An Enterprise with a View: Universal Viewer Essentials

Providers everywhere are chasing the elusive and often ambiguous goal of enterprise imaging. While there are different takes on the concept—and lots of industry buzzwords to decipher—one of the essentials of an image-enabled EMR is a universal viewer available to all physicians no matter where they are.

The story of image exchange via CD illustrates how a technological advance can go from a blessing to a barrier. At first, they allowed providers to ditch film and make images more transportable, but the limits of the medium quickly became apparent in the form of unopenable or error-filled discs. The Mayo Clinic in Rochester, Minn., has reported that 0.6 percent of the CDs it receives are unreadable, and others may contain information on the wrong patient.

Moving beyond CDs, many sites have implemented image access through HL7 by sharing URL links along with reports that call back to an individual PACS. These links, however, could open up any number of viewers, which presents a new workflow challenge for sites hoping to build a true enterprise image solution.

The Cleveland Clinic is one such site. It has integrated 22 departments into its image library, collecting images from wound care, gastroenterology, orthopedics and a number of other non-radiology specialties, according to Director of Enterprise Imaging Louis M. Lannum. The strategy would not be possible without the organization’s universal viewer, which displays DICOM and non-DICOM images from myriad possible sources.

“If your enterprise viewer doesn’t support everything that you’re storing in your medical library, then you’re only doing half the strategy,” says Lannum.

The features required of such a viewer provide a source of debate in the industry, with vendors creating definitions of universal viewers that work best for their product and providers sometimes having their own unique needs. Rasu B. Shrestha, MD, MBA, vice president of medical information technology at the University of Pittsburgh Medical Center, says that beyond having a viewer that can display images no matter where they come from—be it a radiology PACS, a cardiology PACS or elsewhere—other features have not become standardized.

“Many of us are still working through specific use cases and defining what our specific needs are and what the capabilities need to be,” says Shrestha.

The bare necessities

Shrestha points out that there has been a constant evolution in viewing environments from thick to thin clients, and more recently to zero-footprint viewers. The ideal universal viewer would be simple, HTML-5-based, and have no dependency on Flash, Silverlight or any other downloadable software. It would need to be usable from any browser, mobile device or desktop environment, including an EMR, without an install, because many clinical desktops are locked to prevent further installs as an IT security measure.

“If you have viewing needs for images and imaging-related content, launch your universal viewer and use that with a consistent look and feel, consistent user experience, and consistent set of tools that work best in your clinical scenario,” says Shrestha.

Aside from a lack of an install footprint, speed is another essential element for a universal viewer.

“Providers are under a lot of pressure to see lots of patients, and when they want to look at images, number one it has to be fast,” says Charlene Tomaselli, director of medical imaging information technology at Johns Hopkins Medicine in Baltimore.

Tomaselli says the images also need to be in context with the EMR. When a session is closed, the images need to close as well. Side-by-side comparisons with prior images must be readily available. “Physicians have said that if you can’t compare to the last study, then it’s worthless,” she says.

In addition to comparisons between prior images in the same modality, cross-modality comparisons also can improve patient care. For example, a physician might want to view a wound photograph alongside an x-ray of the same body party, says Lannum. “[The viewer has] got to be integrated very tightly in the EMR so that your EMR experience and your imaging experience are one experience; you don’t have to call up a second viewer.”

At the moment, speed and ease of access appear to have trumped advanced features. No viewer can meet 100 percent of the needs for all specialties, so the focus has been on basic image look up. Dedicated diagnostic viewers still provide the toolsets specific to various subspecialities.

Tomaselli says there is still a long way to go before a single universal viewer can simultaneously meet the needs of radiology, cardiology and all the other ‘ologies. Simple measuring tools can be made available, but little beyond that.

In fact, more complex toolsets could simply get in the way of physicians who might not want to navigate through an interface with all the functionality of a full radiology PACS viewer. For many uses cases, clinical grade tools in a viewer, as opposed to diagnostic grade, will satisfy most current needs, says Shrestha. “I shouldn’t have the expectation to do a final read on a study off of a universal viewer. If it has that functionality, fantastic. But when it comes to expectations, I don’t think that expectation is necessarily there.”

While a stripped down viewer might seem like it is setting the bar low, there are quite a few benefits from such a tool. Being able to open any images—including both DICOM and non-DICOM—all on one viewer can have a big influence on care coordination.

There are lots of use cases around image viewing alongside reports. A survey of attending physicians at Stanford University Medical Center published in the December 2013 issue of Academic Radiology found that 89 percent indicated interest in reports with embedded images, and nearly three-quarters of the interested physicians agreed that this would improve interaction with radiologists. Emergency department reads of trauma cases, intraoperative image viewing, telehealth and other quick-read scenarios provide multiple uses for a universal viewer.

Shrestha adds that image-enabling health information exchanges will become more of a focus with Meaningful Use Stage 3.

Looking beyond the basics

As universal viewers continue to evolve, it is possible they will be able to integrate more applications. Advanced visualization, 3D functionalities and integration with voice dictation could become more commonplace, with the viewer doing more of the technical heavy lifting.

Lannum suggests that the key to the next generation of viewers will be their ability to view images diagnostically, rather than just for referrals. Now that the enterprise strategy is taking hold at more sites, the central challenge is shifting from simply capturing images to figuring out the best way to display them in one viewer. Shrestha says he can see this type of next-generation viewer, deployed through the cloud, as the focal point of imaging across the enterprise.

While true enterprise imaging continues to be a tricky proposition, the evolution of universal viewers promises to provide the cornerstone of image access at any time, from any location and by every member of a care team.