opens up possibilities in how deeply and how
quickly providers can choose to embrace these solutions.1
of what picture archiving and communications system (PACS) you have, or
the scale of your needs, cloud-based image exchanges must be exploited
further to meet the needs of an increasingly integrated health care
delivery environment. Despite some simmering concerns over security,
privacy, and cost,2,3 the truth is that we have the right technologies on hand now to enable much more sophisticated, yet simpler,
ways to support image exchange—and rid ourselves of the archaic
practices of printing film and burning CDs. There is no reason to be
handcuffed to the limitations of physical transport, lost media, and
proprietary file formats.
It is common knowledge that we need to
better define the approach to exchanging medical images and their
associated reports. Whether within hospitals, across various provider
locations (eg, trauma, transplant, and cancer centers, and radiology
clinics) or across wider health information exchanges (HIE),
interoperability across disparate silos is critical from a patient care
perspective. Without interoperability, we will continue to merely treat
one series of images at a time, and not the patient as a whole.
to other industries, such as banking, health care still has a way to go
when it comes to adopting clinical data exchange standards and common
data frameworks. There is a wide variety of standards. The problem is
the way those standards are interpreted.
Indeed, health care
organizations, regulators, vendors, and consultants have created
numerous standards that vary widely in their purpose and function. There
are document standards, such as clinical document architecture (CDA);
and conceptual standards, such as Health Level Seven version 3.0 (HL7 V3
RIM). Radiology has worked with the Digital Imaging and Communications
in Medicine (DICOM) image standard for years. But attempts to implement
and streamline these standards have resulted in many different local,
regional, and national clinical data exchanges.
IHE developed a
small group of profiles relevant to the exchange of medical documents,
including cross-document sharing (XDS) and a profile specific to the
sharing of images known as XDS-I. The Centers for Medicare &
Medicaid Services (CMS) and the Office of the National Coordinator (ONC)
have pushed for Meaningful Use guidelines that encourage the adoption
of these standards.
Although these standards have generally been a
tremendous boon to imaging, unlike data exchanges for medications, for
example, not enough has been done to encourage true image exchange.
RSNA image share network
a grant from the National Institute of Biomedical Imaging and
Bioengineering (NIBIB), the Radiological Society of North America (RSNA)
created the RSNA Image Share Network, a secure, patient-centric medical
image-sharing network based on common, open-standards architecture. The
network enables patients to control access to their images and imaging
reports through personal health records (PHRs) without having to depend
on CDs. RSNA Image Share currently provides services to patients at 5
major medical centers across the United States, and plans are under way
to expand the network.
Empowering clinical workflow
true image exchange not only empowers streamlined and coordinated
clinical workflow but also improves patient care by ensuring access to
prior studies and reports. Ready awareness of and ready access to these
studies directly correlates to appropriateness in image study ordering.
almost any connected PACS today can streamline connectivity to
electronic medical record (EMR) systems and health information exchange
(HIE) platforms via local edge devices or more elaborate cloud servers.
Coupled with the emergence of zero-footprint client viewers, this has
greatly facilitated access, retrieval, and viewing of images and reports
from any application and end-user device, including mobile tablets. An
emergency department physician can immediately retrieve an outside study
via the cloud, and submit it for an imaging consult to a specialist
radiologist on call.
A call to action: Meaningful Use 3
radiology received the cold shoulder in Stage 1 of Meaningful Use,
there was some saving grace in Stage 2, including a menu-set measure for
diagnostic image accessibility, clinical quality measures relevant to
radiology, and more flexibility in defining encounters. But for a
clinical specialty so integral to the running of a health system,
radiology measures for now are deemed only optional, not mandatory.
is no doubt that the ONC could do more to encourage widespread support
for an image exchange. Since imaging is critical to all clinicians, the
ONC should make accessibility of radiology results through the EHR a
core objective. Stage 3 of Meaningful Use should ideally encourage
health care providers to offer patients at least the option to have
their images and related information (such as dose) transmitted to other
health record systems. Image-enabling the HIE should be a priority
driven by clinical needs, technology readiness, and regulatory
Furthermore, many opportunities exist to leverage
broader national networks. Surescripts, an electronic prescribing
network used by 95% of U.S. pharmacies, could be used by national
networks not just to send pharmacy orders from the EHR but also to share
imaging reports and links to images across the nationwide network.
The time to enable true image exchange is here, and there is no time like the present.
- Shrestha RB. Imaging on the cloud. Applied Radiology. 2011;40:5.
- Alford T, Morton G. The economics of cloud computing: Addressing the
benefits of infrastructure in the cloud. s.l: Booz A, and Hamilton,
- Rangan K, Cooke A, Dhruv J, et al. The cloud wars: $100+ billion at stake. Technical report. Merrill Lynch. 2008.