The road to electronic health record (EHR) adoption has been anything but smooth as health care organizations grappled with significant cost and workflow challenges.

But, according to The Office of the National Coordinator for Health Information Technology, 96 percent possessed a certified EHR technology in 2015.

Still, most experts agree that the work is far from complete as technological potholes and roadblocks continue to get in the way of establishing a cohesive, interoperable health IT ecosystem across the enterprise. As silos come down, one of the most daunting tasks has been integrating diagnostic imaging into the EHR.

“Each facility has its own PACS and each department such as cardiology, dermatology and oncology has its own devices that take the images,” says Mitali Maheshwari, health care information technology analyst at MD Buyline. “They store their images in their particular systems and those systems cannot talk with each other.”

Health care organizations are now working on making all of the patient records and images within each department available on demand. Some progress has been made with the introduction of the vendor neutral archive (VNA), which stores images in a standard format so they can be accessed by different systems, but it does give rise to important new questions for hospital decision-makers.

“PACS has traditionally been provided by a vendor [that offers] the network, workstations, storage and other components in one package,” says Dr. Eliot Siegel, chief of radiology and nuclear medicine for the Veterans Affairs Maryland Healthcare System. “But some might argue that the best approach might be to have the best workstation from vendor A combined with the best network from vendor B combined with the best storage from vendor C.”

That customized approach to imaging IT is sometimes called “deconstructed PACS,” and although it does put more control in the hands of the facility, it lacks the cut-and-dry simplicity of a single vendor contract. The question providers need to ask themselves is whether those added complications can yield a smoother experience in the era of enterprise imaging where that data needs to play friendly with the health record.

Enterprise imaging as the ultimate goal
In recent years, the concept of enterprise-wide imaging has gained a lot of traction, but not without causing some confusion as to what the term really meant. In May 2016, The Healthcare Information and Management Systems Society (HIMSS) partnered with The Society for Imaging Informatics in Medicine (SIIM) to define enterprise imaging as, “a set of strategies, initiatives and workflows implemented across a health care enterprise to consistently capture, index, manage, distribute, view, exchange and analyze all clinical imaging and multimedia content within the EHR.”

Getting images where they need to be has given rise to many innovative solutions to a problem that virtually every hospital and imaging center has struggled with. Unlike conventional PACS providers, which arose in an era when digital X-rays were mainly the business of the imaging department alone, companies like LifeIMAGE have emerged with a singular focus on improving image and information accessibility.

“What provides value is the interoperability of the different technology components that allow the acquisition of the unique piece of medical information to a specific patient to actually make a difference in a diagnosis or treatment plan,” says Matt Michela, CEO of LifeIMAGE.

His company conducted a survey in 2016 including 100 members of the College of Healthcare Information Management Executives (CHIME) that found enterprise imaging strategies are key priorities for hospital chief information officers (CIOs) with more than 58 percent of facilities having implemented an enterprise imaging strategy to help manage, store and exchange medical image data.

Unfortunately, most of the respondents described poor returns on these initiatives. While interoperability is perfectly in line with value-based care, more than half of the organizations surveyed reported they were not yet able to move imaging data between systems and applications due to unsolved technical issues.

One-third of the CIOs who responded to the LifeIMAGE survey reported that their facility might be losing revenue because of image data interoperability challenges.

So how can a facility make sure its big jump into enterprise imaging enhances value-based care as opposed to delaying diagnosis, causing unnecessary duplicate exams and furthering the pinch on its bottom line? It requires a great deal of homework and choosing the right partnerships to meet specific needs.

What’s on the market?
LifeIMAGE’s enterprise-grade electronic medical image sharing platform is leveraged by some of the nation’s largest health care systems, including UCLA Health, Stanford Hospital and Clinics and NYU Langone Medical Center.

“What we do is provide access to imaging and related medical information regardless of where the image was taken, on what kind of machine or where it is stored and then we get it where it needs to be for diagnosis and treatment,” explains Michela.

In addition to moving images around a hospital, the platform also enables image sharing between different hospitals. For example, an academic medical center can send images to about 54 of its major referral sites.

One drawback to the platform is that all of the hospitals that want to share images with each other need to be on the LifeIMAGE network. To date, 1,400 hospitals in the U.S. are on the network, yet there are 5,564 registered hospitals in the nation, according to the American Hospital Association.

In May, Fujifilm Medical Systems’ Synapse Mobility Enterprise Web Viewer was granted authority to operate on networks in the U.S. Department of Defense. This solution allows providers to view all patient imaging data via the EHR or a web browser.

It utilizes the latest server-side rendering technology so providers don’t have to download any patient data locally. According to Bill Lacy, vice president of medical informatics at Fujifilm, having a server-side solution reduces the likelihood of workstation-related challenges.

Microsoft desktop software requires annual operating system and browser-related updates. If a facility didn’t have the right viewing technology to interoperate and adapt with the new EHR versions, then that can cause problems and delays in workflow.

“Trying to keep up with the desktop variability is what has been really driving a lot of the enterprise viewer activity,” says Lacy. “As of late, [the focus has been on] making sure the enterprise viewers had no desktop requirements.”

The voice recognition software company Nuance Communications offers a cloud-based image sharing platform called PowerShare. To date, 4,500 facilities are connected on the platform and about 200,000 studies are shared every month.

“Some of the large health systems spend half a billion dollars on their EHR so there is an expectation that the enterprise users are going to be working in that system, but the patient information is not necessarily there,” says Karen Holzberger, vice president and general manager for diagnostics at Nuance. “[We’re thinking] strategically about how to move that information into those enterprise systems without having to build different systems.”

At the 2017 Radiological Society of North America meeting, Nuance announced a partnership with NVIDIA to bring its deep learning platform to the PowerShare network. Working together, the companies hope to spur the development and deployment of imaging AI models into the existing radiology workflow for faster detection of key clinical findings.

Interoperability challenges from the enterprise perspective
“The biggest challenge we have in medical imaging is that there is no unified patient EHR,” says Veterans Affairs Maryland Healthcare System’s Siegel. “There is not an easy way to automatically have image data transferred from one facility to another without human intervention that confirms that a particular patient is the same patient at another facility.”

One potential solution may be to give patients access to their own EHR. The RSNA Image Share project, which was launched in 2016, allows patients to store images in the cloud, which can be used as a way to transfer images between hospitals.

The program is open to the vendors of reporting systems, radiology information systems and PACS that want their solutions to connect to image sharing networks. In January 2017, Agfa Healthcare, Ambra Health, GE Healthcare, Lexmark Healthcare, LifeIMAGE, Mach7 Technologies and Novarad became the first to successfully complete the program.

Regarding PACS vendors, one of the biggest challenges is lack of standardization. For example, Cerner has defined its own set of application program interfaces (APIs) for third-party companies, and other vendors have defined their own unique APIs.

“If a patient presents at one hospital then goes to another hospital, [the idea is to] exchange images like they can lab values,” says Erik Abels, senior solution leader for clinical and diagnostic imaging at Cerner. “That isn’t prevalent today, and I think one of the biggest reasons is because the standards aren’t well-suited for it.”

Cerner participates in a committee within CommonWell Health Alliance that is working to better define standards that will help accomplish this interoperability. Once those are defined, the committee plans to promote a national infrastructure with common standards and policies.

“Our goal as part of CommonWell is to get out of the proprietary nature and get into industry standard,” says Abels. “I think we all share a mutual goal of standard-based exchange, but it’s just a matter of how to get from where we’re at to where we want to be.”

Who’s in charge here?
Imaging has historically been under the control of radiology, but now that it’s entering the greater hospital enterprise, will that continue to be the case? At some health care organizations, imaging has become the core responsibility of the IT department.

“To the hospital CIO who thinks of imaging ultimately as part of the EHR, it would seem most logical to have the people whose core expertise is IT, storage and backup to have responsibility for that,” says Siegel. Unfortunately, he adds, there is a precedent for radiology departments, which may operate at all hours of the day and night, to be more responsive to technical issues than conventional hospital IT staff.

Eighty-six percent of the CIOs that took part in the LifeIMAGE survey reported that their IT department owns enterprise imaging either exclusively or as a shared initiative with their radiology departments. In addition, almost half of them believe that a successful enterprise image strategy requires shared responsibility.