Carequality, RSNA Make Progress on Imaging Data Exchange Implementation Guide

Jan. 18, 2021
Dave Cassel, executive director of Carequality, and David Mendelson, M.D., vice chair of radiology IT for the Mount SInai Health System, discuss the significance of this work

The sharing of medical images between provider organizations has lagged behind progress on sharing other types of clinical data. But an image exchange initiative started by Carequality and the Radiological Society of North America (RSNA) will soon expand the scope of the Carequality Interoperability Framework to support the exchange of medical imaging studies. 

A new implementation guide they’ve developed addresses the capability to exchange Digital Imaging and Communications in Medicine (DICOM) imaging exams. In a recent conversation with Healthcare Innovation, Dave Cassel, executive director of Carequality, and David Mendelson, M.D., vice chair of radiology IT for the Mount SInai Health System, discussed the significance of this work.

Mendelson, a member of RSNA’s radiology informatics committee, said the organization has been working on various approaches to interoperability for years. One project called ImageShare involved working with vendors to create image-enabled personal health records to allow patients to direct where their imaging studies should be sent. “It involved tens of thousands of patients across the country,” he said. “Generally patients expressed satisfaction. It made life easier for them.”

At the same time, Mendelson noted, there were silos of people trying to do network-based image exchange through local exchanges. “The problem was that those exchanges were all proprietary,” he said. “A community might have a solution that involved three or four hospitals, but those projects were not interoperable with each other.”  He said RSNA started partnering with the Sequoia Project on interoperability ideas. “We set up a set of standards and testing and we made Sequoia our testing partner. Vendors could apply and basically get a seal that says you have standards that make you interoperable by complying. We had as many as nine vendors at one time that had gone through that process"

Ultimately, he said, they wanted image exchange to take place along the conventional idea of exchange from an HIE and to be standards-based. "When Carequality arose, they were a natural partner," Mendelson said. "They were doing millions of exchanges of documents, just not images yet. They have rules that are standards-based, many of them IHE standards. So here we are. Carequality is writing an implementation guide that has received public comment. Hopefully sometime this year it will become version 1. It will be the guide for how anyone who wants to build an exchange of images from a hospital to an HIE or to a local radiologists’ office would know how to onboard and exchange with others in a standards-based way with good rules of the road.”

Carequality’s Cassel said the implementation guide image exchange supplement for its interoperability framework builds on the work they have done with document exchange. “As that work Dr. Mendelson was describing in image exchange was under way, there was a parallel effort under way to exchange documents. Carequality arose as we recognized regional HIEs and vendor-based networks were all doing good work but had a fundamental flaw, in that they only worked if everybody was part of that community – geographic or vendor-based.”

Carequality was set up to play a role similar to what has happened in the telecom industry, he explained. Individual networks exist, and you choose a carrier for your phone service, but once you do that, you just make calls and it works. That happens because behind the scenes there is a legal and technical framework in place that specifies how carriers work together to make phone call universality work, Cassel said. At a high level, that is how Carequality approaches health information exchange. As a provider organization or public health agency, you choose a regional HIE or EHR vendor, and then you can exchange with all the participants of all the other networks.

“There are technical challenges to be addressed, and more in image exchange than other types of data, but it is not rocket science. We can all get together and solve things like file size issues,” Cassel said. “That is the role RSNA has played along with IHE and others. At the end of the day, we are asking somebody to take a transaction off the internet and release sensitive medical information in response to that transaction,” he said. “Nobody is going to do that without a really solid foundation of trust. That is what Carequality provides. The foundation is the legal structure to allow the organizations to all trust one another. We have built that up over time, and we are rapidly approaching the 2 billion mark in terms of documents exchanged.”

But there is nothing about the framework that is inherent to documents, Cassel said.  “We can take the same framework and apply it to image exchange or to FHIR-based data elements as well.”

“We are ready to apply that existing legal and governance framework to the technical challenge of image exchange,” he said. “We are doing that through the vehicle of the implementation guide developed in collaboration with RSNA. And we are at a point where early adopters have done the partner testing and we have largely gotten the feedback we need to finalize and adopt for production use that implementation guide supplement. We expect to be doing that around the end of the first quarter or beginning of the second quarter of this year.”

Cassel added that they expect a relatively early enhancement to the image exchange supplement to incorporate FHIR as a transport mechanism.

I asked Cassel if image exchange could be part of the TEFCA effort that Sequoia is working on as the Recognized Coordinating Entity.  “There is some potential for that,” he said. “We have talked with ONC at a very conceptual level about how it might make sense from Carequality’s work on FHIR-based exchange. It is reasonable to think the same would apply to image exchange and ultimately image exchange could be covered under TEFCA as well.”

Mendelson said those working in radiology informatics want DICOM data to be treated like all other types of healthcare data. “It needs a little massaging because DICOM is not text data or lab data. The formatting is different. But we would like to see it treated the same way.

Mendelson said he is enthusiastic about the work with Carequality. “Over the last few years, the vendors who provided CD exchange have built networks of their clients. Those vendors are coming to the table, and bringing their networks, which are national, to the table. So we have a vendor at Mount Sinai, LifeImage, that provides us with services in terms of moving images around, importing CDs, et cetera. It is one of the vendors that has signed on and is participating in the initial implementation of the Carequality RSNA project.”

He is also encouraged thinking about the positive impact on patients. “Just like with my experience in that RSNA ImageShare project, taking the burden off patients who are ill is huge. If someone tells you that you have cancer and you want to get second opinion, getting all the records together is a huge challenge if you are well and an even bigger challenge if you are worried that you might have something that is going to kill you. It takes a big effort and not just in imaging. It can take weeks to gather all the medical records” He said you should just be able to go to the radiology department and sign a document about where you want your documents to go.

The companies involved in the pilot project:




Ambra Health

The Carequality implementers:


Athena Health





eHealth Exchange


Glenwood Systems

Health Gorilla

Community Care HIE








Particle Health

PCC Pediatric EHR Solutions


•  Redox

Safe Health

Safety Net Connect

Santa Cruz Health Information Exchange


Zen Healthcare IT

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