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Despite the focus and progress made on health information exchange, diagnostic images have lagged behind and still today are most often not included in this valuable process. While transcribed radiology reports are sometimes exchanged, the image files themselves rely on "sneaker net," with patients carrying CDs to subsequent care encounters. This is an ineffective process - CDs are often forgotten, system incompatibility limits viewing across facilities, and images are unable to be stored in specialist or referring physician's archives or EHRs.
 Although Netflix has made Internet downloading of movies a routine process, diagnostic images have not achieved similar levels of interoperability. Today, more than 700 million imaging studies are performed annually in the U.S. The lack of image interoperability has significant impact:
- Financial cost - A 2009 CBS Evening News report indicated that $100 billion of annual healthcare costs are related to diagnostic imaging tests - but an estimated 35% of scans are duplicates. That translates to $35 billion in unnecessary costs for U.S. patients and insurance providers.
- Radiation exposure - The National Council on Radiation Protection and Measurements (NCRP) reported in 2009 that U.S. patients' exposure to ionizing radiation - delivered through millions of CT scans and other radiation-generating procedures performed annually - has nearly doubled over the last 20 years.
- Treatment delays - Care is often delayed and many appointments are rescheduled because diagnostic images are not available to support the encounter. This results in frustration for both physicians and patients.
Research and anecdotal evidence build a case for why diagnostic images should be easily accessed and shared electronically across healthcare enterprises, regional healthcare information organizations (RHIOs), and statewide health information exchanges (HIEs). It's time to adopt a new vision for an enterprise imaging strategy that focuses on providing electronic access to medical images. Current trends in patient safety and healthcare reform, as well as competition for referring physicians, are driving the need for this new paradigm of image sharing.
What is an Enterprise Imaging Strategy?
An enterprise imaging strategy must focus on image storage, the ability to ingest images from outside of the enterprise, and accessibility to any type of medical image, anywhere across the continuum of care, anytime, by anyone - provider, referring physician, specialist, patient, etc. Three components are critical to the success of an enterprise imaging strategy:
- Storage - a vendor neutral archive (VNA) to create a patient-centric record of images across all sites and modalities
- Gateway - an intelligent DICOM gateway, capable of receiving and morphing studies from outside the enterprise. Digital Imaging and Communications in Medicine (DICOM) is a widely adopted standard for handling, storing, printing, and transmitting information in medical imaging.
- Viewer - a universal viewer that can be used in any environment on any device and is accessed via the browser, thus requiring no software to be downloaded.
Implemented together, these three components will support a comprehensive enterprise imaging strategy. However, each of these solutions can stand on its own merits, allowing an organization to pursue the component that best aligns with its business priorities and timeframes. Simply stated, there is no wrong door to the implementation of an enterprise imaging strategy.
Let's take a high-level look at each of the components.
VNA: High Availability for Images
A VNA goes beyond the traditional process of PACS archiving to create a central, standardized, consolidated system that holds and manages the lifecycle of all images from each individual silo across multiple PACS and sites. This system morphs all DICOM headers into a standard format so that any of the DICOM viewers within the healthcare network can display the images, regardless of which PACS originally held the image. Consequently, the images are much more accessible to the healthcare network's physician community at large.
Although VNA is called an "archive," it is more than image storage - it's actually an image storage and management subsystem, capable of providing new levels of performance, availability and tag morphing. Images from departments across the enterprise can be managed including radiology as well as cardiology, orthopedics, neurology, dentistry, and beyond.
This patient-centric approach saves time for physicians, supports faster delivery of care, and helps decrease duplicate imaging. A VNA also manages the lifecycle of images and automatically moves older images from the VNA to a less expensive storage medium - making it easier and more cost- efficient to comply with regulations and security policies. It can also be an integral part of a disaster recovery and business continuity plan.
Intelligent DICOM Gateway - Eliminating the Need for CDs
While the VNA simplifies the sharing and archiving of images within a healthcare network, integrating an intelligent DICOM gateway will increase the value of the VNA while improving the process of sharing images between sites.
Because the intelligent DICOM gateway can receive images in real time, it eliminates the need for providers to create image CDs and for patients to hand-deliver them to specialists. Using a simple drag and drop interface, images can be sent over a secure Internet connection without requiring a VPN connection or additional hardware at the sending site. Once received by the gateway server, the image is morphed into the receiving location's native PACS format, and a text message or email is sent to notify the physician that the study is available for review in the native system. Once viewed, the physician will have the opportunity to delete the study or to store it for future reference.
Universal DICOM Viewer - Fast Access to Images
The third critical piece of the enterprise imaging strategy is a zero-download DICOM viewer to support the viewing of images stored in the VNA or stored within other DICOM archives. Because it is a zero-client viewer, users do not have to download software, applets, or scripts; and IT departments are spared the effort and cost of maintaining a myriad of downloaded objects that are prone to failure or corruption. The universal viewer should be available from any browser-based device (including smart phones and iPads) to support access from anywhere at any time. This type of solution is physician-friendly and can assist with growing the organization's referral network while lowering IT and support costs.
Why do Healthcare Systems Need an Enterprise Imaging Strategy?
The question is not if, but when a healthcare system should implement an enterprise imaging strategy. Anytime, anywhere access to any image just makes sense. There are many drivers that hospital CEOs, CIOs and physicians can no longer ignore: patient safety issues around radiation exposure; new federal policies to reduce reimbursement and foster information sharing; competition to attract and retain the best physicians; compliance with meaningful use guidelines; support for an accountable care organization (ACO) strategy; and the push for interoperability in EHRs across healthcare systems, HIEs, and RHIOs.
There really is no wrong way to proceed with an enterprise imaging strategy as long as decision-makers fully understand the capabilities of each technology component, relate the capabilities to meeting their top business challenges, and look at the enterprise imaging strategy as a solution that can grow and evolve over time.
Adopting an enterprise imaging strategy with anywhere, anytime accessibility is not a technology issue. The solutions exist today to create this environment. So why not give physicians the ability to have real time access to diagnostic images that are critical to making fast, informed patient treatment decisions?
Michael Warthen has more than 20 years of experience in healthcare information exchange. He is a past faculty member of the Health Information Management Systems Society (HIMSS) and Toward an Electronic Patient Record (TEPR), and is currently responsible for corporate strategy at Merge Healthcare.
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