This piece was originally published in the April 2016 issue of ei, the magazine of the electroindustry.
By Henri “Rik” Primo, Chair, MITA Medical Imaging Informatics Section
Ever since the x-ray was first used for medical imaging in 1896, image sharing has been intrinsic to the practice of medicine.
In the early days, viewing the film on a light box for diagnostic purposes was the task of the radiologist, but sharing the film and the diagnostic report was essential to discussing a patient’s treatment in a team setting. The films were located in radiology departments, which became busy consulting hubs. A major problem arose when physicians left radiology; they relinquished access to the film, as an analog film can be in only one physical location at one time. Furthermore, films could easily be lost or misplaced.
When patients were referred to care locations, film folders seldom traveled with them. Patients would forget to bring them or doctors would not even give them to the patients because the film had been archived. In the interest of providing quality care, medical professionals would repeat x-rays, which unfortunately increased dose exposure, delayed the start of care, and added costs to the patient care process.
DICOM Changes the Paradigm
Despite all efforts to streamline film-sharing practices, image sharing in the analog film world was never ideal. The same problem of “only one image in one place at one time” applied to patient photos, dermatology pictures, pathology slides, drawings, and other images that are instrumental in defining the right care.
In the late 1970s and early 1980s, the availability of digital imaging modalities created the opportunity to finally change the film paradigm. Nuclear medicine, digital subtraction angiography, computed radiology, echography, computed tomography, and magnetic resonance imaging were digital modalities from their inception. Digital solutions for plain x-ray images followed soon. The patient’s images were stored as digital data sets in the modality’s computer backend on digital storage media.
In 1994, as access to intranet and Internet technology became ubiquitous, the American College of Radiology and NEMA published the Digital Imaging and Communications in Medicine (DICOM) 3.0 standard. Its goal was to create a vendor-agnostic digital image format, containing standardized image metadata and defining a transmission protocol for radiology, cardiology, and other specializations.
DICOM enables multiple vendors to create specialized viewers and storage management processes without having to deal with a multitude of digital formats. A DICOM image is a matrix composed of digital values stored in pixels going from left to right and from top to bottom. The metadata in the DICOM object contains patient identification, physical properties of the image, and how to display it for optimal presentation.
DICOM 3.0 was invaluable in enabling the development of a picture archiving and communication system (PACS). PACS is a technology for short- and long-term storage, retrieval, viewing, and distribution of images. Until 1994, PACS was exclusive to academics’ and manufacturers’ research departments. By 2010, 99 percent of hospitals were using PACS routinely.
Enterprise Imaging Allows Access
Changes in today’s healthcare ecosystem are characterized by improving the quality of care while decreasing healthcare costs. This is achievable by embracing quality standards, standardizing the care delivery processes, and seeking economies of scale.
Integrated delivery networks (IDNs) were established by consolidating hospitals through mergers and acquisitions. Consolidation increases the negotiation power of IDNs with payors and vendors. Hospitals with consolidated datacenters manage and staff one datacenter instead of ten in a ten-hospital IDN. Administrative IT applications such as billing, scheduling, electronic medical records (EMRs), and patient portals are deployed enterprise-wide, thereby simplifying support logistics and creating more flexibility with staffing. An enterprise PACS deployment, also called enterprise imaging, gives mandated access to the patient images across the enterprise.
A PACS manages imaging data not only from radiology and cardiology but also from pathology, ophthalmology, dermatology, endoscopy, and other specialties. These departments may have their own imaging repositories, which are often shelves stacked with printed images. In other cases, images may be stored in digital format, but not in DICOM. Accessing these images may be complicated or impossible.
With the advent of enterprise imaging, hospitals can change the old model for image access and create a new paradigm: access to all images by all specialties, anytime, anywhere.
Interoperability and Cybersecurity
This consolidated, multispecialty, single-repository PACS strategy facilitates the integration of imaging information in the EMR. The goal is to create a model in which a healthcare provider can retrieve all patient information by simply providing the patient name and ID.
Achieving this goal requires seamless connectivity between IT applications.
Interoperability is facilitated by standard data formats and data exchange protocols. Standards developing organizations like NEMA/MITA are committed to provide future-oriented technologies to facilitate interoperability in healthcare.
In recent years we have seen a staggering increase in cybersecurity issues in healthcare. Data breaches of electronic protected health information (ePHI) may be caused by cyberattacks, but they can also be caused by poor cybersecurity processes, such as storing ePHI on an unencrypted laptop computer.
Medical imaging devices, like all computer systems, are subject to risks that might harm the software, hardware, data security of the device, and even patient safety if a hacker interferes with the secure operation of the device. As devices become increasingly connected to networks, security risks move beyond the system to intrusions across digital networks.
Advancing cybersecurity measures within healthcare and public health relies on a whole community approach, requiring manufacturers, installers, service staff, and providers to accept shared ownership and responsibility. MITA seeks to foster collaboration so that current and emerging threats can be appropriately addressed across the lifecycle of imaging devices—from design to installation and through end of life. The FDA agrees that this problem requires a collaborative approach.
NEMA recently published Cybersecurity for Medical Imaging, a white paper that identifies a set of best practices and guidelines that healthcare providers and medical imaging manufacturers can implement to prevent cybersecurity incidents. MITA believes that the adoption of best practices and standards by manufacturers and healthcare providers presents the clearest line of defense.
The Future of Enterprise Imaging
Enterprise imaging through the EMR is a reality in only a small number of institutions. The Health and Human Services Office of the National Coordinator includes image access as a menu option in the Stage 2 Meaningful Use (MU) criteria of the U.S. government’s healthcare IT stimulus program.
While this is encouraging, the news carries a flip side. EMR deployments required by the MU program are expensive, often costing $50 million or more, and have taken priority over imaging investments in the past years. With the wave of EMR implementations flattening, we see a trend toward revisiting the legacy PACS. These systems may be more than five years old, which in the world of IT is an eternity. Replacement and upgrade decisions are now being made with the goal of implementing enterprise imaging.
The future of enterprise imaging is closely related to that of of patient care and medicine as a whole. Images now serve many purposes; acadmic institutions and manufacturers have created vast imaging informatics applications libraries. These advanced applications actually process the information contained in images. The output of these algorithms is used in computer-aided detection, 3D reconstructions, surgery and radiation therapy planning, clinical decision support, and quantification of physical processes.
Enterprise imaging will no longer be constrained to images produced in radiology and cardiology departments. Patient data provided by enterprise imaging systems will be an essential enabler of the goal to improve care and manage costs.
Mr. Primo is director of strategic relationships at Siemens Healthcare and a member of the MITA Board of Directors. The opinions expressed in this article are entirely those of the author and not his employer.