Digital Endoscopy: Challenges for Enterprise Imaging

PACS has the potential to serve the needs of the entire diagnostic imaging enterprise; providing archival and connectivity capabilities to deliver image information anywhere across the healthcare continuum. Although PACS has predominantly lived within the purview of radiology, many other diagnostic imaging specialties are now able to produce native DICOM images, or have conversion tools available that convert captured images into the DICOM format for PACS purposes.

As such, many of the medical specialties outside radiology—including cardiology, orthopedics, radiation therapy, pathology, dentistry, ophthalmology, virology, microbiology and hematology—want to harness the power of PACS for storing and distributing images generated by their departments. Of particular interest for many clinicians is the capability for using PACS to store and transmit digital endoscopy data.

Endoscopy is perhaps one of the most widely used visible-light image capture tools in medicine, and almost all of the latest generation of equipment is digital and support DICOM. Gastrointestinal specialists use the technology to perform colonoscopy, esophagogastroduodenoscopy, proctosigmoidoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) studies.

Rhinoscopy and bronchoscopy exams are commonly conducted for the respiratory tract; with panendoscopy (the combination of laryngoscopy, esophagoscopy and bronchoscopy) also ordered for patient studies. Cystoscopy is performed for urinary tract disorders. Gynecologists conduct colposcopy, hysteroscopy, falloscopy, and some laparoscopy exams, while obstetricians utilize the technology for amnioscopy and fetoscopy. Orthopedic specialists utilize arthroscopy, and thoracic specialists use endoscopic tools for thoracoscopy and mediastinoscopy studies.

Visible light, for the capture of microscopy and endoscopy images, has been part of the DICOM standard since 1999. The DICOM-VL specification delineates how to store preparation procedures and image-acquisition conditions in the image headers, which allows for display of these images on a DICOM viewing station, as well as integration of the data into an enterprise-wide PACS image management architecture.

At first glance, it would seem that the pieces are in place for bringing digital endoscopy onto the enterprise PACS; however, according to a pair of healthcare informatics pioneers who have set themselves this task, there are still issues remaining to be resolved.

Integration takes more than DICOM

In a presentation on enterprise PACS made at the 2005 Society for Computer Applications in Radiology (now the Society for Imaging Informatics in Medicine) annual conference in Orlando, Fla., Gary Wendt, MD, vice chair of informatics and enterprise director of medical imaging at University of Wisconsin-Madison, stated: “Perhaps the biggest problem with expanding PACS is the lack of informatics standards in other departments.”

Bringing digital endoscopy effectively onto an enterprise image management system is not based solely on the modality’s capability to generate images that are compliant with the DICOM-VL standard. According to Wendt, who has been part of bringing several specialties’ endoscopy studies onto the University of Wisconsin-Madison enterprise PACS; workflow and informatics issues play a key role in successful integration.

Endoscopic images are captured during an invasive procedure, so technologists performing the exam need easy access to the informatics system, according to Wendt. His facility has found that most user-friendly and least procedure-intrusive options for image and data entry are a foot pedal or touch-screen mechanism.

In addition, technologists need a way to quickly upload patient demographics and the capability to easily annotate the anatomical location of the images being captured, he says. In addition, interpreting clinicians should have the capability to identify key images or cine sequences in the endoscopy procedure that illustrate the findings of their diagnostic report.

“Post-procedure images can be easily confused; the right main stem bronchus looks like the left, so unlabeled images are of minimal clinical value,” Wendt says. “Also, key image selection permits endoscopy physicians to include the clinically relevant portion of the exam in their report, rather than the entire sequence of images obtained during the exam.”

Many times, endoscopy procedures are performed on conscious or minimally sedated patients, he notes. Thus, data entry and exam observations must be able to be made in a manner that does not disturb the patient during the study.

“For example, if a technologist records a voice clip stating they’ve observed a probable malignancy that revelation is likely to stress the patient,” Wendt observes. He suggests that point-and-click categories for standard observations or the use of drop-down menu selections provides technologists a more patient-sensitive option for data entry.

Also problematic on the IT front for digital endoscopy integration is that few systems in place support the downloading of patient demographic information from other IT applications, such as a hospital information system. This means that technologists often have to manually enter patient information and accession number, which introduces the possibility of human error in the data entry process, Wendt notes.

Facilities that have a collection of older, endoscopy equipment are faced with the challenge of placing DICOM conversion applications onto informatics pathways to render their image data DICOM compliant.

“These sites will have to budget for incorporating a DICOM wrapper onto endoscopic images,” says Mony Weschler, director of clinical ancillary systems and emerging health information technology at Montefiore Medical Center in New York City.

Montefiore has been upgrading its endoscopic equipment to DICOM-compliant systems throughout the enterprise, eliminating the need for third-party conversion solutions, he says. However, he cautions that buyers of DICOM-enabled endoscopy systems should be prudent in their evaluations of equipment purchases.

“You need to be careful with your endoscopic system investments,” Weschler says. “Get your vendor’s DICOM and IHE (Integrating the Healthcare Enterprise) compliance statements, understand what you are reading, and be sure that it will integrate into your PACS. And make sure the system is DICOM modality worklist-compliant.”

Both Weschler and Wendt express their desire to see digital endoscopy vendors participate in the IHE connectathon, an annual event that allows vendors to demonstrate the interoperability of their systems with other healthcare IT products.

Montefiore Medical Center is eyeing a timeline of 2010 for bringing all its digital endoscopy modalities onto the enterprise image management system; although it is currently capturing all radiological images in its endoscopy suites, according to Weschler.

Digital endoscopy across the digital domain

The archive of digital endoscopy images and information on an enterprise basis needs to balance the facility’s needs and priorities, Weschler says.

“The institution should provide guidance for the IT department—rather than allowing IT to schedule projects,” he notes.

A centralized image repository for use by all diagnostic imaging specialties has a number of benefits for an institution, according to Wendt.

“For example, a common archive facilitates enterprise-enabled viewing of image interpretation data,  provides cost and scale efficiencies, enables the deployment of a uniform disaster recovery strategy, and allows for the efficient use of IT staff resources,” he says.  

In contrast, separate department-based PACS create independent data silos that generally don’t share data seamlessly and are expensive to support, Wendt notes.

John Koller, president of KAI Consulting, a Larkspur, Colo.-based clinical healthcare IT consulting firm, says that facilities contemplating the deployment of an enterprise-wide image management strategy, incorporating modalities such as digital endoscopy, need to be aware of the challenges in a such an effort.

“The biggest challenges are acquisition and workflow around images in non-imaging centric departments,” he says. “These departments don’t have the systems in place that radiology does; we need to create processes that enable the association of all the meta-data that’s important to their imaging studies.”