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Duke Medicine’s Imaging Informatics Game Plan

November 26, 2013
by John DeGaspari
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How one academic medical center laid the groundwork for an imaging strategy that satisfies the needs of the many, now and in the future

There’s no easy route to creating an enterprise imaging informatics strategy, and extensive planning is critical to a successful implementation. For insight into what such a plan entails, one can look to Durham, N.C.-based Duke Medicine, a three-hospital, 1,500-bed academic medical center. In May 2012 Duke set about the task of selecting of an imaging IT vendor, as it embarked on creating an enterprise-wide imaging strategy and archive that could accommodate rapid imaging growth and meet the needs of every medical specialty. That’s a tall order that required extensive planning, according to Christopher Roth, M.D., associate chair of radiology for health information technology and clinical informatics and director of imaging IT strategy at Duke Medicine. In September, at a meeting of the Vendor Neutral Archive Institute in New York (sponsored by Milwaukee, Wis.-based TeraMedica), Roth provided a detailed account of his organization’s planning process.

Duke’s imaging strategy includes several goals—managing, retrieving and storing images as well as their care, exchange and interpretation. Storage is central to many of those goals, not only in terms of capabilities and functionalities, but also in terms of the different locations of images and a platform for their storage and management, he said.

The Case of an Enterprise-Wide Imaging Strategy

Roth observed that radiology and cardiology save roughly the same amount of data, and almost always have a picture archiving and communications system (PACS). Both departments might have several reasons to wanting to revise their storage architecture. Among them, they might want to get out of a PACS vendor lock-in, or they might have a distribution problem, where not all of their imaging customers can access images in the way they want. In addition, images that are used for teaching or research purposes must be anonymous, which changes the way they are stored, he said.

Enterprise imaging systems can help to improve workflows in areas of specialties that have not been integrated into an enterprise electronic health record, Roth said. One area that can benefit are in free-standing clinics—single radiography rooms or portable ultrasound devices—where images are often used in clinical decisions, but storage is often an afterthought.

Similarly, specialties such as obstetrics, gastroenterology, dermatology, and ophthalmology often have acquired PACS or developed imaging IT systems on their own, he said. At Duke, those specialties were set up locally, so that only a small number of people could view the images, even though they could be of interest to a wider audience, he said.

Duke handles volumes of images that are growing at a fast clip. While cardiology and radiology will always be a factor in imaging, Roth said demand is growing rapidly among other specialties as well. One area is pathology, which he expects to be a major area of imaging IT strategy in the future. Duke produces 1,000 histology slides and 200 cytology slides per day, and the volume is growing at 1 to 2 percent per year. In the future, he estimates, pathology images will account for 4 terabytes of data in a single day, not including whole specimen imaging or cytogenetics imaging. That’s roughly what Duke stores in cardiology and radiology imaging in four to six months today, he said.

Roth also identified video as an area of potentially rapid growth, driven by educational purposes as well as telemedicine. Speaking of the latter, Roth noted that doing synchronous conferencing of adequate length and quality requires significant space. At Duke, which runs a fairly large telemedicine program, a full neurological exam conducted remotely on a potential stroke patient encompasses cranial nerve, motor, speech, sensory, and broad cognitive exams. The amount of storage a provider organization keeps depends on medical considerations as well as the fact that payers are focusing more attention to telemedicine, and are requiring documentation of the video interactions, he said.

Who are the Biggest Consumers of Images?

Roth noted that there are many different groups of consumers in a healthcare system, and said it’s important to have an image management strategy that reflects that reality. “You want the architecture you use to store these images and distribute them across the enterprise strategically hits anything you want,” he said. “You want a flexible archive, something that is going to stand the test of time.”

He named five major image user groups.