Friday, April 1, 2011


Many hospitals are connecting their outpatient facilities and clinics as well as their high-volume users of image and related information databases for exchange and access on a routine basis. Most use a secure Internet connection with a VPN to make sure that the patient privacy and security requirements are met. It gets a little bit more complicated when information has to be exchanged between organizations that are not part of the same delivery network, as patient information, especially Patient ID, often differ at the sites. Even more troublesome, the Accession Number, which is often used as a database key may be a duplicate of a number already in use. 

Some organizations have used tricks, such as automatic prefixes to the Accession Numbers that can be stripped as needed to prevent issues with data integrity. However, most organizations have a semi-automated import procedure for importing images from the outside. 

The good news is that the process of importing images through a VPN is virtually identical to importing images from off-line or exchange media such as CD's. Institutions have learned that it is very dangerous to import images from a patient without checking the patient demographics to make sure there are no data integrity issues. They typically create a new dummy order with a new accession number as well. In the case of images being transferred automatically, most PACS systems leave the images in the unverified or unspecified queue and allow a technologist or PACS administrator to check them and update any information as needed. 

It might be expected that these ad-hoc processes will be streamlined and automated in the US as soon as Health Information Exchanges or HIE’s come on-line. These HIE’s are currently in the process of being formed, mostly funded by federal grants, and will provide the infrastructure by which patient information as well as images can be exchanged between all participants. This will also provide the link with the National Health Information Network, or NHIN, so that information can be exchanged across all states. Critical to the implementation of these HIE’s are the Regional Extension Centers, or REC’s, which will provide technical consulting, vendor selection support for physicians to get their Electronic Health Record Software, and provider interface. 

The impact of the HIE rollout will be huge as, theoretically, every physician connected to the network will have access to any patient’s information, including images. It is almost guaranteed that the information exchange that currently takes place on a semi-ad-hoc basis and among regular high volume users over dedicated VPN’s will multiply as these gateways become the standard for information access. These HIE’s will facilitate the automated exchange and reconciliation of patient ID’s using standard protocols defined by IHE. 

There are still hurdles to overcome. Some states are moving very fast with their HIE implementations, and some are lagging behind. For example, at the recent Texas Health Information Technology Forum in Austin, Tony Gilman, CEO of the Texas Health Services Authority, showed how implementation in Texas is already well underway. State-level services are expected to take place in 2012, and the transition to sustainability will happen in 2013. 

The sustainability is still a risk factor for all of these HIE’s as they face long-term funding issues. Almost all HIE’s are initially funded by federal grants, for example, Texas received $28.8 million. However, after this money will be spent, who is going to support the organization and infrastructure? I am sure that this will take some negotiation between all stakeholders. 

In conclusion, image and information exchanges are increasingly shifting away from importing CD’s to the exchanging files over the Internet using secure VPN connections. These semi-ad-hoc connections will increase and, over the next few years, be replaced by more automated information exchanges using HIE’s whereby patient identifiers and other demographics will be automatically synchronized using the IHE profiles.