Imaging was largely absent in Stage 1 meaningful use, but with new requirements in Stage 2 to include viewing of image data within the EHR, there will likely be a new focus to develop enterprise imaging strategies and expand interoperability solutions. The picture in this space isn’t as clear as some might hope, but there are pioneering organizations nonetheless making headway to allow anytime, anywhere access to diagnostic images.

Picture archiving and communication systems (PACS) technology has seen great market penetration in the new millennium, according to a white paper from the Dorenfest Institute and HIMSS Analytics. In 2000, 8.5 percent of hospitals reported PACS technology installed, which grew to 76 percent in 2008. (Four more years later industry experts agree that PACS systems are universal.) The report also found that image distribution, through PACS will continue to spread outside of the hospital, as more procedures are performed in the outpatient setting or as technology enables users to access images outside of the hospital.

When it comes to a choosing a particular enterprise image strategy, Joe Marion, founder and principal of the Waukesha, Wis.-based Healthcare Integration Strategies, says there is a lot of FUD—fear, uncertainty, and doubt—out there. “There’s still a lot of confusion,” he says. “The consequence of that is that I don’t think a lot of people have enough of a grasp yet what differentiates [vendors].”

Joe Marion

Marion recommends organizations first identify their objectives for imaging enterprise solutions. If the organization needs to find a common way of archiving images between radiology and cardiology, that’s not really a true enterprise solution, he notes. “If the need is a common image accessibility source for an electronic medical record, that is probably more of a true enterprise requirement,” Marion adds. “I think there is a significant difference in the context and the definition of what the intended purpose of the device is. It really boils down to defining what you’re trying to accomplish with the device.”

According to a KLAS (Orem, Utah) study, “Enterprise Imaging 2012: Provider's Strategies and Insights,” most healthcare providers are in the early stages of forming an enterprise imaging strategy to enable “getting the right image to the right place at the right time.” Many providers are having to rely on more than one vendor to deliver all of the pieces needed for their enterprise imaging strategy, and are considering one of two main approaches: a vendor-neutral archive (VNA) centric approach or a PACS enterprise archive solution.

“Providers are looking at two different paths to go down,” says Ben Brown, KLAS’ imaging research director and author of the report. “Almost all providers have a PACS, so there are a lot of them that want to leverage their PACS that started in radiology and leverage this archive for other DICOM images or other clinical content. It tends to be smaller facilities that are sticking with a PACS-centric archive solution.”


Ben Brown

Brown says that the larger organizations (more than 500 beds) that were interviewed for the study are more focused on a vendor-neutral archive, incorporating not only DICOM, but non-DICOM images and clinical content “that can be archived in some type of repository for access with the patient record.”

Brown sees more providers taking steps to image-enable their EHRs and begin leveraging image archives as a service within their community, using private cloud models and virtualization. “I think you’ll see larger organizations leverage something like that as a resource, not only to give clinicians in the area that are either affiliated, owned or employed by a healthcare system access to these images,” he says. “I think you’ll start to see in next few years these types of models evolve like an archive that could be leveraged for disaster recovery, business continuity, long-term archive, image accessibility to providers in the area.”

Health Imaging Exchanges

Diagnostic images would be a natural fit for health information exchanges (HIEs) to include along with the clinical care summaries to be exchanged, but most HIEs haven’t addressed images largely because imaging preceded HIEs, says Marion. “[HIEs] haven’t done that with imaging because I can walk into any facility that I’ve had a study done at and request my images and walk out with a CD or a film folder under my arm,” he adds.

However, there is one state that is building a statewide image repository. Maine’s image repository that jumpstarted in May is a central cloud archive spread across three data centers that houses the full study and report for radiology and cardiology images. Currently, five hospitals are involved in the pilot, which is expected to come to conclusion by early 2013, says Todd Rogow, director of information technology at HealthInfoNet, Maine’s statewide health information exchange. At a future point the image repository and the HIE will align so clinicians can access images and other clinical content from one central location.  

Todd Rogow

Among the lessons Rogow has been learning from the pilot is that is difficult fitting imaging in with all of the competing health IT priorities of meaningful use and ICD-10. For smaller organizations, the difficulty lies in their lack of IT resources; while larger health systems present their own challenges because they already have well-established regional PACS in their geographic area. HealthInfoNet is preparing to hire additional account managers to handle issue resolution for customers.

Multi-Hospital/PACS Approaches

When it comes to complexity, the 40-hospital Dignity Health system (formerly Catholic Healthcare West) has it in spades. To pursue its enterprise imaging strategy, the San Francisco, Calif.-based health system has sought interoperability before consolidation and is in the midst of connecting all 30 of its imaging care centers to its enterprise archive before paring down its five PACS providers to one.

“Enterprise imaging for Dignity Health focuses on imaging interoperability,” says Scott Boswell, the organization’s IT director for medical imaging and identity management. “We wanted to create solutions that could extend and/or share the imaging study anywhere it was needed at any point in time. The solution would not just be to support extension and exchange within the Dignity Health system, but also with outside entities and our referring physicians.”

Dignity Health, not unlike other large health systems, is a regionally deployed integrated system, which has facilities that store images locally onsite for 18 to 24 months, and then houses the rest of the images in a centralized image repository in Phoenix.

So far, Dignity Health has deployed an interoperability solution (Merge iConnect; Chicago) to link up its 25 Catholic hospitals, 15 secular hospitals, and seven imaging centers. The health system currently has five different PACS providers at its facilities, all with various software versions that include 14 installations of Merge, 12 installations of DR Systems, eight installations of McKesson, three installations of GE, and one installation of Carestream.

Dignity Health is now moving toward a sole-source PACS strategy in order to achieve consistency, standardization, and vendor leverage, says Deanna Wise, executive vice president and CIO. “There are definitely some efficiencies to be gained from that financially,” she adds. “The next step will be validating how do we put a consistent enterprise in place and what’s the true ROI. So I’m in the process of building that as we speak.”

KLAS’ Ben Brown agrees that organizations can get a better discount when creating economies of scale by consolidating larger bulk storage purchases. “As tight as budgets are, when you can consolidate a purchase and get greater discounts, everyone is looking to squeeze as much juice out of the lemons that are available,” he says.

Image-Enabling the EHR

Dignity Health is also in the process of image-enabling its EHR for its employed physicians, merging iConnect with its EHR through a clinical work interface, since its EHR (Dignity has an mix of Kansas City, Mo.-based Cerner and Westwood, Mass.-based Meditech installations) can’t launch native URLs. Beyond cardiology and radiology, Dignity Health has brought oncology and non-DICOM images (its imaging software wraps non-DICOM images in a DICOM wrapper) into its archive and will eventually route in digital pathology.

Referring physicians are able to access images through MobileMD, Dignity Health’s health information exchange (HIE), which launches an integrated viewer via a link contained within clinical reports. MobileMD was piloted in August 2011 by 5,000 physicians, and the HIE has since penetrated nine markets.

Another pioneer in the imaging arena is the University of Pittsburgh Medical Center (UPMC) health system, which developed its federated diagnostic image repository, called SingleView, in 2008 to link up multiple imaging archives (UPMC has 12 PACS systems in radiology alone) into a more “patient-centric” view. The health system has successfully flowed in several ‘ologies of images including cardiology, radiology, gastroenterology, ophthalmology, dermatology, ENT, and neurology.

“SingleView creates a federated PACS and matches the patient’s identities and medical record number with his or her other records across the enterprise, all in a single view,” says Rasu Shrestha, M.D., UPMC’s vice president for medical information technology and medical director for interoperability and imaging informatics. “It is meant to be a patient-centric platform and directly integrate into the clinical workflow. The notion of SingleView was to make it into multi-ology aggregation platform.”

Shrestha says that UPMC took a federated perspective due to the geographical challenge of its disparate hospitals spread across western Pennsylvania, which calls for the need to have the major PACS reside closest to the hospital. “It was important to have those PACS systems in close proximity so that the images would come up quickly,” he says, “and there wouldn’t be a lot of network chatter going back and forth.”

Rasu Shrestha, M.D.

Shrestha sees UPMC’s enterprise imaging strategy as a journey, not an end goal. “We’re working steadfastly to aggregate additional sources of data around the patient’s context—whether it’s different types of imaging data, audio, or video images,” he says. One of these initiatives is an ongoing project to create what is termed as the Clinical Content Foundation, which “provides a singular place to house all of the patients’ [non-DICOM] content that you don’t typically house in EMR systems and PACS systems.” Work still needs to be done to integrate these non-DICOM images into the clinical workflow, providing the right XDS handshakes to funnel images into SingleView.

Cross-Institutional Image Exchange

But what about image exchange between unaffiliated institutions? Researchers at Wake Forest School of Medicine in Winston-Salem, N.C., have developed the Patient-Controlled Access-key REgistry (PCARE) system to make radiological images as mobile as other patient health information to digitally allow the transfer medical images without the hassle of CDs.

“This is the critical design feature that sets our framework apart from existing patient-coordinated sharing frameworks such as PHRs,” says Yaorong Ge, Ph.D., co-investigator for PCARE, and associate professor of biomedical engineering. “Instead of dealing with actual clinical data as in a PHR, PCARE is a collection of access keys or secure tokens that uniquely represent clinical datasets. These unique access keys are generated by a healthcare imaging facility upon patient authorization to provide a secure electronic conduit to the actual dataset.”

PCARE capitalizes on the strengths of both the patient and organizational-based approaches. The token generated by the healthcare imaging facility contains encoded metadata that identifies in which hospital the images were taken, what time, the facility-generated patient identifier, and the facility-specific URL that links to the actual clinical data. When the patient goes to the second healthcare facility, they swipe a patient identity card, much like a credit card, at a patient controlled portal or kiosk. The patient is asked if they want to share the specified images, and once that option is selected, a digital signature signs a secure token that is then sent to that facility’s edge server, which transmits the token to the original healthcare imaging facility’s edge server, which validates that token and ships the validated token with the image links back to the second facility.

PCARE’s next phase hasn’t been completely finalized yet. In the next three to six months, the investigators will partner with a healthcare economist to begin interviews with patients, families, and providers to ascertain what they would like to see in the PCARE platform and how much they would be willing to pay for it. There are also plans for a regional demonstration project.

Yaorong Ge, Ph.D., Wake Forest School of Medicine (in back); David Ahn, architect (in front); and Jeff Carr, M.D., co-principal investigator(right), demonstrating the PCARE patient kiosk. Photo: Wake Forest School of Medicine

Despite a recent report from Frost & Sullivan that says the PACS industry will see slow growth over the coming years, there is likely to be an expansion in interoperability solutions as organizations figure out the best paths to follow to image-enable their EHRs.

“I think the market is primed for additional growth around expanded archive use,” says Brown. “I think the market around archiving solutions around clinical images is going to continue to grow, but with that you’ll see the market for viewing solutions required because the need for more accessibility to those studies and with the growth of mobile devices.”

Shrestha recommends healthcare IT leadership not be sidelined by vendor-speak when choosing or enhancing their imaging solutions. “I would encourage my peers to go beyond the buzzwords and really push your vendors to deliver the true things that you absolutely need to get toward the patient-centric approach, and also at the same time not being afraid to innovate,” he concludes.