Wide Load: Puzzling Out the Place of the Diagnostic Image in the Emerging Healthcare Landscape

Nov. 17, 2017
Even as the U.S. healthcare system shifts from volume to value, how best to integrate image exchange into overall data exchange remains unresolved.

For years now, the question of how to fully inte­grate the appropriate sharing of diagnostic imag­es into healthcare data exchange—including into the phenomenon of health information exchange (HIE) has been a vexing one for healthcare IT leaders. Industry experts and observers agree: there’s got to be a better way than burning CDs and handing those to patients to hand to the next clinician down in the line in the chain of care delivery. And of course, the burning of CDs has been predicated on the shift nearly two decades ago now to digitized diagnostic images. Before that, health­care was stuck in the world of physical films.

But the landscape has been changing steadily over time. To begin with, “We’ve made a great deal of prog­ress in the industry in the last couple of years, as we’ve talked about freeing up the data and unshackling the image of the data repository,” notes Rasu Shrestha, M.D., a practicing radiologist and the chief innovation officer at the 20-plus-hospital UPMC health system, based in Pittsburgh. “We created the VNA [vendor-neutral archive] to free images from PACS systems. And then we realized that wasn’t even good enough; we needed more of a cloud-based, enterprise-wide ca­pability, regardless of where the patient, the clinician or the radiologist might be, as those are the three main actors who need to leverage the image and image-re­lated content.”

Indeed, Shrestha says, “There’s been a real mind shift in the last three years, that it’s not just about capturing the image and making it available; what it is about really is—you capture it once, you store it once, you imme­diately cloud-enable it, and you then make it available multiple different times. And what that’s given rise to is a solution that really addresses some of the key chal­lenges we have with going digital generally, which is one of scalability. There’s been an increase in demand for im­ages, with a need to focus on workflow, so that we can make this scale and make sense. We’ve moved from film to filmless, to image archives, to the VNA. And we’ve said, OK, we’re going to focus on enterprise content management, and that inherently requires that it all be cloud-based.”

And, amid that broad set of changes, one question that has arisen, as U.S. healthcare has begun to shift from a volume-based payment paradigm to a value-based one, has been how to integrate the flow of di­agnostic images, and of radiological reports, into the flow of data moving back and forth among clinicians. HIE organizations have made some inroads in some communities and states; but the sheer digital weight of diagnostic imaging studies has made their sharing via HIE networks—and their storage as well—problematic. So what is the solution? Increasingly, some healthcare IT leaders, industry experts, and observers, are conclud­ing, it won’t mean moving images around at all, but rather, providing access in situ to secured repositories holding those images.

Solutions Hiding in Plain Sight?

Speaking of the ongoing challenge of ensuring that diagnostic images and radiological reports are acces­sible and available at the point of care, Joe Marion, principal of the Waukesha, Wis.-based Healthcare In­tegration Strategies consulting firm, says that “I have personal experience of that, so it’s a hot button for me. I think there are a couple of things that are begin­ning to gel in the industry,” he goes on to say, and the most important emerging trend is that of “server-side rendering.” In that regard, he says, “Visage [the Rich­mond, Victoria, Australia-based Visage Imaging] is a prime example” of a new wave of vendors offering the ability to provide access to diagnostic images without having to laboriously move them through online pipes. In the case of these vendors, “All the manipulation of the images is done on the server side, and all I need is an HTML 5-type web-based viewer, with all the in­formation staying at the server—from a security point of view, I’m not passing information, and I’m not risk­ing PHI, because I’m not moving anything anywhere or waiting for anything to be moved.”

Another company that’s moved in this new direction is the Dallas-based WhamTech, which uses a trademarked “smart data fabric” approach to index-based data virtual­ization, federation, and inte­gration. As WhamTech’s chief technology officer Gavin Rob­ertson notes, his firm’s technol­ogy combines aspects of data warehousing, federated adapt­ers, and advanced web search, allowing authorized end-users to find images and data, as given permission, and to pull those images and data out for specific purposes, thus obviating the need to move web-heavy images around in traditional ways.

Marion says that, as these newer technologies are ad­opted, “That is going to open up the opportunity for greater sharing of images, because as a patient, I could get access to my images without physically having to access a DICOM viewer, or someone creating a CD. It’s there, it’s in the cloud. And from an ownership point of view, if I have my exam done at Aurora, Aurora can con­tinue to store the information, and I don’t need to physi­cally get a copy of it.”

As Marion puts it, “There’s no logical reason that di­agnostic images couldn’t be pushed to a storage site that I control as a patient.” Indeed, he says, in that con­text, “One might consider the idea that Google got out of the game too early, and though Microsoft hasn’t achieved this with their HealthVault, it’s something that is achievable. So I think that it’s all about storage and about access to that storage,” he says, “really just giv­ing people access to images through linkages. I think that that’s what’s going to open up the ability to share images across entities, in conjunction with CommonWell and some of these other initiatives that allow access to data. Also, the XDS—cross-document-sharing, protocol, which has emerged as an extension of the IHE, Integrat­ing the Healthcare Enterprise—that is a data format” that will allow more extensive sharing of diagnostic im­ages in the next few years.

David Muntz, the former Principal Deputy National Co­ordinator for Health IT, who is now a consultant with the Dallas-based Starbridge Ad­visors, agrees with Marion. “I had that same experience with my mother a year-and-a-half ago,” Muntz reports. “My mother was being treated at a couple of different facilities within the same integrated health system, and she was required to carry CDs from one facility to another; and the CDs couldn’t be read from one to the other, even though they were under the same corporate par­ent.” For purposes of disclosure, he notes that he is on the board of WhamTech, but he notes more broadly that the key to all of this is that “You have to look at what really comprises a medical image. There are two things—one is the image itself, including its techno­logical provenance. Then there is the interpretation of that image or set of images. Those two things do not necessarily have to move together. Unfortunately, right now, the state of the nation is that we’re able to move the interpretation or the report a lot more easily than the image, and that’s really related to bandwidth.”

What’s more, Muntz continues, “The second chal­lenge is, do we have the appropriate monitors, to ac­tually see the relevant and pertinent data, and so the quality of the image, whether in a diagnostic or con­sultative context, is also an issue. So those are trouble­some issues. If I see what people are doing now to try to solve the problem, it’s really around trying to move the image, and I’m not sure that that’s really the best way to do things. There are technologies that will al­low the image to be accessed at the source, and that changes the definition of interfacing, to that of remote access. If you had a link, which is what a lot of people use, to get to an image at its source—that involves both pluses and minuses. The minus is that you’ve got to move the image, but the plus is that you can then view it where it is,” he says.

George Reynolds, M.D., who for years served as the CIO and CMIO of Children’s Hospital & Medical Center in Omaha, and who is now a principal in his own con­sulting firm, Reynolds Healthcare Advisors, agrees with Marion and Muntz that there are challenges inherent in attempting to use the mechanism of the traditional health information exchange as a vehicle for efficient diagnostic image-sharing, and that newer technolo­gies are needed. “I think the idea of a common image repository, whether organization-specific or HIE-gen­erated, remains to be seen,” he says. “I think Denver has worked on a common image repository at the HIE level. But these things are not inexpensive. It seems like a great idea, but it hasn’t caught fire at the HIE level, whereas it clearly is catching fire at the IDN level. The other part of the question is, what level of image access should be involved? If you’re an ED doc and you know a CT was done yesterday—and maybe some­times, even access to the interpretation is enough; whereas, for the surgeon or radiologist, seeing the im­age may be more important.”

Matthias Kochmann, M.D., a pediatrician practicing in Indianapolis, agrees. “From the informatics perspec­tive, you will have very large files when you’re working with diagnostic images, and there’s a question of the value—do I need to see hundreds of slices, as a physi­cian? And maybe if it’s easier, I might want to see chest x-rays instead. So size is a problem; and also the type of images involved. And also, even though all the ra­diologists are board-certified and trained—I work in a hospital where there’s no children’s ward, because we’re next to Riley Hospital for Children, which is next door— when we need to consult over an image, we send it into the cloud. The more complex and specific you get, the more the institutions want to see it themselves. For ex­ample, the hospitals related to Harvard will always de­mand to see the images themselves. So the size, the type of image, will both be significant factors. And from the IT perspective, there’s another problem, in terms of integrating it. It’s very easy to integrate text everywhere. But the data file of the image is tricky. And then the last issue is that if you only have the report, that’s often suf­ficient, in many cases.”

Still, there are times when accessing a specific image or set of images can be impor­tant, including for a referring physician. Kochmann notes that, “A couple of weeks ago, we had a young child who had food stuck in his esophagus. It was circular and looked like a coin; but could also have been a button battery. If it were a button battery, that would have posed a real emergency, because the metal would start to erode. So you could argue that when it comes to more complex pictures, like the CT, you only need to send 10 slices. In that case, it went to Riley Children’s Hospital, they put him into sur­gery, with the endoscope, they pulled it out, and it was a coin. But seeing the image directly as a pediatrician was important in the moment.”

So appropriate image access and availability continue to matter, those with clinical backgrounds agree, includ­ing George Reynolds. Image access is “already easy,” Reynolds says, “in that, if you have access to a system’s PACS [picture archiving and communications system], you can literally access images via a web browser, sitting in your jammies in your basement. And now, increasing­ly, you’ve got incredible leaps beginning to take place in terms of leveraging AI [artificial intelligence] in the PACS system, where they’re able to help the radiologist pre-interpret. In my mind, the bigger issue is getting all the images—whether radiology, cath lab, GI lab, etc., into a common repository, so that you can see the continuum of images, the way you expect to see the continuum of data. It really is increasingly a part of how you tell the patient story.”

HIEs Move Forward on Image Exchange

Meanwhile, despite the fact that some in healthcare are urging that the industry adopt newfangled technologies in order to create new options for accessing diagnostic images and reports, some traditional HIE organizations are making progress in making diagnostic images more available to clinicians. One statewide organization that is helping to lead forward one version of that scenario is the New York eHealth Collaborative (NYeC), which over­sees the operations of the Statewide Health Information Network of New York (SHIN-NY). The appropriate sharing of diagnostic images is indeed one element in the broad strategy that NYeC and SHIN-NY are pursuing, says Val­erie Grey, NYeC’s executive director. “Image exchange is happening in a lot of parts of New York state now,” Grey reports. “In the last couple of years, we have used public funding to get image exchange up and running in vari­ous parts of the state” where image exchange had not yet occurred. Meanwhile, she notes, “Some form of im­age exchange has been happening within the RHIOs [re­gional health information organizations] for eight years or so now. The Buffalo and Rochester RHIOs identified the need, found a vendor, and added this as a service within their HIE. In the past several years, more RHIOs have ad­opted the technology, and in the past two years, we’ve had an initiative to fund this technology. It’s a bolt-on to your standard architecture. So in six of the eight RHIOs, image exchange is live, and we’re working to make it pos­sible across the RHIOs and regions.”

In fact, about 500,000 imaging studies (CT, MR, x-ray, etc.) are moving through New York state’s RHIOs every month, while “Upstate, in broad numbers, about 60 im­aging providers—private radiology clinics and hospital imaging departments—are connecting their images,” Grey reports. “By February 2018, we expect that to be about 80,” she says, adding that, in terms of the volume of imaging studies flowing through the RHIOs, “We ex­pect that to rise into the millions, when the downstate sites are connected live.”

Grey explains that, right now, in the SHIN-NY, a par­ticipating primary care physician or radiologist can look at an image or a report, through the HIE. Also, another radiologist, because of the system the RHIOs in NYS have implemented, can grab an image and download it into a PACS. “We feel that’s a really big benefit, be­cause there’s no need to repeat an image,” Grey says. “In some ways, we’re doing both right now. Also, go­ing forward, working with the vendor that all the RHIOs use, to implement the RSNA standards, around XDSI and XCAI gateways.”

Things are actually moving forward in a number of states now in terms of HIEs and im­age exchange. “What we’ve seen in the last several years, and we’re seeing a lot of this in western Pennsylvania,” UPMC’s Shrestha says, “is that these private HIEs are prolif­erating. Public HIEs weren’t quite the right business mod­el. And we have CCHIE, Clini­cal Connect HIE here in west­ern Pennsylvania; we’ve got a dozen-plus institutions in the region. And the HIEs are saying, we want more than a continuity of care exchange; we want access to the imaging reports as well as to the images them­selves. The HIEs know this is important, and it’s impor­tant for patients moving across these different sites of care. And you want to do what’s in the best interest of the patients.

What Should CIOs and CMIOs Be Doing?

Meanwhile, regardless of the channels, networks, or tech­nologies involved, one thing is clear: sets of diagnostic images, as well as radiological reports, will increasingly come to be essential to the success of population health management and care management initiatives under risk-based contracts in U.S. healthcare.

Asked what the CIOs and CMIOs of patient care or­ganizations should be doing, Reynolds says that “You could tie yourself into knots anticipating new business arrangements; but the single most important thing I would be doing as a CIO or CMIO in this context, is making sure I have a robust governance structure guid­ing the development of whatever architecture I’m de­veloping, so it’s clear what will be accomplished. Is it view versus diagnostic quality? Where will the images go? I need a battle plan so that I know how to present the information to the clinicians in a way that meets their needs and tells the patient’s story. And what’s the ROI for this? It’s going to be situational. It depends on where you are in the marketplace. It would be great if you had a statewide repository, and paid a fee to have a study there or access it,” he adds, “but we’re a long way from that in today’s market.”

“CIOs and CMIOs need to be working hand in hand with their clinicians and radiologists, to really look at, and push the boundaries of security and workflow,” Shrestha says. “They need to be looking at not just unshackling that image from their PACS systems, but at enabling im­ages to be freely shared across institutions and orga­nizations, and also giving patients direct access to im­ages, through portals as well as through patient apps.” Meanwhile, he says of HIEs, that “They really need to be taking a stronger leap of faith, and move away from just exchanging CCDs [continuity of care documents] and discharge summaries, and look at leveraging the power of the cloud, to allow for one-click access to images. The technology has really moved forward in the last four to six years on this, and HIEs need to capitalize on those capabilities. I do think HIEs are moving forward. RSNA [the Oak Brook, Ill.-based Radiological Society of North America] has been very supportive, through the RSNA Image-Sharing Network, of this effort.”

Will the journey forward be a long, complex one? No doubt. But image exchange is getting more attention now, and deservedly so. And the next few years will be important ones in the evolution of that phenomenon.