Images in the Health Information Exchange: Getting the Picture?

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Health information exchanges are expanding into new states and regions, delivering fast access to patient health information. But image exchange is all over the map. Some HIEs are exchanging images via cloud systems and viewers; others are looking for a business case and more seamless ways of exchange.

One HIE that is getting the picture is the Rochester RHIO, which was founded in 2006 and now serves 10 counties in the Finger Lakes region of New York. The RHIO includes 15 hospitals, three regional reference labs and many radiology providers and serves 1.2 million patients.

Axolotl provides the RHIO’s HIE services to members who use a variety of imaging vendors and PACS (Carestream, Fuji, GE/IDX and others), says Ted Kremer, MPH, executive director of the Rochester RHIO. When a radiology report is sent to the HIE, a web service call performs a DICOM fetch from each of the connected PACS, stores it on a separate image edge server and keeps that information on disk for 30 days, Kremer says.

“When someone calls up a radiology report through our HIE services, there’s an embedded link to the image, again using a service-oriented approach. They click on that link, it pops up a PACS-independent viewer that we provide, and provides diagnostic quality viewing,” says Kremer. “Of course, the better the monitor, the better the viewing.”

The service, which has been in place since July 2009, is available to all Rochester RHIO participants, who must download the PACS-independent viewer onto their PC to see images, he adds. With regard to Health Information Portability Accountability Act (HIPAA) compliance, “any covered entity that wants to look at a radiology image would first have to go into a community portal and note that they have patient consent, then with that consent, they can look at reports and images,” says Kremer.

Patients and doctors appreciate this service, he says. “As much as sometimes RHIOs will say, ‘how often is it used?,’ it’s the one service patients have actually credited with saving lives.” Patients also value image exchange as a timesaver, because they can more easily access and present images to their primary care physicians.

Image exchange also brought radiology providers to the table: “We now have 23 different radiology data sources connected to the RHIO and about half of them are image-enabled,” Kremer says.

Each image provider ends up having a small edge server where images are kept. The issue of image storage also presents a business opportunity: “We can facilitate some level of business interruption insurance because we will have another instance of their images and another viewer available should their PACS go down.” Images are kept on disk for 30 days. If an HIE member requests an image older than 30 days, an asynchronous process reloads the image and notifies the requestor when it’s available. The process takes a couple of minutes, according to Kremer.

The Rochester RHIO is now looking at emergent workflows, which enable providers to immediately transport images along with patients from one facility to another.

“That’s another place where, as soon as you start getting the images out there, people start rethinking how they’d like to work with them and the market angst starts to disappear,” Kremer says.

Images coming into focus

Radiology Associates of Tarrant County (RATC), in Fort Worth, Texas, provides inpatient and outpatient diagnostic radiology and imaging services across north Texas and has been a member of the SandlotConnect HIE for close to two years. RATC uses a RIS (GE) with an HL7 interface to share radiology reports, but not images, with SandlotConnect, says David R. Phelps, MD, radiologist and interim CIO.

Sandlot LLC, a wholly-owned subsidiary of North Texas Specialty Physicians, based in Fort Worth, currently exchanges clinical information among 1,400 physicians in four counties of the Dallas-Fort Worth area. The HIE is built on a Lawson Software system and is capable of exchanging images, says Tom Deas Jr., MD, CMO of Sandlot.

“Our exchange has the technical capacity to access those images on the radiologists’ systems. But in order for us to have images linked into the HIE, you have to have the agreement of the folks on the exchange end as well as the vendors. They have to incur some of the interface costs,” Deas says.  

“I think ultimately we’ll get there, but it’s going to require the vendors to understand they’ve got to step up and be a part of the [financial] plan.”

Phelps cites several reasons why images aren’t widely exchanged in HIEs yet. “Providing the radiology report to the HIE is not a lot different than providing a chart from an EMR in a physician’s office or hospital. The size of the dataset is about the same and it’s relatively small. … It’s in the kilobyte range,” he says. In contrast, datasets for images can be tens of megabytes or larger. “So right off the bat, you have issues with storage of those images, and the bandwith required to transmit [them] into the systems and back out for physician access,” says Phelps.

In addition, “the way that [image] data are used is different from how a physician traditionally looks at data in an EMR. [These are] large sets of images that require specialized viewing tools, not single snapshots, like a chest x-ray. … That requires a lot of processing power and imaging tools that are not necessarily part of a standard EMR system,” he adds.

Standards are still a work in progress as well. “With DICOM [still evolving], a lot of PACS don’t store the radiologist’s annotations in a standard way. That piece of information may not be reliably transmitted to the HIE or to the specialist who sees that patient after the test is done,” he says.

“We really need to [have] virtually instantaneous access to both the report and the images the patient has had, regardless of where it’s done,” Phelps says. “We’re still quite a ways off from that.”  

Despite technical challenges and some vendor reluctance, pioneers like the Rochester RHIO demonstrate that image exchange in the HIE is possible and delivers benefits. For patients, it can accelerate and inform care. It also can engage radiology practices in the HIE and add a layer of business continuity for participating practices.