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PHR's: Is a Picture Worth 1000 Words?

July 21, 2008
by Joe Marion
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In my last installment, I discussed Cloud Computing and its relationship to imaging. On a somewhat related note, with all the interest in Personal Health Records (PHR’s), I thought it might be interesting to explore the issue of images as part of the PHR. I’m wrestling with whether adding images to the PHR really adds anything? And, it presents a number of challenges that need to be addressed.

Level of Understanding: What is the point of adding images to the PHR? As the expression goes, “a picture is worth a thousand words,” but this assumes one understands the picture – sort of like a Da Vinci versus a Pacasso. A Da Vinci such as the Mona Lisa is clear to most people, while Picasso’s The Glass is probably more difficult to interpret. Similarly, an X-Ray of Johnnie’s radius fracture may be fairly straightforward, whereas a nuclear SPECT image may not be. The point is – not all physicians are skilled in viewing images, and sometimes leave them to the specialists. So of what benefit is the image to the patient? There may be legitimate cases where the image would be valuable, but only experience will determine this.

Ownership: While the case might be made that the patient “owns” their images, in reality, the imaging service is most likely the actual curator. If one follows the diagnostic cycle, a patient most likely sees a general practitioner, who may refer to a specialist, who may order some diagnostic studies, which are done by an image service. So, what is the point in the imaging service submitting images to a PHR? By themselves, there is no value. With a radiologist’s report, there is value, but the report probably gets sent to the specialist or the general practitioner. So, who provides the information to the patient’s PHR? The imaging service? The Radiology Group? The Specialist? The General Practitioner? The most likely source would be the physician ordering the study, once they have seen the results, but how will this be managed, and is the physician likely to forward the image and an explanation, or just the report? What would be the basis of the imaging service sending the information, unless requested by the patient using proper HIPAA procedures?

Readiness: Is the world ready for imaging accessibility? How important is the image to the patient? While it may be a medical curiosity to see one’s kidney stone, it’s not the sort of image one is going to print and show to all the relatives! Is the infrastructure ready to take on massive movement of images? If imaging is going to become part of the patient’s PHR, do I store the whole study, or just selected images? And if selective, who does the selecting?

Image Size: Images require substantially more capacity than textual content, both in terms of storage capacity and transmission time. Depending on the number of images sent, format, etc., transmission time could be excessive at standard home connectivity rates (DSL, Cable). Image type will also play a factor, as will compression levels. There may be competing issues here, as the highly compressed image needed for manageable transmission times may not have enough detail to show the diagnosis.

Image Viewing: Delivering images to the patient will require that the patient be able to view them. The most likely format for managing images in a PHR archive would be DICOM, but how does one conveniently deal with viewing a DICOM image on a home PC? While there are many simple DICOM viewers available, almost all require download of some add-in. Again, for the number of times a patient will access an image, will they tolerate the download, and who resolves issues with the download and the setup? This suggests that it may be far simpler to use existing image viewing technology such as Windows Picture and Fax Viewer, or whatever viewer the patient has installed that supports standard formats such as Jpeg, bmp, etc.

These are a few of my thoughts. I would be interested in other’s perspective to this. It would seem prudent that healthcare professionals think this through thoroughly before the consumer-base infrastructure runs with it. Is anyone familiar with any medical professional group that might tackle this? SIIM comes to mind, but there may be others.



Wouldn't the best solution be to only include the URL of the image inside the PHR? That would allow access if required, but would also keep the size of the record reasonable.

In a perfect world, I would concur. Unfortunately, it's not a perfect world with respect to image storage/viewing. If the PHR only contained a URL pointer to the image, the question is, where would the image be stored? If the PHR had to access multiple storage locations, it could get complicated.

Also, the issue is not so much the image storage, as the display. If stored in DICOM format, the application would still have to convert the image to HTML and load it in a veiwer. The question is - where would such an application reside? Within the PHR? On the local client accessing the PHR? Depending on how this is structured, it could still have an impact on performance and support.