Workflow Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper

Celebrating 10 Years of the HIMSS-SIIM Enterprise Imaging Community and Enterprise Imaging Informatics

In response to the growing recognition of enterprise imaging as a critical component of healthcare's digital transformation, in 2014, the Healthcare Information and Management Systems Society (HIMSS) and the Society for Imaging Informatics in Medicine (SIIM) signed a Memorandum of Understanding to form the HIMSS-SIIM Enterprise Imaging Community (HSEIC). At the time of the agreement, the two organizations decided to collaborate to lead enterprise imaging development, advancement, and adoption. This paper celebrates the past 10 years of the HSEIC's thought leadership, industry partnerships, and impact while also looking ahead to identify enterprise imaging challenges to solve in the next decade.

How Image Exchange Breaks Down: the Image Library Perspective

While in the last decade there has been significant technical infrastructure development to support standards-based image exchange through organizations like Integrating the Healthcare Enterprise, Carequality, DICOM, and HL7 FHIR, the human operationalization of such infrastructure using centralized, intuitive, standards-based applications remains the cornerstone of effective and reliable electronic image exchange. Image libraries managing the highly transactional and often uncertain inflows and outflows of images have a unique perspective on the challenges of image exchange. This manuscript will summarize frequent collaboration and communication, release of information, staffing, technology, information localization, and analytics difficulties for image exchange from the perspective of the image library staff managing the transactions.

Visible Light Imaging: Clinical Aspects with an Emphasis on Medical Photography-a HIMSS-SIIM Enterprise Imaging Community Whitepaper

Photodocumentation is a subset of visible light imaging and is an important growing segment of enterprise imaging. Medical videography is another subset of visible light imaging that shares many of the challenges of photodocumentation. Medical photographs are used to document clinical conditions, support diagnosis, guide, and document procedures and to enable collaboration among colleagues. They also play a significant role in patient engagement and are a mechanism for patients to share information with their provider without the need for a clinical office visit. The content of medical photographs raises issues for acquisition, management, storage, and access. Medical photographs may contain protected health information, and these images benefit from the standardized, secure processes inherent in any enterprise imaging program. The ability to securely acquire images on mobile, and sometimes personally owned devices, is a necessity. In addition to containing protected health information, photograph content can be sensitive or gruesome or the images may be used for forensic purposes. These types of images require additional protections. Access to these images should be role-based and auditable. To properly identify photographs and to convey information about their acquisition parameters new metadata requirements and mechanisms for its association with the imaging files are evolving. Institutional policies need to be developed to define the organization's requirements for medical photography, including consent processes. Existing policies such as those defining the designated record set and legal health record should address the management of medical photography.

The Enterprise Imaging Value Proposition

As resources in the healthcare environment continue to wane, leaders are seeking ways to continue to provide quality care bounded by the constraints of a reduced budget. This manuscript synthesizes the experience from a number of institutions to provide the healthcare leadership with an understanding of the value of an enterprise imaging program. The value of such a program extends across the entire health system. It leads to operational efficiencies through infrastructure and application consolidation and the creation of focused support capabilities with increased depth of skill. An enterprise imaging program provides a centralized foundation for all phases of image management from every image-producing specialty. Through centralization, standardized image exchange functions can be provided to all image producers. Telehealth services can be more tightly integrated into the electronic medical record. Mobile platforms can be utilized for image viewing and sharing by patients and providers. Mobile tools can also be utilized for image upload directly into the centralized image repository. Governance and data standards are more easily distributed, setting the stage for artificial intelligence and data analytics. Increased exposure to all image producers provides opportunities for cybersecurity optimization and increased awareness.

Impact of an epic-integrated point-of-care ultrasound workflow on ultrasound performance, compliance, and potential revenue

OBJECTIVES

The purpose of this study was to describe the design and impact of a point-of-care ultrasound (PoCUS) workflow integrated into the electronic medical record (EMR) on PoCUS utilization, documentation compliance, and resultant revenue potential.

METHODS

This was a single-center retrospective study at an academic center. The study period spanned from December 1, 2018 to June 30, 2019 (pre-implementation) to August 1, 2019 to February 29, 2020 (post-implementation). The implementation date was July 11, 2019 at which time a PoCUS workflow was integrated into the EMR in the emergency department without the purchase of middleware. Prior to this new workflow, a non-automated workflow was in place. PoCUS scan data were extracted from the EMR and archived examinations. The mean number of PoCUS examinations performed per month per 100 ED visits before and after implementation of the new workflow were compared using an unpaired t-test, stratified by all health care professionals, and attending physicians alone. The rate of documentation compliance before and after implementation of the new workflow were compared using a chi square contingency test. Potential revenue was calculated for each period by multiplying the number of eligible examinations by the respective 2020 Medicare conversion factor Relative Value Units.

RESULTS

Utilization of PoCUS from pre-implementation to post-implementation increased 28.7% from 5.01 to 6.45 mean examinations per month per 100 ED visits by all health care professionals (p = 0.063), and 75.1% from 2.01 to 3.52 by attending physicians (p = 0.0001). Examinations in compliance with workflow requirements increased from 153 (14.7%) to 1307 (94.0%). The rate of workflow compliance improved from 14.7% to 94.0% of examinations (p < 0.0001). Potential revenue increased from $546.01 to $22,014.47.

CONCLUSIONS

The implementation of a middleware-free PoCUS workflow at our institution was associated with increased PoCUS utilization, documentation compliance, and potential revenue.

The Importance of Body Part Labeling to Enable Enterprise Imaging: A HIMSS-SIIM Enterprise Imaging Community Collaborative White Paper

In order for enterprise imaging to be successful across a multitude of specialties, systems, and sites, standards are essential to categorize and classify imaging data. The HIMSS-SIIM Enterprise Imaging Community believes that the Digital Imaging Communications in Medicine (DICOM) Anatomic Region Sequence, or its equivalent in other data standards, is a vital data element for this role, when populated with standard coded values. We believe that labeling images with standard Anatomic Region Sequence codes will enhance the user’s ability to consume data, facilitate interoperability, and allow greater control of privacy. Image consumption—when a user views a patient’s images, he or she often wants to see relevant comparison images of the same lesion or anatomic region for the same patient automatically presented. Relevant comparison images may have been acquired from a variety of modalities and specialties. The Anatomic Region Sequence data element provides a basis to allow for efficient comparison in both instances. Interoperability—as patients move between health care systems, it is important to minimize friction for data transfer. Health care providers and facilities need to be able to consume and review the increasingly large and complex volume of data efficiently. The use of Anatomic Region Sequence, or its equivalent, populated with standard values enables seamless interoperability of imaging data regardless of whether images are used within a site or across different sites and systems. Privacy—as more visible light photographs are integrated into electronic systems, it becomes apparent that some images may need to be sequestered. Although additional work is needed to protect sensitive images, standard coded values in Anatomic Region Sequence support the identification of potentially sensitive images, enable facilities to create access control policies, and can be used as an interim surrogate for more sophisticated rule-based or attribute-based access control mechanisms. To satisfy such use cases, the HIMSS-SIIM Enterprise Imaging Community encourages the use of a pre-existing body part ontology. Through this white paper, we will identify potential challenges in employing this standard and provide potential solutions for these challenges.

Fundamentals of Enterprise Photodocumentation: Connecting the Clinical and Technical-a Review of Key Concepts

Photodocumentation is an invaluable tool in many specialties, including dermatology, facial plastic and reconstructive surgery, and wound management. As digital cameras and camera-enabled smartphones have become omnipresent in our society, they have brought photodocumentation to all corners of healthcare organizations including the emergency department as well as family medicine and pediatrics. Simultaneously, enterprise imaging programs have evolved enabling access to all medical images for all providers throughout these organizations. Through their unique perspective, enterprise imaging teams have an opportunity to guide development of high quality, ethical programs that are compliant with legal and regulatory requirements. Clinical and technical standards for photodocumentation are not fully evolved and thus establishing an enterprise photodocumentation program will require communication and education. Development of such a program requires an understanding of the clinical, ethical, and technical issues around photodocumentation. This article explores how photodocumentation is utilized, the patient's experience, current quality concerns, tools and technical issues around image acquisition, and the topics of informed consent, privacy, security, and lifecycle and health information management.

Transforming Dermatologic Imaging for the Digital Era: Metadata and Standards

Imaging is increasingly being used in dermatology for documentation, diagnosis, and management of cutaneous disease. The lack of standards for dermatologic imaging is an impediment to clinical uptake. Standardization can occur in image acquisition, terminology, interoperability, and metadata. This paper presents the International Skin Imaging Collaboration position on standardization of metadata for dermatologic imaging. Metadata is essential to ensure that dermatologic images are properly managed and interpreted. There are two standards-based approaches to recording and storing metadata in dermatologic imaging. The first uses standard consumer image file formats, and the second is the file format and metadata model developed for the Digital Imaging and Communication in Medicine (DICOM) standard. DICOM would appear to provide an advantage over using consumer image file formats for metadata as it includes all the patient, study, and technical metadata necessary to use images clinically. Whereas, consumer image file formats only include technical metadata and need to be used in conjunction with another actor-for example, an electronic medical record-to supply the patient and study metadata. The use of DICOM may have some ancillary benefits in dermatologic imaging including leveraging DICOM network and workflow services, interoperability of images and metadata, leveraging existing enterprise imaging infrastructure, greater patient safety, and better compliance to legislative requirements for image retention.

Twenty Years of Digital Pathology: An Overview of the Road Travelled, What is on the Horizon, and the Emergence of Vendor-Neutral Archives

Almost 20 years have passed since the commercial introduction of whole-slide imaging (WSI) scanners. During this time, the creation of various WSI devices with the ability to digitize an entire glass slide has transformed the field of pathology. Parallel advances in computational technology and storage have permitted rapid processing of large-scale WSI datasets. This article provides an overview of important past and present efforts related to WSI. An account of how the virtual microscope evolved from the need to visualize and manage satellite data for earth science applications is provided. The article also discusses important milestones beginning from the first WSI scanner designed by Bacus to the Food and Drug Administration approval of the first digital pathology system for primary diagnosis in surgical pathology. As pathology laboratories commit to going fully digitalize, the need has emerged to include WSIs into an enterprise-level vendor-neutral archive (VNA). The different types of VNAs available are reviewed as well as how best to implement them and how pathology can benefit from participating in this effort. Differences between traditional image algorithms that extract pixel-, object-, and semantic-level features versus deep learning methods are highlighted. The need for large-scale data management, analysis, and visualization in computational pathology is also addressed.

The Current State and Path Forward For Enterprise Image Viewing: HIMSS-SIIM Collaborative White Paper

Clinical specialties have widely varied needs for diagnostic image interpretation, and clinical image and video image consumption. Enterprise viewers are being deployed as part of electronic health record implementations to present the broad spectrum of clinical imaging and multimedia content created in routine medical practice today. This white paper will describe the enterprise viewer use cases, drivers of recent growth, technical considerations, functionality differences between enterprise and specialty viewers, and likely future states. This white paper is aimed at CMIOs and CIOs interested in optimizing the image-enablement of their electronic health record or those who may be struggling with the many clinical image viewers their enterprises may employ today.

A Foundation for Enterprise Imaging: HIMSS-SIIM Collaborative White Paper

Care providers today routinely obtain valuable clinical multimedia with mobile devices, scope cameras, ultrasound, and many other modalities at the point of care. Image capture and storage workflows may be heterogeneous across an enterprise, and as a result, they often are not well incorporated in the electronic health record. Enterprise Imaging refers to a set of strategies, initiatives, and workflows implemented across a healthcare enterprise to consistently and optimally capture, index, manage, store, distribute, view, exchange, and analyze all clinical imaging and multimedia content to enhance the electronic health record. This paper is intended to introduce Enterprise Imaging as an important initiative to clinical and informatics leadership, and outline its key elements of governance, strategy, infrastructure, common multimedia content, acquisition workflows, enterprise image viewers, and image exchange services.

Enterprise Imaging Governance: HIMSS-SIIM Collaborative White Paper

Enterprise imaging governance is an emerging need in health enterprises today. This white paper highlights the decision-making body, framework, and process for optimal enterprise imaging governance inclusive of five areas of focus: program governance, technology governance, information governance, clinical governance, and financial governance. It outlines relevant parallels and differences when forming or optimizing imaging governance as compared with other established broad horizontal governance groups, such as for the electronic health record. It is intended for CMIOs and health informatics leaders looking to grow and govern a program to optimally capture, store, index, distribute, view, exchange, and analyze the images of their enterprise.

Implementation of Enterprise Imaging Strategy at a Chinese Tertiary Hospital

Medical images have become increasingly important in clinical practice and medical research, and the need to manage images at the hospital level has become urgent in China. To unify patient identification in examinations from different medical specialties, increase convenient access to medical images under authentication, and make medical images suitable for further artificial intelligence investigations, we implemented an enterprise imaging strategy by adopting an image integration platform as the main tool at Xuanwu Hospital. Workflow re-engineering and business system transformation was also performed to ensure the quality and content of the imaging data. More than 54 million medical images and approximately 1 million medical reports were integrated, and uniform patient identification, images, and report integration were made available to the medical staff and were accessible via a mobile application, which were achieved by implementing the enterprise imaging strategy. However, to integrate all medical images of different specialties at a hospital and ensure that the images and reports are qualified for data mining, some further policy and management measures are still needed.

Technical Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper

This white paper explores the technical challenges and solutions for acquiring (capturing) and managing enterprise images, particularly those involving visible light applications. The types of acquisition devices used for various general-purpose photography and specialized applications including dermatology, endoscopy, and anatomic pathology are reviewed. The formats and standards used, and the associated metadata requirements and communication protocols for transfer and workflow are considered. Particular emphasis is placed on the importance of metadata capture in both order- and encounter-based workflow. The benefits of using DICOM to provide a standard means of recording and accessing both metadata and image and video data are considered, as is the role of IHE and FHIR.