Advancing Imaging Informatics: Looking at the Leading Edge in Accessibility of Images Across the Medical Enterprise

Sept. 22, 2014
As imaging informatics strategize around new technological trends, they are changing the way images are retrieved, analyzed, and exchanged across the medical enterprise forever. What are the emerging challenges of the new imaging landscape?

As the landscape in imaging informatics continues to shift, the challenge for healthcare IT leaders lies in being aggressive in their strategies to keep up with accelerating new technological and process trends. Imaging informaticists are devoting themselves to looking at how information contained within medical images is retrieved, analyzed, enhanced, and exchanged across—and beyond—the patient care enterprise. The leaders are also looking at how diagnostic images fit into a changing medical practice landscape and the thrust toward patients’ ownership of their images.

The most progressive organizations are beginning to explore a universal viewing application to interact with their electronic medical records (EMRs), says Joe Marion, founder and principal of the Waukesha, Wis.-based Healthcare Integration Strategies, which assists clients with imaging strategy and implementation. Those who are looking to advance, says Marion, are doing it through a vendor neutral archive (VNA) architecture. Historically, of course, medical image storage has been under the control of individual picture archive and communications system (PACS) applications, requiring management of that data to be completely reliant upon system functionality.

Joe Marion

Healthcare facilities have now begun to deploy VNA technology to consolidate image archive and data accessibility. As imaging data throughout the enterprise grows, so does the need for a VNA for more cost-effective storage. “Moving to a VNA can reduce migration costs and avoid the proprietary data storage often found in PACS applications, making information more accessible,” says Marion. “If you can store all of the service areas in one environment, there is a cost savings from having that singular platform as opposed to multiple platforms.” As such, according to a recent report from research firm MarketsandMarkets, the global VNA market will hit $165.3 million and will grow by 15.2 percent annually to $335.4 million by 2018.

Mark Jacobs, CIO of the Delaware Health Information Network (DHIN), a health information exchange (HIE) that serves all of Delaware’s hospitals and providers, says that for an HIE, the biggest challenge with medical images is community viewing, which can be described as “a work in progress.” But Jacobs agrees that the VNA is a critical component to community viewing. “If you look at community viewing, just implementing a UniViewer in the community is going to be problematic because of response times, access speeds, and bandwidth issues. Remember, you’re talking big, heavy images. We have learned with an HIE, if you have to wait for anything at the point of care, physicians will get frustrated and not use it. If the world was perfect, we would have the UniViewers, big communication pipes, and also a VNA—those are three success components for community viewing. But it’s a very expensive business proposition.”

The next step in image exchange is the rise of HIEs, which has been recently expanding, adds David Mendelson, M.D., director of radiology information systems at the N.Y.-based Mount Sinai Medical Center. Cross-enterprise document sharing for imaging (XDS-I.b) extends XDS to share images, diagnostic reports, and related information across a group of care sites.

Mendelson is also co-chair of Integrating the Healthcare Enterprise (IHE), an initiative designed to improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as Digital Imaging and Communications in Medicine (DICOM) and Health Level Seven International (HL7) to address specific clinical needs in support of optimal patient care.

David Mendelson, M.D

When the HITECH (Health Information Technology for Economic and Clinical Health) Act was passed, image exchange became a major agenda item in the White House, and thus for the National Institutes of Health (NIH). Over the last four years, says Mendleson, using NIH funding, IHE has established a small, but growing, network of hospitals that are enabled to export—with patient consent—images into the servers of a few vendors that maintain image-enabled personal health records. The idea moving forward, he says, is to build a network such that it uses an infrastructure that is very similar to the infrastructure used for HIEs, so they can all live on the same national highway. “We are trying to get the vendors to all adopt this XDS standard, so no matter how you exchange images, it’s all the same standard,” he says.

As Jacobs notes, though, for many healthcare organizations, cost remains a major barrier when it comes to being progressive with their medical imaging capabilities. At the five-hospital University of Colorado (UC) Health, MariJo Rugh, vice president of application services, says finances are one of the system’s biggest deterrents right now. “If you look at the cost per study in your own PACS system, and an additional cost for the cloud to share the image, it adds up. Each image you need to store has a significant dollar value associated with the storage and exchange of it. Then, you get into image life management, such as how long you will hold onto it, based on how much storage you’re going to have. It all comes back down to cost.”


Key to image exchange is interpretation, a service provided by the Carol Stream, Ill.-based Virtual Radiologic (vRad), a technology-enabled national radiology practice working in partnership with local radiologists and hospitals to optimize radiology’s pivotal role in patient care. vRad has provided radiology interpretations from more than 2,000 hospital sites throughout the country by transferring images from the hospital sites to its centralized server in Minneapolis, and then accessing those images over the Internet using individual workstations from radiologists’ home offices, says Ben Strong, M.D., CMIO of vRad. Those radiologists, in turn, use a DICOM viewer to analyze the images and integrated voice recognition software program to create reports which are then sent back to the hospital system that ordered that interpretation, he explains.

Ben Strong, M.D.

The trend considered to be leading in terms of the cutting-edge activity, continues Strong, is the normalization of data. “We realized some time ago, the key to a managing a practice of this scope would be to normalize data. By that I mean know exactly what we’re dealing with, know what kind of study, what kind of patient, and what kind of facility we’re handling, because an interpretation can be influenced by all of those factors. Precise knowledge about the studies we’re handling and the precise needs that are thus required are really only possible by normalizing the terminology for studies across the entire platform on which we deal.  That is really the cutting-edge trend now.”

Raymond Montecalvo, M.D., medical director at vRad, provides an example: “We may have clients for multiple hospitals. They will have hundreds of different descriptors for foot X-rays, and they send us this data. Unless you know on the back end how to turn the same study described in a number of ways into a single descriptor, you can’t conglomerate that data and figure out how many foot X-rays this hospital is doing, or what the national average of this hospital is compared to a national benchmark, or who’s ordering it. There is no single repository of that data in the U.S. [At vRad], we probably have the greatest opportunity to conglomerate that data and make it useful for the [hospital] sites.”

Both Strong and Montecalvo acknowledge they were concerned they would have difficulty demonstrating the value of normalization and data analysis, because over the years, radiology groups and hospital networks have been slow to respond to market forces. “But today, everyone is well aware of the pressures on medical imaging and healthcare in general,” says Strong. “As a result, there are more efforts to look at your data and analyze the utilization of resources and develop the need to do that analysis.” Montecalvo warns that this is not something that happens in a quantum leap, however, with larger integrations which will only accelerate more in the coming years with the Affordable Care Act and growth of accountable care organizations (ACOs).


One of the next steps in imaging informatics is giving patients some form of ownership over images and reports, through image-enabled personal health records, an idea that is embedded as a goal in Stage 2 of the meaningful use process under the HITECH Act.

Patient portals and meaningful use are drivers to accessibility, as providers now want it, says Mendelson. “We have learned there is a large constituency of patients who want ownership of their data. Certainly, it’s not for everyone—there are those with limited Internet skills,” Mendelson says. “But if you had a CT scan because you have a tumor, and you’re shopping for care and going to specialists, the burden is eased if you can move your images around. That becomes important.”

Being able to not only potentially share an image that a patient has taken through the portal, but also view their images through the portal is great, agrees UC Health’s Rugh. “We’re already allowing them to view their images through the portal. I think using the portal and allowing them to view and share from another physician is right where we’re headed. It’s a way to get patients involved in their care.”

It is important to remember that any patient receiving an imaging study has a right to request copies, guaranteed by the Health Insurance Portability and Accountability Act (HIPAA), adds Strong. “It’s in their best interest to keep an archive of their own imaging. There is no national repository or universal medical record number—patient record numbers vary from hospital to hospital or network to network, making it difficult for a patient to travel and have his or her medical record follow him or her in any accurate format. That being said, we would like—and have considered—a system in which a patient could request a second opinion. This has been done by no one in a concerted fashion that I’m aware of. In the future, there could be a portal where a patient could upload images and request a second opinion.  I think that day is coming.”

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