PACS is a foregone conclusion at many sites in the U.S. with early adopters replacing legacy systems with second- and third-generation archives. At the same time, later adopters are leapfrogging their predecessors with state-of-the-art implementations. As PACS matures, digital image management is extending its reach beyond radiology and into the enterprise. One of the primary next-generation tasks is bringing enterprise images—think cardiology, endoscopy, ophthalmology and pathology—into the archive.

Enterprise PACS produces a powerful clinical vision. A number of sites on the enterprise path are looking at wrapping endoscopy into the digital archive in the not-too-distant future, enabling a multi-disciplinary, enterprise image-enabled conference that could improve patient care. That’s because the ability to view and compare endoscopic images with radiology data-sets and pathology slides promotes better coordination among specialists. In addition to enhanced communication and collaboration, the enterprise approach offers economies of scale, which, in turn, saves dollars and extends resources. This month, Health Imaging & IT visits a pair of pioneers wrangling with one of the first ‘ologies to join radiology and cardiology in the enterprise archive—endoscopy.

‘Not your typical radiology exam’

The first challenge associated with endoscopy image management, says Gary Wendt, MD, vice chair of informatics and enterprise director of medical imaging at University of Wisconsin-Madison, is the image capture environment. “It’s not your typical radiology exam.” Endoscopic images are captured during invasive procedures, so operators need easy access to the digital system. The most user-friendly and least invasive options are a foot pedal or touchscreen mechanism, continues Wendt. In addition, technologists need a way to quickly identify the patient and anatomical location of the images. That’s because post-procedure images can be easily confused; the right main stem bronchus looks like the left, so unlabeled images are of minimal clinical value. Similarly, exams not captured or labeled with a patient name can not be integrated into the patient’s clinical plan. While it is absolutely essential that techs capture and incorporate key data, labels or observations must not disturb the patient during the procedure. For example, a voiceclip stating probable malignancy is likely to stress a patient. Point-and-click drop-down menus offer one less intrusive option.

Physicians at the University of Wisconsin-Madison use McKesson’s Horizon Optical Imaging system to review endoscopy images such as these that include an anatomical diagram of a nasopharynx at the center, a postnasal space at top left, a lung at top right and an esophagus at bottom right.

Par for the course, however, IT presents one of the most significant challenges. “Images must be captured in standard DICOM format,” Wendt says. But few image capture systems outside of the radiology domain are DICOM-compliant; in fact, some may not reside on the hospital network. The problem with proprietary or non-DICOM systems is their inability to export or link images to the EMR or archive onto PACS. “A JPEG in the EMR has no concept of a like prior, so physicians can not readily access historical images,” explains Wendt. Unfortunately, getting endoscopic images into PACS takes a fair amount of IT legwork.

“Sites have to find a way to incorporate a DICOM wrapper on endoscopic images,” says Mony Weschler, director, clinical ancillary systems and emerging health information technology at Montefiore Medical Center in New York City.

University of Wisconsin-Madison uses McKesson Corporation’s Horizon Optical Imaging solution to overcome DICOM hurdles. “It’s vendor-independent and mounts on any scope, so the hospital is not locked into a single scope vendor,” notes Wendt. As a result, the hospital can employ a best-of-breed approach to its scope inventory.

Other options include Merge Healthcare’s ExamBox, an MPPS and Integrating the Healthcare Enterprise (IHE)-compliant systems that can be added to legacy endoscopy systems to enable modality worklists. “The major benefit of modality worklist is one-click data entry. It produces a clean archive and prevents future patient errors,” states Weschler.

Another option is to upgrade endoscopic solutions to new systems. “Typically, upgrading to new equipment eliminates the need for a third-party box,” says Weschler. Still, sites should tread carefully as DICOM is not quite a universal language. “Be careful with scope investments going forward,” says Weschler. “Get the vendor’s DICOM- and IHE-compliance statements, and understand what you are reading. And make sure the system can use modality worklist.”

Other IT considerations aren’t quite so painful. Typical endoscopy file sizes are on the order of a few hundred megabytes (MB). A cine clip acquired showing vocal cord motion is a 50 to 60 MB file. “They aren’t monstrous, but they aren’t tiny,” sums Wendt.

What’s more, the IT pluses of the enterprise archive are significant. “Data silos in separate departments don’t talk to each other and are expensive to support,” states Wendt. On the other hand, a common enterprise archive facilitates enterprise viewing and communication and brings cost and scale efficiencies, enabling a single disaster recovery strategy and allowing sites to maximize training and IT staff resources.

Timing is everything

Despite the clinical, economic and IT advantages associated with wrapping endoscopy and other ’ologies into the PACS archive, it remains a long-term vision for most sites. UW Madison is at the forefront and has brought all ENT clinics, radiation therapy and endoscopy online. Works in progress include GI, pulmonary medicine and visible light pathology. The common denominator among all UW Madison ’ologies is Horizon Optical Imaging, which creates native DICOM-format images at the point of care.

The Montefiore Medical Center enterprise plan places online endoscopy as a 2008 project. “Timing these projects can be very tricky,” states Weschler, who recommends that other sites eyeing endoscopy and other ’ologies apply a case-by-case basis to schedule projects rather than following in other sites’ footsteps in a lockstep fashion. The image archive should balance enterprise needs and priorities, says Weschler. “The institution should provide guidance for the IT department—rather than allowing IT to schedule projects.” This approach provides an enterprise vision and lets IT focus on what it does best.

Endoscopy image management at a glance

The digital archive is growing, and facilities and departments need to prep for enterprise additions, including endoscopy. Endoscopic images present new challenges as images are acquired and stored in different formats than radiology exams; however, the benefits of integrating endoscopy into PACS encompass patient care, storage consolidation and cost-savings. Sites need to carefully plan and schedule the endoscopy integration; new endoscopic solutions should be screened to ensure DICOM- and IHE-compliance. Vendor-independent DICOM translators provide another option for non-DICOM endoscopy equipment. Endoscopic image management presents a few hurdles; however, including endoscopy in the archive enhances and extends the benefits of enterprise digital image management solutions.