Non-DICOM Imaging Studies Should be Accessible thru the EMR

Image-enabling the Electronic Medical Record (EMR) is generally the last step in providing the clinician with access to the patient’s complete Medical Record. The EMR itself is reasonably capable of managing and displaying the discrete data about the patient such as that data forwarded by measuring or monitoring devices, the medication list, documented allergies, etc.  An Enterprise Content Management (ECM) solution is the ideal way to manage the unstructured data associated with the patient such as scanned documents, diagnostic reports, lab results, care summaries…the non-image data. This unstructured data is easily accessed and displayed through a link from the EMR to the ECM solution.  Accessing and displaying the structured data associated with the patient, the medical images, has historically been more problematic.

Until recently, accessing and displaying the patient’s radiology and cardiology studies was reasonably straightforward.   The clinicians would directly access and launch the clinical display application associated with the radiology or cardiology PACS.  Alternatively those images being managed by a PACS could be accessed through the EMR by invoking a link to the studies associated with the radiology report being displayed by the EMR. Unfortunately there are number of problems with this approach to accessing/display a patient’s medical images.

  •  The clinician has to learn and remember how to use multiple viewing applications.
  •  Each display application is limited to displaying only those images being managed by that PACS.  There is generally no way to display images from different imaging departments (radiology and cardiology) on the same screen at the same time. This means the clinician has to bounce back and forth between two viewers to display disparate studies related to a single episode of care.
  • PACS-based imaging studies represent a fraction of the medical images that belong in the patient’s complete Medical Record.  There are imaging studies in other departments like Endoscopy and Ophthalmology that are not yet being managed by a PACS.  There are also all of those non-DICOM images that are being managed on mobile devices and PC’s.

The strategy for image-enabling the EMR should include a methodology and timetable for accessing the DICOM images (studies being managed in PACS and non-PACS scenarios), as well as what I refer to as the “informal images”, those images that are typically acquired in non-DICOM data formats like JPEG and MPEG. Examples include: [1] a series of JPEG images representing a burn wound that were captured by a digital camera or iPhone in the burn unit, [2] a series of JPEG images illustrating a skin rash that were captured during a series of dermatology office visits, [3] a series of MPEG clips taken during visits to the podiatry clinic representing the patient’s gate with and without the orthotic appliance. All of these imaging examples are clinically relevant to the patient, whether there is an associated formal report based on those images or not, and they rightfully belong in the patient’s complete Medical Record.

Current generation department PACS are focused on a specific imaging department.  They can acquire, manage and display most DICOM objects, therefore DICOM imaging studies, and the features and functions of the display are customized for the type of studies performed in that department.  These PACS typically do not handle non-DICOM image objects unless they are wrapped with a DICOM header and are associated with an existing DICOM study.  Department PACS typically do not handle imaging studies comprised solely of non-DICOM image objects.  These inherent limitations of the current generation of PACS is the major reason why the UniViewer (universal image viewer) was developed to image-enable the EMR.

There are a number of commercially available UniViewers that can accept and display non-DICOM images, but in many cases those images once again have to be wrapped with a DICOM header and associated with an existing DICOM study (added to the DICOM study as a new series) in order to be properly managed and recalled.  It may be appropriate to associate a series of JPEG images of a wound with the X-rays of the underlying broken bone, but in many cases, there is no formal DICOM study to which this type of informal imaging study can be associated. It is a standalone medical imaging study in its own right.

The ideal UniViewer application can accept, temporarily manage (if necessary) and display the non-DICOM images in their native format and therefore treat the set of images as an independent study.Slide1

The question is, how are these images acquired from the capturing device, assembled into a formal study, and how is the appropriate metadata that identifies the patient, the study, and describes the study type created and associated with the study?  Should this “acquisition application” be associated with the UniViewer, perhaps the VNA, or an enterprise workflow application?  Is there an argument for it existing as a freestanding application?  Regardless the source or configuration of the application, a methodology for creating an informal imaging study comprised of non-DICOM image objects should be a component of a healthcare organization’s strategy for image-enabling the EMR, because the clinicians will argue that they need access to the patient’s complete Medical Record, which should contain all of the clinically relevant images, not just radiology and cardiology.

What is Enterprise Imaging WorkFlow?

The current generation of department PACS was designed over ten years ago. That statement also applies to the workflow and worklist components of the PACS solution as well as the system architecture. The workflow application was designed to assemble images for interpretation by a single physician group working in a single imaging department, working with a single department PACS. The concept of prioritization was placing a STAT icon next to a study ordered by an Emergency Room physician, and perhaps applying a background color to that line item in the list. Today, even mid-sized healthcare organizations are commonly made up of several amalgamated radiology groups (some owned, some affiliated). They have multiple EMRs and PACS solutions. These organizations have to manage complex cross-site credentialing issues while trying to deliver a common standard of care across the new integrated enterprise. In addition to this, the organization has to hold each physician group to similar performance goals. The worklist of each individual physician absolutely has to consider such input as: physician availability (schedule, locations, etc.), turn around time, physician RVU loading, sub-specialty reading, credentialing, critical results reporting, and peer review. None of the current generation department PACS have a workflow application that addresses today’s issues much less future issues we can barely imagine. A new generation of workflow application that is applicable to the enterprise is clearly needed.

Slide4

Enterprise Workflow Launching Most Suitable Display Application as determined by Study Descriptors

There have been improvements over the last ten years in the features and functions of the diagnostic display application, and yet most imaging departments have had to augment their core PACS application with a number of third-party specialty display applications. The physicians have to work through a pull down list of these applications in order to find the one that is the most suitable to use in the interpretation of the study they have pulled off their worklist. Similar to the way the enterprise workflow solution needs to provide a federated view of available studies to read, the enterprise workflow needs to provide federated access to all the available diagnostic display resources within a site or across a multi-site enterprise.

An enterprise workflow/worklist application is also one of the key components of the next-generation PACS. The PACS 3.0 configuration that I describe in the white paper recently published as a three-part series on AuntMinnie.com. is based on a Vendor Neutral Archive. The various diagnostic display applications that might be used in one or more imaging departments to interpret the images are simply plug-ins to the VNA. As the brain of the PACS 3.0 configuration, the enterprise workflow/worklist application is the entry point of all of the interpreting physicians in all of the imaging departments. The individual physician worklist presents the highly specific list of studies to be read and the underlying workflow launches the most appropriate diagnostic display application based on the pre-defined choices of the physician and the specific type of study selected from the list.

The new diagnostic imaging paradigm, PACS 3.0, is relevant to more than the radiology department. Medical imaging has always been an enterprise operation. Radiology and cardiology are the most obvious medical imaging operations, but many more clinically relevant medical images are generated in other departments. The images captured during an endoscopic procedure do in fact comprise an imaging study that is interpreted. Images captured during an office visit (dermatology) or throughout the course of treatment (wound care) are perhaps not considered an imaging study, but they nonetheless are clinically significant and should be retained as part of the patient’s medical image record.

The PACS 3.0 paradigm should be extended to all of the departments in the enterprise that utilize imaging. The endoscopy study can be ingested by the VNA and the enterprise workflow application can create the worklist for the Endoscopist, and that workflow application would most likely launch a basic clinical display application to review the study, whether the images are DICOM or JPEG.

A similar scenario can be applied to each of the other imaging operations, whether those images are DICOM or non-DICOM. The later may require a front-end application to create the study from a collection of individual images and associate the proper patient and study metadata to the study, but the VNA is the data repository and the enterprise workflow application is the entry-point for the physicians responsible for interpreting the images.

Now is the time for a single workflow/worklist application that can be used across the entire enterprise. Not only does a single workflow application simplify physician access, a single workflow application consolidates software applications, simplifies IT support, and makes economic sense.

The white paper I recently wrote on Enterprise Workflow would be useful in your strategic planning. The paper describes a key attribute of Enterprise Workflow being [1] its ability to auto-route the new image study and its relevant priors to the server hosting the display application that is most suited to the interpretation of the study, and [2] its ability to launch that display application in patient context when the study is selected from the worklist. This functionality is based on the workflow application’s ability to recognize and use the study descriptors and the physician reading preferences to determine the most suited display application. In this sense, the enterprise workflow application is really the brain of the enterprise medical image management solution.