Image Management Across the Ologies: A Tale of Two Modalities
For 20 years, imaging informatics has been radiology's territory. However, an increasing awareness of all types of images as patient data may bring those days to a close. A growing number of hospitals are transitioning to an enterprise-wide, centralized archive that houses both radiology and non-radiology imaging datasets. These organizations aim to give physicians access to a whole range of patient data, which includes clinical images from non-radiology departments, such as endoscopy or pathology, and make imaging data available at the time of need, whenever that might be.

The whole story

The goal at Florida Hospital, a 2,200-bed system comprised of eight Orlando hospitals, is to create a complete birth-to-death EMR. Rather than just summaries or interpretations of data, physicians will be able to view images regardless of whether they originate in radiology, cardiology, endoscopy, wound care or any other image-producing department, says Ed Majors, director of imaging information systems.

There are a number of reasons to make the transition, Majors says. Apart from the clinical benefits of assisting physicians in diagnosis, there are operational benefits to centralized image management. In addition to boosting cost effectiveness, security of clinical data improves as smaller department-specific systems may not be backed up like a central data center.

Chapter one: Endoscopy

One of the first non-radiology, non-cardiology departments to be integrated into Florida Hospital's EMR was endoscopy, which was no small feat considering  the hospital generates 15,000 to 18,000 endoscopy images every month. Jason Aspinwall, director of clinical applications at Florida Hospital, says that endoscopy had been handling image management internally with niche solutions for capturing, storing and indexing by patient, but these technologies were a decade old and never integrated into the EMR.

"As these solutions reached end-of-life, we had to take a step back at an enterprise-level and find the best solution to integrate these images into the EMR," says Aspinwall.

To solve the problem, the health system adopted a technology that translates JPEG images from the capture device and allows them to flow from the procedure into the EMR. Now, as opposed to taking physical copies of the images, physicians can view them online from a laptop, and Aspinwall says statistics show as many as 1,400 views a month.

"That tells us physicians are viewing  them from their offices, or they are using images online for teaching," says Aspinwall, adding that physicians appreciate the accessibility of pulling up images digitally, rather than handling physical copies.

The preface

While some physicians are excited about the movement in informatics toward centralized image archives, Mony Weschler, MA, director of clinical ancillary systems and emerging health IT at Montefiore Medical Center in New York City, says there are sometimes cultural and workflow issues in departments that need to be overcome. Each department has unique needs, and one system may not satisfy everyone. The resulting solution must be fully integrated to the core system and function seamlessly for clinicians. Montefiore modified its initial strategy of a single enterprise-wide archive after introducing the model in cardiology. Adapting departmental workflow to an enterprise system proved an arduous challenge.  

After the cardiology rollout, Montefiore maintained its initial goal of an enterprise-wide archive but determined a hybrid approach was best. To preserve functionality, some departments are required to have their own "integrated" imaging system, customized workstations and short-term storage space, with images also sent for long-term archiving on the enterprise PACS. Surgeons and referring physicians still can access all images, while departments can retain their required toolsets. Images eventually drop off the short-term storage system, staying there for about a year based on the department's needs, but can be retrieved from the long-term enterprise archive.

Weschler says the hybrid approach will be the model for integrating ophthalmology, nuclear medicine, pathology and other departments. Even though some archive systems claim they can meet the needs of multiple departments, at Montefiore, the integrated hybrid approach was the only way to meet every department's needs.

The sequel: Pathology & beyond

Similar to Montefiore, departmental workflow is a major concern at Massachusetts General Hospital (MGH) in Boston, says David S. McClintock, MD, a pathology informatics fellow. The integration of pathology into imaging archives remains in its infancy. However, McClintock sees the benefit of an enterprise model, and looks to radiology as an image management model.

"Radiologists have the best clinical image management model to date. For departments that have not transitioned to digital management, it would be nice to leverage what radiology has done and use what they've already proven to work rather than trying to reinvent the wheel," says McClintock.

But workflow is a key difference between radiology and pathology. While radiology image management can be digital from image acquisition to archival to display, McClintock says that pathology requires physical specimens and involves a lengthy chain of custody with multiple possibilities for human error. There can be anywhere from 20 to more than 100 handoffs in the pathology specimen chain of custody and a single mistake in container labeling or slide creation would be perpetuated into the archive.

To prevent errors, MGH utilizes barcodes instead of handwritten notes for every part, block and slide generated.

Another problem standing in the way of integrating pathology images into the digital archive is the sheer size of whole-slide images captured by a virtual slide scanning robot. These devices reproduce glass slides at high magnification that can be zoomed in for more detail, says McClintock. Size often reaches 4GB, compressed, per slide (uncompressed they can be 40GB each), which is a huge strain on enterprise archives as most pathology labs produce thousands of slides per day and one or two petabytes of data per year.

These challenges could be worth overcoming to realize the potential benefits of an enterprise model. McClintock says the most prevalent model today is to manage pathology images by storing files on a HIPAA-compliant server using a simple folder structure. Moving those data to a comprehensive EMR would aid patient care.

"If you have a patient with a lung mass who first undergoes a CT of the chest, followed by surgical resection and pathologic diagnosis of the mass, it would make sense to have the CT scan, any peri-operative images, gross images of the removed specimen and diagnostic microscopic or whole-slide images all in one place for viewing," says McClintock.

The next step at Florida Hospital, Aspinwall says, will be integrating more video into the EMR, opening up the possibility to include image datasets such as video clips of patients walking to examine their gaits before and after procedures.

Maternal medicine is also on the docket with fetal monitoring systems flowing waveforms and annotations from the device to the EMR. Majors expects vendors to continue to adapt and offer more versatile products that can meet the diverse needs of an enterprise system.

"Someday, we hope to have a set of common clinical viewers, or viewer, that would be able to access data and view images, not caring if it's a radiology, ophthalmology or pathology image," says Majors, acknowledging this "broad clinical use" type of viewer probably wouldn't totally replace those used by radiology or cardiology PACS.

In the meantime, the transition to an enterprise archive serves as a solid stepping stone, not only for a universal viewer but also improved clinical access and cost savings.