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Imaging’s Next Steps: A Paradigm Shift in Patient Care

November 4, 2013
by John DeGaspari
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Cleveland Clinic makes its case for integrating text and imaging information in the EMR

C. Martin Harris, M.D., chief information officer of the Cleveland Clinic in Ohio, has this piece of advice for provider organizations that are making the shift from paper to electronic medical records (EMRs): when moving data from paper to an online model, make sure that you include all information—basic clinical data and imaging—in that shift. Imaging needs to be part of the strategy in a way that integrates the two types of information together, he says.

About three years ago, Cleveland Clinic embarked on a project to integrate its enterprise imaging data into its electronic medical record, tightly tying its imaging data to textual clinical data. Harris shared details of the project in July as part of a presentation on enterprise imaging, hosted by the Health Information Management Systems Society (HIMSS) and sponsored by Agfa Healthcare. Since implementing its integrated imaging approach, Cleveland Clinic has started a program, called MyPractice Imaging Solutions, to advise other provider organizations on imaging strategies.

Harris spoke of a paradigm in the traditional practice of medicine as practiced in this nation: make observations, run tests, analyze and diagnose, come up with a treatment plan and follow the patient over time. “When we think about caring for the patient, that is the process that is driving us,” he said. Historically, the information was captured on a paper chart and was separate from the image data, he said.

Now that paradigm is shifting, as basic data moves to the EMR at the same time there has been a migration toward imaging. Those parallel trends go to Harris’s point that provider organizations moving to electronic data need to also decide what their imaging strategy is going to be. “The management and delivery of great care to patients means managing all of the information—not just basic data, but imaging data as well,” he said.

The Case for Integration

Harris observed that images today are often captured distinct from one another, and in unique encounters that are related to a specialty. “If you can name a medical specialty over the next five to 10 years, I will guarantee you that they will have an imaging solution that is specific to their specialty,” he said. Those distinct images are linked by capturing some sense of an encounter before being moved to the EMR.

This can be done in either an interfaced way or an integrated way, he said. In an interfaced EMR, imaging modalities often require dedicated systems, displaying images apart from, and not linked to, EMR encounters. An integrated EMR displays images through a single viewer and incorporates images into the patient’s EMR encounter.


Source: Cleveland Clinic


Source: Cleveland Clinic

In Harris’ view, true integration that ties images with clinical data is more effective in delivering good care to patients. Integration allows various types of clinical information to appear seamlessly in an EMR, so the physician can better direct all of his or her attention on the patient and the information at hand, he said. “In my institution, the physician doesn’t have any idea of what the name of the laboratory information system is; and the reason is, he doesn’t need to,” Harris says. “All he really needs to know is the result, and whether or not it is in the normal range, and if it’s valid.”

As imaging moves forward, “We have to make image management as effective and as easy and as integrated for the patient as we are for basic data like laboratory information,” he said. Seeing a chest x-ray and having the image taking over the computer isn’t helpful to the physician; what is helpful is the ability to view the imaging data in the context of the patient data, he explained. “The EMR should effectively manage all of the data relating to the patient, maintaining the context, delivering the basic data and the image data, so I can keep the focus on caring for that particular patient,” he said. Ideally, without leaving the window for the patient, the physician has done acute care and screen work, all of which is driven by basic data and imaging, which appears in a single patient encounter.

Harris said that an integrated approach means getting rid of the distinction between text and images, and moving toward an integrated model. “The way to get there is to think about imaging as part of the EMR strategy from the very beginning, so you are constantly building a comprehensive medical record system that will allow your clinicians to deliver good care.”

Imaging Strategy and the Enterprise

How to make this work? At Cleveland Clinic, imaging grew up in radiology, a large department that had a picture archiving and communication system (PACS) early on, which was matched by a practice model. “The PACS system was designed fundamentally for the radiologist, making diagnostic interpretations,” Harris said. The same thing was true of cardiology. In each example, the specialty was thought of separately, so neither had a shared plan going forward.  ”They were doing what they were used to, which was, ‘I’m a sub-specialty, and my goal is to optimize my component of the practice,’” Harris said.

Originally, Cleveland Clinic used an interfaced model, or a siloed approach, in building out its systems. For radiology, it built out workflow ability, storage and retrieval, with a viewer linked to radiology. The pop-up viewer, which was accessible from the EMR (which at Cleveland Clinic is supplied by Epic, Verona, Wis.), took the clinician outside the EMR as it presented radiology images of the patient.


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