Two bedrock principles of federal meaningful use initiatives are interoperability and data exchange between electronic health record (EHR) systems and picture archiving and communication systems (PACS) in the radiology, cardiology and endoscopy departments.
Opening up proprietary images enterprise-wide to patients and their physicians sounds simple. In theory, it is; but in practice, it's not, said experts at a recent MedicExchange.com virtual seminar: The process requires planning, preparation and testing. Despite the challenges, larger health care institutions are proving it's possible to share images in a way that complies with the Health Insurance Portability and Accountability Act (HIPAA).
PACS viewer alone can't deliver interoperability
Different types of PACS archives traditionally haven't worked together very well because they're tied to specific imaging equipment, said health imaging consultant Gregg Cohen, director for medical technology at Abrio Healthcare Solutions Inc. Right now, so-called PACS interoperability typically means that radiologists distribute a lightweight viewing tool along with the images to practitioners outside their departments. With health technology's trend to increasingly interconnected systems, however, such tools aren't robust enough.
New demands on patient data mean that PACS image archives are being used in ways that make a simple viewer inadequate:
- Patients and practitioners are viewing images on smartphones and Wi-Fi-connected tablets, such as the Apple Inc. iPad.
- PACS images are being served to personal health record (PHR) and e-health systems.
- Hospitals, primary care practitioners and specialists are sharing data through telemedicine services and health information exchanges.
These activities all require robust viewing tools that can accommodate such features as user comments, as well as audit logs that track the users who accessed an image and when. Furthermore, because state and federal laws require images to be archived for various lengths of time depending on the patients' age, image metadata sometimes needs a regulatory "expiration date."
Vendor-neutral archives bridge radiology, other departments
A PACS calls for metadata-processing and interactivity capabilities that lightweight viewers cannot handle. Pairing a vendor-neutral archive with an image management system, however, can create the interoperability that providers and patients need.
This pairing does not replace the PACS for a particular piece of imaging equipment, such as a computed tomography, or CT, scanner or magnetic resonance imaging, or MRI, machine; but it does reduce the size of the PACS archive.
Gregg Cohendirector for medical technology, Abrio Healthcare Solutions Inc.
Collecting images from various imaging devices in a central image-management system or vendor-neutral archive does two things. First, it creates an interface between radiology imaging and other hospital departments and PHR systems, and potentially can reduce the storage footprint of images using the standard image format and compression. Second, it can streamline the process of a health care provider's regulatory compliance by applying rules to one PACS archive rather than to many separate archives.
"The goal is to produce an archive device that can store data from multiple sources and, theoretically, serve it up to other sources, such as an [EHR]," Joseph Marion of Healthcare Integration Strategies LLC, a Waukesha, Wis.-based consultancy, wrote in an email to SearchHealthIT.com.
"The image management solution is what CIOs really should be looking at. As such, they do not replace a PACS, but they would negate the need for the PACS to have its own archive," Marion wrote. "The most likely criteria would be for the local PACS to have enough cache to maintain 18 to 24 months of studies locally, and back them up to the [vendor-neutral archive or] image management device."
EHR, PACS integration not simple
Getting the PACS archive and EHR systems to talk to each other isn't a simple proposition. In his presentation at the virtual seminar, Abrio Healthcare's Cohen said IT leaders for a health care enterprise must first draw up a plan that covers the goals of interconnecting the two systems -- including who will access which images and what they will do with them -- before they can compile the list of tools and deployment steps.
A key concept for clinicians is reading versus viewing. Viewing is simply that -- displaying an image or playing a video study on screen. Reading, in contrast, is the deep, expert analysis of the content in an image or video. This requires software support for reporting and dictation, as well as such specialty features as comparing a new image to previous studies to see how a patient's condition is changing.
Determining who reads versus who views within a hospital will define the complexity of a PACS-to-EHR implementation. It also will dictate which tools will have to be licensed to how many users.
After that IT leaders must tackle other issues, including the following:
- How the imaging system will interact with the virtualization setups that might be employed on the network. Will images render when virtualized? Does PACS licensing cover virtualization?
- How user identity will be authenticated -- both inside the facility and outside, if PACS images are deployed to PHR services -- to uphold HIPAA privacy rules.
- Which bandwidth and, possibly, infrastructure upgrades all this new imaging traffic will require.
If a hospital has invested in mobile initiatives -- smartphones, the iPad and other tablets -- deployment plans also should include accommodations for the Apple Inc. iOS and Google Inc. Android operating systems, too, Cohen said.
While it might seem complicated, it can be done, Cohen said.
"I would say that we are still in the 'early adopter' phase of image-enabling the [electronic medical record]. It is not a common implementation for anyone but the larger institutions that have gotten their first pass at EMR implementation complete," Cohen wrote in an email. "EMR adoption gives the market an opportunity to solve enterprise image distribution issues in the context of what everybody is doing. … It fills the holes that PACS doesn't serve well."
Once a health care provider connects its PACS archive and EHR system, the work continues, Cohen said. To get the most out of an implementation, the organization should survey users about how they use the system, as well as how easy (or not) it is to use; and it should monitor server and network performance. Use the survey results and monitoring data to improve usability and infrastructure, Cohen said.
Choosing a new PACS software vendor
Planning to share images could lead a hospital or radiology practice to consider expanding or even replacing its PACS software. It might need to add a vendor-neutral archive or image management system to its current PACS setup; that also requires up-front planning before vendors are evaluated.
Healthcare Integration Strategies' Marion provided a few tips for IT leaders selecting a PACS vendor:
- Interview IT staff and clinicians who use the current PACS software, and analyze operational data to benchmark imaging processes in order to determine how much efficiency an upgrade will provide.
- Assess needs through this benchmarking, and map current processes. Meet with practitioners and patients to learn how they want workflow to improve. It's important to reach a consensus on what the future state of the PACS should be.
- Consider regulatory compliance requirements.
- Develop a top 10 list of must -have features in order to differentiate the vendors that have answered requests for information.
- Once the system is installed, test it against the benchmarks the vendor previously agreed to. If results are unsatisfactory, don't pay for anything.
Let us know what you think about the story; email Don Fluckinger, Features Writer.