Building a Better Mousetrap: Developing Models for Cross-enterprise Image Sharing

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When researchers at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., undertook phase one of a two-part National Institutes of Health/National Institute of Biomedical Imaging and Bioengineering (NIH/NIBIB) research project focused on cross-enterprise image sharing, they uncovered a nasty, universal truth. “No one likes CDs—this includes physicians, patients and staff,” says Yaorong Ge, PhD, assistant professor of biomedical engineering.

The primary cross-enterprise image sharing mechanism—the lowly CD—consumes an inordinate amount of physician and staff time, often doesn’t include the necessary viewing tools, presents security risks and fails to provide an adequate framework for historical comparison in many cases. Health Information Exchange (HIE)-based image sharing offers a partial solution, but isn’t nationally scalable. HIEs also are plagued by growing privacy concerns, with some facilities foregoing or reconsidering participation.

Federal agencies have recognized the universal nature and magnitude of the problem and are investing in a pair of research projects designed to craft a next-generation solution. NIH/NIBIB awarded Wake Forest Baptist a $2 million, two-year grant to investigate the image sharing challenge and develop a patient-controlled, scalable solution geared to address the needs of smaller and rural providers. NIBIB also granted RSNA $4.7 million to spearhead a two-year pilot project and develop an internet-based network for sharing of patient images in partnership with five academic medical centers —Mount Sinai School of Medicine in New York City, the Mayo Clinic in Rochester, Minn., the University of California, San Francisco, the University of Chicago and the University of Maryland in Baltimore.

The status quo: Failure points abound

But how problematic are CDs? According to a January survey published in the Journal of American College of Radiology, more than half of sites reported that up to 10 percent of patients underwent repeat studies because of media problems. However, in many cases, the physician needs prior images to adequately evaluate the patient, which means the patient must be rescheduled. Both scenarios disrupt productivity for the physician and patient.

The process may be flawed even when the CD is fully loaded with a complete image set. That’s because the image viewer forces the physician into an unfamiliar workflow, or the tools needed for adequate comparison may be unusable or unavailable. “The end results range from lost productivity derived from trying to view images or, more importantly, potential errors associated with nonstandard viewers,” explains J. Jeffrey Carr, MD, professor of radiologic science at Wake Forest Baptist. One of Carr’s orthopedic colleagues estimates that it takes up to 30 minutes per CD to view images on outside CDs if one accounts for all the steps involved. (The IHE has proposed a Basic Image Review profile to standardize the operations of viewers to reduce the challenges, but this is not yet widely implemented.)

Although developing HIE image-sharing mechanisms offer a partial fix, they do not address all clinical scenarios as patient care often crosses HIE boundaries. “One of the biggest challenges [of cross-enterprise image exchange] is observing proper protection of patient confidentiality,” explains Bradley Erickson, MD, PhD, co-director of the radiology informatics laboratory at Mayo Clinic. HIEs bypass the challenge to a degree with a Business Association Agreement (BAA), which allows fairly free exchange of information among groups of organizations, such as members of an HIE.

However, as Erickson points out, it isn’t feasible to allow a nearly infinite number of BAAs. “BAAs make sense in high volume image exchange situations, but there is a limit to HIE scalability.” What’s more, according to Ponemon Institute’s Benchmark Study on Patient Privacy and Data Security, published in November 2010, HIEs expose healthcare providers to a host of privacy concerns such as unauthorized access, violation of data breach laws and potential identity theft.

Finally, in such organization-mediated solutions, providers do not know which images will be needed. For example, a person with a twisted ankle and negative x-rays is unlikely to require image sharing. However, a prior chest CT or brain MRI performed at another facility in the clinical settings of a potential stroke could alter patient management if available.

Simplified sharing