The big picture: Interoperable medical image exchange

This content is sponsored by lifeIMAGE

The concept of transmitting diagnostic medical imaging files has been around for at least 30 years. By 1993, Digital Imaging and Communications in Medicine (DICOM) became an internationally accepted standard for healthcare organizations to handle, store and transmit medical images to a Picture Archiving Communication System (PACS). Teleradiology was the first use case for transmitting images from a PACS in one location to another PACS where a remote radiologist could "read" and interpret the exams. The handshake between the two PACS installations was complicated, time consuming, expensive, and for some time it required use of the same equipment at both ends.

The difference between PACS' ability to exchange information and an interoperable image exchange is akin to fax machines versus Facebook, says John Halamka, MD, CIO of Beth Israel Deaconess Medical Center in Boston. Medical image exchange basically allows the ability to easily send images from hospital to hospital regardless of the PACS system they use. Dr. Halamka says. "Why would you fax when you have Facebook?"

The value of medical image exchange
In essence, a medical image exchange network is a cloud-based platform that enables organizations, individual physicians or even patients to send and share medical images with outside organizations or physicians. The images do not have to be stored centrally, and when they need to be shared across entities, they are transported through the cloud.

Apart from the ease of use, medical image exchange also holds significant value in the spheres of patient safety and economic incentives.

First, excessive imaging can be harmful to patients, as excess exposure to radiation from multiple images can elevate the risk of damaging side effects. Imaging has long been the primary diagnostic tool in an acute care setting, so providers often default to image or reimage patients who present in their emergency rooms, says Mony Weschler, chief technology and innovation strategist of Montefiore Medical Center in Bronx, N.Y. The ability to access and view images from other providers can drastically decrease the number of times patients are exposed to radiation due to duplicative imaging.

Additionally, images are critical to tracking patient progress through treatment and evaluating the efficacy of a treatment plan. While an initial image can show the acute onset of an ailment, physicians need a series of prior images to see whether a tumor, for example, is getting bigger or smaller, which will in turn inform treatment decisions. This becomes an issue when patients go to different facilities for different care purposes or decide to switch providers. "If a patient's whole healthcare is provided by Montefiore, it's very easy with the click of a button to see all the priors and that the tumor is growing or shrinking or if the treatments are working," Mr. Weschler says. "But if a patient comes from other organizations, then you're missing that [access to priors]."

Not only is excessive imaging detrimental to patients' health, but the new reimbursement practices set forth by the Affordable Care Act encourage providers to reduce duplicative imaging as a cost containment measure. "Under the ACA, you're given a fixed amount to keep patients healthy, and redundant and unnecessary testing is a cost [center], not a profit [center]," Dr. Halamka says. "There's this imperative for sharing images across competitive organizations, especially things like CT or MRI, which are very expensive imaging tests. That never existed before."

The ACA has also spurred merger and acquisition activity. However, consolidating organizations are often functioning on disparate PACS systems. From a business standpoint, bringing those systems together carries significant cost measures. "As an IT guy, the cost of ripping and replacing everybody's PACS system to have unified image sharing is prohibitive," Dr. Halamka says. "What I need is some kind of glue that allows me to take my existing imaging infrastructure and now share images across different manufacturers' PACS systems because we're a merged system."

Then there are patients, who are increasingly signing up for more affordable health plans and higher deductibles. Conventional wisdom says that as image sharing becomes more prevalent, patients will use it to seek second opinions and shop around for quality and affordability. In this era of patient engagement, physician loyalty has taken a back seat to patient satisfaction and convenience.

An enterprisewide solution
Even within organizations, hospitals can face barriers to image exchange. Though imaging has traditionally been viewed as mostly residing in the radiology department, nearly all subspecialties require and produce images. The problem is that most departments have their own imaging devices, creating information silos.

"You've got radiology, cardiology, pulmonology, gastroenterology and every one of them has their own imaging device," Dr. Halamka says. At the same time, care teams from various departments and specialties are expected to collaborate more closely than ever before.

Hamid Tabatabaie, CEO of medical image exchange network lifeIMAGE, says care collaboration among different providers necessitates interoperability and access. "Nearly half of the doctors in the U.S. practice a specialty or subspecialty that interacts with imaging data," he says. "Whether it's to receive a referral or access a patient's history, access to prior imaging is important to enable collaboration among clinicians during the diagnosis and treatment planning."

IT leadership as the intermediary
Given multi-disciplinary demand, hospitals and health systems need a central strategy for coordinating image exchange initiatives across the enterprise. The IT department can spearhead this, given its objectivity among departments and ability to translate between clinical and technological needs.

From Mr. Tabatabaie's point of view, which is the vendor side, such objectivity between departments and an enterprisewide approach are key for successful image exchange adoption. "The image exchange needs of departments are different and they all have to be considered radiology cares about a different set of priorities than do cardiology or neurology, oncology, trauma, and others," Mr. Tabatabaie says.

IT can step in as a third-party, unbiased player to facilitate discussions and ensure selection of a solution apt for the whole organization. What's more, IT leaders are already tasked with implementing enterprisewide change and handling such issues on a larger scale. "IT is busy, in fact too busy," says Mr. Tabatabaie, adding, however, that they know how to implement a new technology and deal with the implications of change, and they are department neutral and by definition have a mandate to think about the entire enterprise.

From Dr. Halamka's point of view, the provider side, IT should take the reins on such a project because these professionals speak the languages of all parties involved and serve as the go-between for clinical and business needs.

"Every business owner at BIDMC, or any hospital. has a clinical need, but they're often not bilingual in the terms of both the clinical need and the technology necessary to support the need," Dr. Halamka says. "There's nobody outside the IT department who can be that translator of clinician requirements into technology tactics."

The gaps of vendor-neutral archives
As Dr. Halamka pointed out, there are a number of image intensive departments within the enterprise that today hold their own imaging repositories. Cardiology has its own PACS, as does gastroenterology (GI) and so do dermatology and the emergency department and so on.

"There's no doubt that creating larger and smarter repositories such as a VNA is beneficial as opposed to various imaging data sitting on its own [in departmental imaging devices]," Mr. Tabatabie says. "It's a good idea to have those repositories be neutral from the image generating system, but because VNAs aggregate data, there is a misconception that vendor neutral archive also does image exchange."

Oftentimes vendor-neutral archive systems get confused with medical image exchange, Mr. Tabatabaie says. Vendor-neutral archive systems are large repositories to which different departments send their images for storage. Storage and retrieval is where VNA capabilities are focused. Its focus is not on exchange of images with the outside or the distributed collaborative care environment of which Dr. Halamka, Mr. Weschler and Mr. Tabatabaie speak.

Mr. Tabatabaie continues, "It's important for IT departments to see beyond [this] and make imaging and non-imaging data available across the boundaries of their health systems network, not just among entities that participate in a VNA."

Three stages of medical image interoperability
Sharing images across organizations is certainly a critical part of electronic data exchange, but Mr. Tabatabaie says it is just one of many steps on the path to interoperability.

To be interoperable, images need to do three things, according to Mr. Tabatabaie. First, images need to be able to connect to the host's EMR so imaging can be integrated locally. Secondly, images need to "ride the same rails" that EMRs do when patient records are exchanged.

For example, Mr. Tabatabaie says vendors like Epic and Cerner exchange patient records using networks like Care Everywhere and the CommonWell Alliance, respectively. This is a solution medical imaging is still figuring out. "Ideally, a doctor sending lab results and pathology results to a patient using Epic's Care Everywhere, should not have to switch screens and go to another application to exchange images," he says. "Image exchange can be integrated into the interoperable transactions of the EMR."

Mr. Tabatabaie says the healthcare industry is currently approaching this second stage of multisite, multivendor exchange.

The third stage of medical image interoperability is exchange between the medical image networks themselves, such as between lifeIMAGE and other platforms that also offer image exchange. "You have to be able to talk across those two networks, similar to how I'm on a Verizon [cellular] network today and [can talk to somebody] connected to an AT&T network," Mr. Tabatabaie says. "That's the ultimate component of interoperability."

The future of imaging
While the industry doesn't know what the future holds, it can take some precautionary measures to try to be as best equipped for whatever is ahead. Investing in a new software platform is a significant undertaking, and hospitals run the risk of purchasing a system that will be upgraded or outdated in a handful of years.

"It's like a car: The moment you drive it off the lot, it drops in value," Mr. Weschler says.

To combat this, healthcare organizations should consider solutions that are malleable and flexible enough to provide the infrastructure for the changing technological environment. Dr. Halamka says this capability is one of the key benefits of the cloud.

"The cloud isn't going to solve every problem for everyone, but it creates an architecture that is flexible enough to adapt to multiple different business needs," Dr. Halamka says, adding that solutions like lifeIMAGE that function on the cloud are the types of solutions that are going to last long-term. "There is potential for different kinds of workflow once you have that capability."

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