No Image Left Behind

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Screenshots courtesy of National Center for Biotechnology Information, Montefiore Medical Center

In the good old days, image management was an insiders' club largely comprised of radiologists and PACS administrators well-versed in the nuances of DICOM, modality worklist and imaging informatics. Today, however, image management is hurdling toward an enterprise model characterized by broader, looser boundaries and lots of data.

What's driving the new model? "At the end of the day, someone in Washington is going to say a picture is just as meaningful as data, and [an enterprise image record] is meaningful use," predicts Lou Lannum, director of enterprise imaging at Cleveland Clinic. (And someone in Washington has. "We can't have an effective electronic health information system that can't move images," David Blumenthal, MD, former national coordinator of the Office of the National Coordinator for Health Information Technology said in January.)

A centralized enterprise archive provides a platform for regional health information organization (RHIO)- or health information exchange (HIE)-based imaging sharing, says Mony Weschler, director of clinical ancillary systems and emerging health information technology at Montefiore Medical Center in New York City. Departmental archives make it difficult to replicate and share data.

Economics and technical developments also are fueling the enterprise approach. Multiple departmental archives are costly to deploy and manage. Finally, new software applications create DICOM wrappers for previous imaging outliers like endoscopy and ophthalmology.

Toward the enterprise image record

Cleveland Clinic epitomizes the transition to an enterprise model. Early in 2011, the health system promoted Lannum from administrator for radiology imaging informatics to administrator for enterprise imaging and tasked him with locating images across the enterprise. The ultimate goal? Build a longitudinal imaging record to correlate with the EMR.

Lannum and his team are taking an asset management approach and inventorying imaging including dermatology, pathology, endoscopy and point-of-service imaging.

The team opted to focus on easy images first. These "x-ologies," in Cleveland Clinic parlance, are equipped with an intermediate device that can produce an outbound DICOM message. Such systems can be interfaced with an EMR, and patient demographics are automatically shared and reconciled. Initial targets include women's health, ophthalmology and the Digestive Disease Institute, which produces endoscopy images, and C-arm datasets.

Montefiore Medical Center has solved earlier challenges of integrating its endoscopy imaging data into PACS; the center has transferred about 40 to 50 percent of the data into PACS. "Most PACS don't yet natively accept endoscopy data," shares Weschler, "but there are solutions that create a DICOM wrapper around the video data. It's no longer the challenge it was two years ago." Some new endoscopy cameras output DICOM natively.  Alternately, a few third-party systems provide the middleware between modalities and PACS, and some PACS provide the DICOM wrapper.

As technical issues are conquered, human issues take center stage. It's critical that providers in image-generating departments adapt workflow to image management and generate an image order to link the patient to the image. If an image is put into the archive without normalizing the demographics with the EMR, it's nearly impossible to track the image. "This isn't just about storage," Lannum says, "it's about storage and subsequent access." Image retrieval requires that workflow is modified in a way that allows matching between imaging metadata and the EMR, which ultimately enables future viewing via the archive.

Departments outside radiology, however, don't necessarily generate image orders. A dermatologist might decide to take a digital photo at the end of the appointment and request storage. Without an order or accession number, there is no link for retrieval.

Montefiore employs a closed loop PACS to address the retrieval issue. All orders go through computerized physician order entry (CPOE). They are generated in the EMR and sent to the RIS, which populates the PACS and provides the modality worklist. As radiology, cardiology and endoscopy images are acquired, they are profiled and matched to the orders to guarantee patient integrity, interpreted on the PACS and resulted via voice recognition or exception-based reporting