Image Sharing

Unified Approach to Internal and External Image Sharing

Continuity of care, especially for patients that are transferred between organizations, suffers from the lack of any organized, efficient methodology of collecting and forwarding the required records and diagnostic images required for treatment. Healthcare organizations have been struggling with these problems for many years, and despite all of the digital technology and social media that connects us as individuals, our healthcare system remains broken. Rather than disparate and mostly unconnected solutions for transferring records and sharing images both inside and outside the organization, we desperately need a single, unified solution that will assure timely arrival of records and images to the caregivers that are responsible for the patient’s treatment.

This is the opening paragraph of a white paper I recently wrote under an unrestricted grant from eHealth Technologies.  The paper can be retrieved from the eHealth Technologies web site using this link.  The video of the webinar on the same subject can be viewed from the eHealth Technologies web site using this link.  The paper can also be downloaded from this web site using this link.

The choice of technologies is interesting, because of the multiple packaging options that are supported.  One combination of the technology components becomes a standalone electronic image share solution designed for image sharing between organizations as well as between the organization and outside physicians…a replacement for the dreaded CD exchange program.  Another combination of the components becomes a universal viewing application that supports image sharing within the organization through image-enabling of the Electronic Medical Record system.  A third combination of the components becomes a method for image enabling the local Health Information Exchange.  Each of the three image sharing problems can be solved individually, or a single unified configuration can be used to solve all three image sharing problems.

The title of the paper, “Unified Approach to Sharing all Images and Records to Streamline Continuity of Care and Achieve Meaningful Use” is a mouthful, but the paper itself does a good job of presenting the problems, critiquing traditional solutions, and presenting the eHealth Technologies solution suite.  I recommend reading the paper and taking a look at the webinar video, if you prefer a visual presentation

Three-Step Strategic Plan for Achieving Meaningful Use of Medical Images

These are difficult times for Healthcare’s C-level administrators, as there are a number of major challenges looming on the horizon, appearing as dark clouds threatening to merge into a perfect storm. First and foremost I suppose would be figuring out how to support and encourage Meaningful Use according to the July 13 release of the final Stage 1 guidelines. Still no specific use of the word “images” in the text, but the same two objectives that reference the exchange of “key clinical information” are now codified in the 14 core objectives that hospitals are required to comply with at least six months before November 30, 2011 deadline. That’s the last day for eligible hospitals to register and attest to receive an incentive payment for FY 2011.

The incentives drop for every year of delay, so in this case, delay will be expensive, and effectively cost the organization precious development money.

While one may argue whether medical images should or could be included in the term “key clinical information”, there is no argument that exchanging images with outside organizations and providers based on data copied to CDs is problematic. It’s also expensive (labor and shipping costs). No wonder then that there are now twelve vendors offering either Electronic Image Share appliances or Cloud-based Image services. Should the C-level administrators look into solving this problem at the risk of taking their eyes off of the Meaningful Use issue? If the two issues are mutually exclusive, probably not.

Perhaps the darkest cloud on the horizon, because it is associated with hundreds of thousands of dollars in service fees, is the upcoming PACS data migrations. This cloud might appear to many as faint and unspecified, but make no mistake…it is there, it is coming, and it is going to be bad. Once again, should the C-level administrators spend time worrying about future data migrations, when there is only a year left to get the Electronic Health Record system up and running and meeting those Stage 1 objectives? If these two issues are mutually exclusive, probably not.

Here’s another important date bearing strong negative implications…2015; the year when Medicare payment adjustments begin for eligible professionals and eligible hospitals that are NOT meaningful users of Electronic Health Record (EHR) technology. “Adjustments” is political nice-nice for lowered reimbursements. Medical Images will most certainly be a stated inclusion in the Meaningful Use criteria by that time.

One way to look at the big picture is that there are a maximum of four years of financial incentives available for hospitals that can demonstrate support of Meaningful Use of key clinical information, for every year of eligibility. Deploying an IT and Visualization infrastructure over a five year period that will ultimately deliver all of a patient’s longitudinal medical record data to the physicians and caregivers is going to be expensive. It makes perfect sense to develop a Strategic Plan that goes after every bit of incentive funding available. That plan should and can weave all of the looming challenges into a single cohesive step plan. The aforementioned challenges are not mutually exclusive.

If one takes the position that electronic sharing of medical images outside of the organization is supportive of Stage 1 objectives, Step 1 of the Strategic Plan would be to deploy an electronic Image Share Solution. Whether that solution is an on-site, capitalized appliance or a Cloud-based service is another discussion, as the pros and cons are very organization-specific. Just make sure that the solution has upgrade potential, and is not a dead-end product.

By mid 2011 it’s time to start deploying Step 2 of the Strategic Plan…image-enabling the EHR. This might seem like an early jump on the image access issue, but we don’t know if specific mention of images will show up in the core objectives for Stage 2 or Stage 3, so why risk having to scramble to catch up? Perhaps the easiest way to image-enable the EHR would be to deploy a standalone universal viewer (display application). There are already a number of good universal viewers that require minimal server resources, feature server-side rendering, and require zero or near-zero client software. The IT department develops a simple URL interface between the EHR Portal and the universal viewer, and then individual interfaces between the universal viewer application and all of the image repositories in the enterprise (i.e. PACS). Ah but there’s the rub. All those PACS interfaces are going to be expensive to develop and maintain and replace with each new PACS, and there is no assurance that the universal viewer will be able to interpret all the variances in those disparate PACS headers.

Those of you that have been following my posts on this web site, see where this is going. The best solution, certainly the best long-term solution, is the deployment of a PACS-Neutral Archive and an associated Universal Viewer (aka UniViewer). The EHR is not designed to manage image data, relying instead on interfaces between its Physician Portal and the various established image data repositories in the enterprise. The PNA solves most of the organizations data management problems by consolidating all of the image data into a single “neutral” enterprise repository, which directly supports and encourages Meaningful Use of all the data objects that will constitute the patient’s longitudinal medical record. The problem is, most organizations will not be prepared to deploy a PACS Neutral Archive in 2011, so this would be a bit much to schedule for Step 2.

My Step 2 would be to expand the Image Share solution from Step 1 to include more storage…enough storage to accommodate the image data that the organization will start migrating from each of its department PACS. Of course this would mean making sure that the Image Share solution that is chosen in Step 1 was capable of becoming a PACS-Neutral Archive. At a minimum it would have to support bi-directional tag morphing. By the time the organization has completed the migration of the most recent 12 to 18 months of PACS image data, it will be possible to support Meaningful Use of the most relevant image data both inside and outside the organization. It is important to appreciate that the set of features/functions of a PACS-Neutral Archive required to meet the objectives of Step 2 (while the data is being migrated) is a fraction of the full set of PNA features/functions, so the cost of the software licenses required for Step 2 should be a fraction of the cost of the licenses for a complete PNA. Fortunately there are a few PNA vendors that appreciate this subtlety.

Step 3 could occur out there sometime beyond 2012, when the organization has sufficient funds approved to turn on all of the features and functions of a PNA, and purchase sufficient storage to accommodate all of the enterprise’s image data.

In this Strategic Plan, all of the major challenges looming over the horizon that have to do with images are addressed and solved in three creative yet logical Steps. Using the infrastructure to support and encourage Meaningful Use, in turn qualifies the organization for significant financial incentives that should go a long ways toward financing the Plan.

Hospitals required to demonstrate Electronic Image Sharing in 2011

Despite the key role that medical imaging plays in patient care, the inclusion of medical images in the Meaningful Use criteria for ARRA funding was supposedly all the way out in 2015.  One would think that that would give a healthcare organization plenty of time for planning, choosing a solution, budgeting and picking a vendor.

In theory, there are a number of ways to support Meaningful Use of images through the Physician Portal.  Whether you believe the best approach is [1] an Enterprise Archive with a UniViewer, [2] a multi-department PACS with its UniViewer, or [3] a continuation of individual department PACS, each with their own viewers; four-plus years would seem to be plenty of time to watch what the early adopters deploy and figure out your own strategy.

I think those four years just disappeared…in a puff.

In a recent article, Keith Dreyer, D.O., Ph.D., included a statement in his conclusion that came as something of a surprise to me.   That statement is worth repeating here in its entirety.  The underlines are mine.

“The Centers for Medicare and Medicaid Services proposed rulemaking of December 2009 suggests that providers will be required to demonstrate cross-provider patient medical data sharing by 2011. Furthermore, at least 80% of patient requests for electronic medical data must be able to be delivered within 48 hours. It is expected that medical imaging will be an important component of these requirements. As the federal government begins to require even more communication among all healthcare providers, the need for standards-based technology will undoubtedly become an integral part of the medical imaging IT infrastructure.”

“By taking a proactive approach and deploying technology such as image sharing applications, your department—and organization—will be better prepared for the impending future.”

Since this admittedly came as a surprise to me, I did a search and came up with an article in Healthcare IT News that listed the actual wording of the December rulemaking that Dr. Dreyer was interpreting.  Sure enough, in # 15 and #17 in the list of 23 Stage 1 Meaningful Use criteria, there appears a reference to “diagnostic test results”, and one can easily agree with Dr. Dreyer that that should be interpreted to include the actual images themselves.

What a timely discovery!

Medical Image (data) Sharing is already a hot subject.  By my count there are already 20 companies pitching some version of electronic Image Sharing…data transfer from site A to site B over a Virtual Private Network (VPN) or through an encryption application over the internet.  In most cases, these products are simply replacing the method of data transfer, replacing CDs with a network.  Most of these solutions fail to address a more subtle problem with data exchange between systems.  That problem is data compatibility.

All PACS systems are largely DICOM-conformant, but that conformance in and of itself does not guarantee data compatibility between different PACS.  Image data formatted by PACS A is not necessarily going to be fully compatible with PACS B just because the data is in the DICOM format.  I’ve already posted a piece on this subject on this web site. These new electronic image sharing products/services must be able to perform bi-directional dynamic tag morphing on the image data being transferred between systems in order to assure compatibility on the receiving end.

What makes Dr. Dreyer’s conclusions regarding electronic image sharing in 2011 so interesting is that they link Image Sharing with the larger subject of Meaningful Use by 2015.

I believe Meaningful Use in 2015 will depend on Ease of Use, and that strongly suggests a single consolidated image data repository and a single UniViewer, and the foundation of that concept is dynamic tag morphing…the ability to make image data from disparate PACS compatible with a single viewer.   So the PACS-Neutral Archive and the Image Sharing System have a very important key ingredient in common…Bi-directional Dynamic Tag Morphing.

There may be plenty of time to build the infrastructure necessary to achieve Meaningful Use of image data in 2015, but there’s no point in overlooking opportunities to build the stepping stones of that infrastructure this year.  An Image Sharing solution that includes the tag morphing application might easily be expanded, step-by-step, year-by-year to become the Neutral Archive an organization will need in 2015.

Picking the right Image Sharing solution, the one that grows into Neutral Archive, means having the bigger plan in place for the Neutral Archive.  Getting from 2011 to 2015 with the least number of dead-ends, restarts, forklifts, etc, means taking the time to build the big plan now.  Thank you, Dr. Dreyer, for providing a more immediate motivation.

Medical Images must be included in Meaningful Use Criteria…ASAP

A very insightful article appeared on line today in HealthImaging.com.  In it, Dr. Charles Rosen, MD, PhD, professor of neurosurgery at West Virginia University School of Medicine in Morgantown said “the government approach (to meaningful use criteria) seems ignorant of the issues”.  He’s right, and I suspect a good many others actually involved with patient care are in complete agreement.

I’ve written a commentary on this subject before.  Spending the next 2 to 3 years figuring out how to integrate Lab Results, Medication Histories and Care Summaries into the Electronic Health Repository seems like a lot of misguided effort to replace a FAX machine.   As Dr. Rosen points out, “…sharing images presents a greater challenge than contacting another facility to fax documents such as discharge summaries or lab results.”  The fact that Dr. Rosen has “…reached out to policymakers several times regarding the subject, with no response or further questions from the committee responsible” is puzzling.   Just exactly what is motivating that committee?

If you have been paying any attention to the medical image market of late, you’ve probably noticed Image Sharing products and services popping up like mushrooms after the rain.  Apparently a good many companies and Health Care Organizations believe that it is critically important to patient care to gain access to relevant medical image data, not just the associated reports.  However, the statement in the article that hospitals and facilities already exchange DICOM images on CDs, which “demonstrate that the images are needed and the data standard works across sites” is a little misleading.

True, the fact that there is a such an effort to exchange images demonstrates the importance of the image data to the patient’s record, but the reason that there are so many new efforts to replace the use of CDs as the transfer mechanism is not because everyone is tired of handling CDs and the Image Sharing movement is simply the new, techno-sexy way to exchange data.

The real problem with the current methods of image exchange based on CD transfers is that they are based on the premise that one vendor’s DICOM is going to be compatible with another vendor’s DICOM.  There are numerous real world examples that stand as evidence that this is not entirely true.   I’ve written on that subject in this blog as well.  The real objective of the new Image Sharing concept is to get the DICOM Image data created by one PACS into a neutral place, where it can be modified to meet the requirements of the recipient PACS.  Image Sharing services or products that cannot perform this dynamic data manipulation will not likely be any more successful that the CD exchange methods.

I am very encouraged to see a call for the inclusion of images in the meaningful use discussion sooner rather than later, but I also encourage those proponents not to assume that image exchange is simply a matter of a secure internet connection facilitated by a service or a server.  DICOM is not the rigid standard that many believe it to be.  There is a lot of room for “interpretation” in the DICOM standard, and most Modality and PACS vendors have taken full advantage of this opportunity to be creative.   The successful exchange application will have that something extra in the middle to make the data truly useful on the receiving end.   If we succeed in getting image data moved up in the meaningful use schedule, let’s not blow it by overlooking the details.

Whether policymakers wake up and recognize the true importance of image exchange or not, the market already recognizes the value of meaningful image exchange, and the replacement of the CD exchange methodology is long overdue.  Washington may not get it right, but the market always gets it right.

Next Step in Image Sharing…Beyond the CD/DVD

The task of getting a patient’s medical images into the hands of the Specialists, Surgeons and Primary Care physicians becomes considerably more complicated, when those images are produced in an “outside” Organization.  The practice of forwarding film-based images ahead of or with the patient is increasingly rare, having been replaced with the conveyance of digital copies of the patient’s images on CD or DVD.   While this method of data exchange between organizations is considered more efficient and less expensive than forwarding films, the problems associated with data exchange using the CD/DVD are now legendary.

Aside from such obvious issues as viewing software and media compatibility, the principal problem is frequently basic data incompatibility.  The DICOM standard allows a significant degree of “customization” of the DICOM image data header by the PACS vendors.  In a white paper recently written by Dr. Wayne DeJarnette, titled Context Management and Tag Morphing in the Real World and posted on their informational web site, there are 10 examples sited where certain key pieces of information stored in the DICOM header need to be created, modified or moved in order for one PACS to be able to properly interpret the data created by another PACS.  I highly recommend reading this paper to catch up on the subject generally referred to as Tag Morphing.

Apparently the problems associated with sharing medical image data using CD/DVD media has reached critical mass, because a number of solutions in the form of Data Exchange Servers and Data Exchange Services have recently entered the market.  The focus of these new products and fee-per-study services is clearly to provide an end to the pains of data exchange.  Unfortunately there is now yet another set of issues.

Clearly the  most exciting solution to the data exchange issue is the “Image Share Service in a Cloud”.  How can one not get excited about anything in a cloud?  I counted a half dozen such “cloud” service solutions being exhibited at the 2009 RSNA or being advertised since.  The simple, high-level summary description of this fee-per-study service is as follows.  An authorized organization/user accesses the upload application through a secure web site.  A couple of simple clicks and data insertions later and a patient’s medical image data is uploaded to a central server in the cloud.  There are a number of methods for announcing the availability of these images in the cloud to the intended recipient, ranging from email notification to a phone call.  The authorized organization/user then accesses the secure web site hosted by the cloud server and is granted access to only those images intended for their use.

Here is the interesting part.  The intended user then downloads to their PC a very small piece of client software, in some cases there is no client software (zero), and this allows the user to view the images on their PC.  Most of the display applications I have seen associated with this version of the cloud service are based on what is called “server-side rendering”, meaning all of the image rendering, processing, etc. being directed by the user is actually being executed on the server in the cloud.  The result of this rendering, an HTML page, is all that is actually downloaded to the user’s PC.  The actual image data itself is not downloaded to the user’s PC.  The actual image data itself does not leave the secure server in the cloud, making this a very HIPAA-compliant application.

The current state of server-side rendering display applications allows for support of full-fidelity (loss-less) images and a full range of image processing features (2D, 3D, even Orthopedic templating), so the display application associated with most of these cloud-based image exchange services should be well received by a wide range of physicians seeking access to a patient’s images that were produced in an “outside” organization.

What I find most interesting about this approach to image sharing is that this solution totally avoids the data incompatibility problems encountered when an organization attempts to actually import digital image data from an “outside” PACS into their local PACS.  Instead of importing “outside” study data into the local PACS, so the images can be accessed and viewed by the physicians using the local PACS web viewer, the cloud solution depends on its own embedded display application to access and display the image data.  Just like all PACS that customize the image header of incoming image data, the cloud server only has to make the incoming study data produced by the contributing PACS completely compatible with its own display application.  Moreover these new server-side rendering display applications frequently offer a wider range of features and functions than the incumbent local PACS “web Viewer”.   It’s a clever solution that simply avoids the data incompatibility problem.  As mentioned, this version of image sharing is available as either a purchased/leased “appliance” or a fee-per-study cloud-based service.

However clever this solution appears, it is important to remember that this version of image sharing does not solve the data incompatibility problem.  If an organization wishes to assimilate a patient’s image study data created by an outside organization into that patient’s local longitudinal medical record (acquire the outside study data into the local PACS and add the study to the patient’s local folder); the data must first be modified,  more specifically the DICOM headers must first be modified, to satisfy the idiosyncrasies of the receiving PACS.  That means executing Tag Morphing of the type and complexity mentioned in the DeJarnette white paper.  Unless the contributing and receiving organizations have only a few studies a day to exchange, a manual approach to this Tag Morphing would be too labor intensive to be practical, not to mention fraught with the potential for human error.   In short the exchange of study data between two different organizations, and especially between disparate PACS requires an appliance or a fee-per-study service that can automatically execute Dynamic Tag Morphing on the incoming DICOM image data headers, prior to exporting the data to the recipient PACS.  Any solution that does not support this key process, is naively  relying on “DICOM conformance”, and we already know the problems with that approach.

In summary, I think an appliance or a cloud-based service that can provide the physicians with HIPAA-compliant internet access and display of a patient’s outside images is a significant advance over the CD/DVD method of data exchange.  I think the display-only approach is a clever way to avoid the problems inherent in exchanging data between disparate PACS.  The participating organizations simply need to understand their needs and make sure that the chosen solution will meet their expectations.  Products or Services that suggest that actual data exchange between the PACS is an option should be expected to provide evidence that their product or service supports Dynamic Tag Morphing.  Otherwise the organizations will likely end up right back where they are today with their CDs and DVDs.

Note: Currently there’s not a lot of information available on DICOM Tag Morphing out there on the web.  In addition to the DeJarnette paper already mentioned, you might want to focus your favorite search engine on “vendor-neutral archive”, as I’m sure any of those vendors can provide additional info on this subject.