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.