In the US, more
than 90 percent of healthcare institutions have a radiology PACS (Picture
Archiving and Communication System) in place managing medical images in a digital
format. However, sharing these images has been a challenge, especially when
they are to be shared among different enterprises. There are many barriers,
ranging from lack of infrastructure, non-unique patient identifiers needing patient
information reconciliation, security and privacy issues, and a lack of
incentives by the providers to share them to begin with. This lack of
incentives can only be solved by having the proper policies and motivation in
place, possibly using federal regulations such as the Meaningful Use incentive
program, which, along with other quality criteria, has now been
rolled into Medicare Access and CHIP Reauthorization (MACRA) requirement in the US. However, incentives
won’t work unless the infrastructure and right architecture is in place.
How are images
exchanged within an enterprise? There are two options: If there is a VNA, one
could access the VNA through a universal viewer, or if not, one can provide a
workflow manager that sits in between the viewer and multiple image sources
(i.e. PACS systems) and is able to provide a universal worklist. These workflow
engines are available from third parties and/or PACS vendors and are useful as
long as they know how to interface with the different PACS vendors’ archive/image
management systems.
To access images
from outside the enterprise, one can use image brokers that allow for storage
of the images in the cloud, basically managing the access by external
physicians. This is a good solution for big institutions that have a large
referral base: The institution will tell a physician to sign up with the broker/service
provider, and, if authorized, will have access to the studies of his or her
patients. The disadvantage is that the interface protocols are often
proprietary. Therefore, if you need to access images from multiple enterprises
you might need to sign up for their affiliated providers/brokers and have
multiple gateways connecting to your PACS.
What is needed
to implement a cross-enterprise imaging strategy? First of all, it is NOT
necessary to have a deconstructed PACS, VNA, uni-viewer, or anything else that
is touted as the latest and greatest by imaging vendors. One needs to look at
its use case and find the best solution depending on access to the existing
PACS and/or VNA’s, and available infrastructure such as gateways and HIE’s.
When
implementing cross-enterprise imaging one should be prepared to a deal with
interoperability issues such as finding the right comparisons and priors from
other image sources as body part descriptions and protocol definitions are
non-standard and likely differ. Hanging protocols for studies from different
enterprises might not work requiring configuration changes and/or changes in
the image metadata to make them consistent. Look for a vendor who has
experience with this and is able to map and/or facilitate these. The same
applies to interfacing to the different PACS/Image managers, especially for the
workflow engine as each vendor has its own proprietary protocol for
synchronizing the worklists, look for proven performance.
Do your
homework, check with colleagues and friends who have the same vendor and/or use
case and find out what their issues are and how they got resolved. If you take
these pre-cautions, you will likely succeed, but expect it to be a bumpy but fun
ride. For an in-depth discussion on this topic you can download a comprehensive
six page white paper here.
