Image Sharing is Critical to Robust Healthcare Information Exchange

 

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In the preceding article image sharing/image exchange was introduced as a key factor for reducing costs through an Enterprise Imaging program.  The costs reductions associated with the elimination of physical media, such as CDs, for image sharing between organizations that contribute to significant cost savings were discussed.  This article will take a deeper look at current concepts in Image Sharing.

Background

First, let’s clarify terminology.  A review of the literature suggests that the terms “image exchange” and “image sharing” are used interchangeably.  This author prefers the term “image sharing” as a more accurate representation of the most current technology.   We are evolving from the transfer/exchange of physical media.  Today outside images can be viewed without the need to transfer those images into a local system (although some institutions desire local storage for medicolegal reasons).

The need to share all forms of information along the continuum of care has long been recognized.  Numerous national initiatives and organization have been developed to support and promote information sharing endeavors, including IHE (Integrating the Healthcare Enterprise, the Sequoia Project and others.  Multiple Health Information Exchanges (HIE) have been established.

Yet, few of these HIEs are image-enabled.   To achieve comprehensive health information exchange, images, and not just the reports, from other institutions must be accessible.  This ability to view images is critical* for many sub-specialists including pulmonologists, neurologists, and orthopedic surgeons.

The Image Sharing Journey

Image exchange is not a new concept.  In years gone by when a patient was seeking a second opinion or transferring care to a new organization, they would request copies of their x-ray jackets.  These patients would lug heavy film files from one appointment to the next.  Even after the advent of digital imaging, we still relied on patients to courier their information; the vehicles just became more portable, CDs, DVDs or USB drives. 

As electronic imaging information management became more sophisticated, we began to develop more streamlined methods for image transfer eliminating the patient as courier.  However, we needed to rely on established relationships between organizations.  Those relationships were needed to build point-to-point VPN connections.  Maintaining these connections can be expensive and time-consuming.  VPNs are not flexible and limit the extent of a network.  They do not allow immediate/emergent image exchange with new organizations.  Establishing each new connection can be an onerous process engaging numerous IT individuals to approve and then build.

Cloud based exchange services are the current iteration of the image sharing journey.  Cloud services employ a central repository where images are pushed by the sending institution and then pulled by the receiving organization.  This download maybe automated.  As these models evolve additional automation is being introduced allowing the receiving organization to directly retrieve studies form the sending institution without human intervention at the sending site.  A further step in the journey allows the patient to direct the sharing of their images.  The most common current process* for patient directed image sharing is cumbersome and limited to CDs.

Our ultimate goal should be to achieve a universal “information infrastructure”.  As described by Motta et al, a global image sharing infrastructure is without central elements or authority and it is scalable, comprehensive and secure.  This infrastructure seamlessly blends local PACS with the global need for sharing information.  Physical media, point-to-point connections, and an intermediary cloud service are eliminated.  All imaging information is accessible to providers regardless of organizational affiliation or physical location.

Use Cases and Goals

Several use cases detailing the importance of image exchange are highlighted in the HIMSS-SIIM Enterprise Imaging Community Whitepaper on Image Exchange. Recognized use cases can be summarized as follows:

• Emergency consultation and/or preparation for patient transfer

  • The need for transfer can be assessed, appropriate therapeutic steps can be initiated prior to transfer and the receiving site can be better prepared to receive the patient and prevent treatment delays.

• Telehealth (photography-based patient-provider image sharing)

  • Synchronous and asynchronous image sharing can allow patients with medical conditions which require visual inspection to take full advantage of the benefits of remote consultation with their physicians and can improve physician efficiency.

• Teleconsultation (provider-to-provider for all image formats)

  • Second opinions and peer-to-peer discussion are no longer confined to the local environment. Image-based consultation can be conducted in a secure fashion.

• Scheduled appointment preparation

  • Providers can be better prepared to meet their patients’ needs by ensuring patients are matched with the best specialist. If needed, repeat imaging can be scheduled and the risk of an incomplete visit due to lack of imaging information is eliminated.  Radiologic consultation can be obtained prior to the visit.  For imaging-based appointments comparison examinations from outside institutions can be included in the interpretation of a current study.  The provider maintains their EMR based workflow.  The entire visit is streamlined.

• Patient follow-up

  • After completion of a visit, either clinical or radiologic, images can be shared with referring providers and institutions. As discussed in a previous article patients also desire to view their images.

Example: Impact of Robust Image Sharing

Without robust image sharing

Let’s examine the case of a patient with a ruptured abdominal aortic aneurysm being transferred to your tertiary care center.  The patient presents to a small community hospital which does not have emergency vascular surgery services.  Upon arrival a CT of the abdomen and pelvis is obtained.  The CT reveals a ruptured abdominal aortic aneurysm.  Plans are made for transfer to the nearest tertiary care center.  The Emergency Physician calls the receiving hospital to report on the patient’s condition and convey the imaging findings.  The helicopter arrives to transport the patient.  It’s take-off is delayed while the CD with the imaging study is being created.  Upon arrival at the tertiary care center the patient arrives in the Emergency Department.  The CD is sent to radiology for upload into the PACS which takes 15 minutes.  The vascular surgeon is waiting to view the images and determine the appropriate treatment option – open surgery versus endoscopic repair.  Once the images are viewed the appropriate treatment team is mobilized.

With robust image sharing

If a robust image sharing program is in place the scenario is much different.  As the referring physician calls the receiving hospital the images are sent to the tertiary care center’s PACS.  This image transfer can occur even if there is no pre-existing relationship between the two institutions.  Once the helicopter arrives it can take off as soon as the patient is onboard.  While the patient is in transit the vascular surgeon can review the images on the local PACS and make a treatment decision.  The appropriate treatment team can be mobilized.  When the patient lands, they can be assessed and immediately taken for intervention, shaving minutes, possibly hours, off the time-to-treat.

The Costs of Failure to Share

The failure to share medical images can leave gaping holes in a patient’s story and add unnecessary costs both in terms of dollars and the burden of additional radiation exposure.  Additional costs come in the form of treatment delays.

Just look at a sample of the evidence:

•  Neurosurgeon access to imaging at referring hospital reduced the number of transfers by 40%*.
•  Comparison of duplicate CT rates following patient transfer to one trauma center from two referring hospitals, one without image sharing and one with recently implemented image sharing capabilities, revealed that access to outside imaging reduced repeat imaging 22% in the first year with continued year over year reductions. 
• In a meta-analysis image sharing technology was associated with a statistically significant decrease in repeat imaging especially within the Emergency Department.

As our healthcare system strives to achieve operational efficiency and high value care it can no longer tolerate these costs.  Robust image sharing is no longer optional.

Final Thoughts

Image sharing is an essential component of any Enterprise Imaging Program.  While the vast majority of the currently available information is derived from radiology operations, similar scenarios play out in other imaging intensive departments such as cardiology and ophthalmology.   In many of those departments the image sharing process is less well defined adding further costs to the system and the expectations for image sharing might be lower.  However, image sharing is critical to building a patient-centric comprehensive longitudinal medical record.

References

1. Interoperability in Healthcare.   https://www.himss.org/resources/interoperability-healthcare.  Accessed March 1, 2021
2. Making Healthcare Interoperable. IHE International.  https://www.ihe.net/.  Accessed March 1, 2021
3. The Sequoia Project. https://sequoiaproject.org/.  Accessed March 1, 2021
4. Jung HY, Gichoya JW, Vest JR. Providers’ Access of Imaging versus Only Reports:  A System Log File Analysis.  J Am Coll Radiol 14:217-223, 2017.  https://www.jacr.org/article/S1546-1440(16)30446-X/fulltext
5. Lye CT, Krumholz HM, Eckroate JE et al. Evaluation of the Patient Request Process for Radiology Imaging in U.S. Hospitals. Radiology, 292: 409-413, 2019. https://pubs.rsna.org/doi/pdf/10.1148/radiol.2019190473 *
6. Motta GHMB, Araújo DAB, Lucena-Neto JR, Azevedo-Marques PM, Cordeiro SS, Araújo-Neto SA. Towards an Information Infrastructure for Medical Image Sharing. J Digit Imaging. 33:88-98, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064679/pdf/10278_2019_Article_243.pdf
7. Vreeland A, Persons KR, Primo HR, Bishop M, Garriott KM, Doyle MK, Silver E, Brown DM, Bashall C. Considerations for Exchanging and Sharing Medical Images for Improved Collaboration and Patient Care: HIMSS-SIIM Collaborative White Paper. J Digit Imaging 29:547-58, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023527/pdf/10278_2016_Article_9885.pdf
8. Moya M, Valdez J, Yonas H, Alverson DC. The impact of a telehealth web-based solution on neurosurgery triage and consultation. Telemed J E Health 16:945-9, 2010.   https://www.liebertpub.com/doi/10.1089/tmj.2010.0044*
9. Sheppard CW, Groll AL, Austin CL, Thompson SJ. Impact of duplicate CT scan rate after implementation of transfer image repository system at a level 1 trauma center. Emerg Radiol 25:275-280, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5940706/pdf/10140_2017_Article_1575.pdf
10. Vest JR, Jung HY, Ostrovsky A, Das LT, McGinty GB. Image Sharing Technologies and Reduction of Imaging Utilization: A Systematic Review and Meta-analysis. J Am Coll Radiol. 12 Pt B:1371-1379, 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730956/pdf/nihms752025.pdf