Moving Toward Seamless Interinstitutional Electronic Image Transfer

The fact that medical images are still predominately exchanged between institutions via physical media is unacceptable in the era of value-driven health care. Although better solutions are technically possible, problems of coordination and market dynamics may be inhibiting progress more than technical factors. We provide a macrosystem analysis of the problem of interinstitutional medical image exchange and propose a strategy for nudging the market toward a patient-friendly solution. The system can be viewed as a network, with autonomous nodes interconnected by links through which information is exchanged. A variety of potential network configurations include those that depend on individual carriers, peer-to-peer links, one or multiple hubs, or a hybrid of models. We find the linked multihub model, in which individual institutions are connected to other institutions via image exchange companies, to be the configuration most likely to create a patient-friendly electronic image exchange system. To achieve this configuration, image exchange companies, which operate in a competitive marketplace, must exchange images with each other. We call on these vendors to immediately commit to coordinating in this manner. We call on all other stakeholders, including medical societies, payers, and regulators, to actively encourage and facilitate this behavior. Specifically, we call on institutions to create appropriate market incentives by only contracting with image exchange vendors who are committed to begin vendor-to-vendor image exchange by no later than 2024.

Impact of COVID-19 pandemic on radiology education, training, and practice: A narrative review

Radiology education and training is of paramount clinical importance given the prominence of medical imaging utilization in effective clinical practice. The incorporation of basic radiology in the medical curriculum has continued to evolve, focusing on teaching image interpretation skills, the appropriate ordering of radiological investigations, judicious use of ionizing radiation, and providing exposure to interventional radiology. Advancements in radiology have been driven by the digital revolution, which has, in turn, had a positive impact on radiology education and training. Upon the advent of the corona virus disease 2019 (COVID-19) pandemic, many training institutions and hospitals adhered to directives which advised rescheduling of non-urgent outpatient appointments. This inevitably impacted the workflow of the radiology department, which resulted in the reduction of clinical in-person case reviews and consultations, as well as in-person teaching sessions. Several medical schools and research centers completely suspended face-to-face academic activity. This led to challenges for medical teachers to complete the radiology syllabus while ensuring that teaching activities continued safely and effectively. As a result, online teaching platforms have virtually replaced didactic face-to-face lectures. Radiology educators also sought other strategies to incorporate interactive teaching sessions while adopting the e-learning approach, as they were cognizant of the limitations that this may have on students' clinical expertise. Migration to online methods to review live cases, journal clubs, simulation-based training, clinical interaction, and radiology examination protocolling are a few examples of successfully addressing the limitations in reduced clinical exposure. In this review paper, we discuss (1) The impact of the COVID-19 pandemic on radiology education, training, and practice; (2) Challenges and strategies involved in delivering online radiology education for undergraduates and postgraduates during the COVID-19 pandemic; and (3) Difference between the implementation of radiology education during the COVID-19 pandemic and pre-COVID-19 era.

The Successful Usage of the DICOM Images Exchange System (ePACS) in the Czech Republic

BACKGROUND

The picture archiving and communication system (PACS) has already replaced classic hard copy film technology. With new functions of PACS under consideration, attention turns to the sharing of medical images between different institutions. The Czech Republic is one of the few countries using a nation-wide medical images exchange system known as ePACS. It is based on dedicated hardware and one central router, although theoretical models tend to prefer cloud-based sharing.

OBJECTIVE

Despite its simple design and lack of advanced features, this system has successively evolved into a widely used tool. The aim of this article is to offer an overview of its use and functions and to show that even a simple system can be widely used.

METHODS

Using data from the producer of ePACS (the ICZ company) and from other sources, the system was described and data about its performance have been obtained.

RESULTS

Every acute-care hospital (140) and about a quarter of outpatient facilities (105) in the Czech Republic are now equipped with ePACS and are therefore able to share medical images. The number of studies transmitted rises every year, from 12,000 in 2008 to more than 640,000 in 2018, which is approximately 4% of all studies produced. The system was primarily designed and is used to share images between acute-care hospitals but a very special usage has also evolved, as it is employed in a teleradiology service with private enterprises too.

CONCLUSION

ePACS is expanding in the Czech Republic despite having only limited functions and despite its principle that simply copies a classic workflow when sending studies on Compact Discs. Although other systems for image sharing might be more advanced, ePACS brings to the Czech health care system the capability to exchange medical images on a national level.

Automating Import and Reconciliation of Outside Examinations Submitted to an Academic Radiology Department

Although advances in electronic image sharing have made continuity of patient care easier, currently, the majority of outside studies are received on CD. At our institution, there were 9 full-time employees (FTE) at three locations using three workflows to manually upload, schedule, and process studies to PACS. As the demand to view and store outside studies has grown, so has the processing turnaround time. To reduce turnaround time and the need for human intervention, we developed an automated workflow to import outside studies from a CD to our PACS and reconcile them with an internal accession number and exam code.

Sharing De-identified Medical Images Electronically for Research: A Survey of Patients' Opinion Regarding Data Management

PURPOSE

Secondary usage of patient data has recently become of increasing interest for the development and application of computer analytic techniques. Strict oversight of these data is required and the individual patients themselves are integral to providing guidance. We sought to understand patients' attitudes to sharing their imaging data for research purposes. These images could provide a great wealth of information for researchers.

METHODS

Patients from the Greater Toronto Area attending Sunnybrook Health Sciences Centre for imaging (magnetic resonance imagining, computed tomography, or ultrasound) examination areas were invited to participate in an electronic survey.

RESULTS

Of the 1083 patients who were approached (computed tomography 609, ultrasound 314, and magnetic resonance imaging 160), 798 (74%) agreed to take the survey. Overall median age was 60 (interquartile range = 18, Q1 = 52, Q3 = 70), 52% were women, 42% had a university degree, and 7% had no high school diploma. In terms of willingness to share de-identified medical images for research, 76% were willing (agreed and strongly agreed), while 7% refused. Most participants gave their family physicians (73%) and other physicians (57%) unconditional data access. Participants chose hospitals/research institutions to regulate electronic images databases (70%), 89% wanted safeguards against unauthorized access to their data, and over 70% wanted control over who will be permitted, for how long, and the ability to revoke that permission.

CONCLUSIONS

Our study found that people are willing to share their clinically acquired de-identified medical images for research studies provided that they have control over permissions and duration of access.

Technology and Policy Challenges in the Adoption and Operation of Health Information Exchange Systems

Objectives

This study aimed to identify problems and issues that arise with the implementation of online health information exchange (HIE) systems in a medical environment and to identify solutions to facilitate the successful operation of future HIE systems in primary care clinics and hospitals.

Methods

In this study, the issues that arose during the establishment and operation of an HIE system in a hospital were identified so that they could be addressed to enable the successful establishment and operation of a standard-based HIE system. After the issues were identified, they were reviewed and categorized by a group of experts that included medical information system experts, doctors, medical information standard experts, and HIE researchers. Then, solutions for the identified problems were derived based on the system development, operation, and improvement carried out during this work.

Results

Twenty-one issues were identified during the implementation and operation of an online HIE system. These issues were then divided into four categories: system architecture and standards, documents and data items, consent of HIE, and usability. We offer technical and policy recommendations for various stakeholders based on the experiences of operating and improving the online HIE system in the medical field.

Conclusions

The issues and solutions identified in this study regarding the implementation and operate of an online HIE system can provide valuable insight for planners to enable them to successfully design and operate such systems at a national level in the future. In addition, policy support from governments is needed.

Image Sharing in Radiology-A Primer

By virtue of its information technology-oriented infrastructure, the specialty of radiology is uniquely positioned to be at the forefront of efforts to promote data sharing across the healthcare enterprise, including particularly image sharing. The potential benefits of image sharing for clinical, research, and educational applications in radiology are immense. In this work, our group-the Association of University Radiologists (AUR) Radiology Research Alliance Task Force on Image Sharing-reviews the benefits of implementing image sharing capability, introduces current image sharing platforms and details their unique requirements, and presents emerging platforms that may see greater adoption in the future. By understanding this complex ecosystem of image sharing solutions, radiologists can become important advocates for the successful implementation of these powerful image sharing resources.

Patient-directed Internet-based Medical Image Exchange: Experience from an Initial Multicenter Implementation

RATIONALE AND OBJECTIVES

Inefficient transfer of personal health records among providers negatively impacts quality of health care and increases cost. This multicenter study evaluates the implementation of the first Internet-based image-sharing system that gives patients ownership and control of their imaging exams, including assessment of patient satisfaction.

MATERIALS AND METHODS

Patients receiving any medical imaging exams in four academic centers were eligible to have images uploaded into an online, Internet-based personal health record. Satisfaction surveys were provided during recruitment with questions on ease of use, privacy and security, and timeliness of access to images. Responses were rated on a five-point scale and compared using logistic regression and McNemar's test.

RESULTS

A total of 2562 patients enrolled from July 2012 to August 2013. The median number of imaging exams uploaded per patient was 5. Most commonly, exams were plain X-rays (34.7%), computed tomography (25.7%), and magnetic resonance imaging (16.1%). Of 502 (19.6%) patient surveys returned, 448 indicated the method of image sharing (Internet, compact discs [CDs], both, other). Nearly all patients (96.5%) responded favorably to having direct access to images, and 78% reported viewing their medical images independently. There was no difference between Internet and CD users in satisfaction with privacy and security and timeliness of access to medical images. A greater percentage of Internet users compared to CD users reported access without difficulty (88.3% vs. 77.5%, P < 0.0001).

CONCLUSION

A patient-directed, interoperable, Internet-based image-sharing system is feasible and surpasses the use of CDs with respect to accessibility of imaging exams while generating similar satisfaction with respect to privacy.

Challenges of cardiac image analysis in large-scale population-based studies

Large-scale population-based imaging studies of preclinical and clinical heart disease are becoming possible due to the advent of standardized robust non-invasive imaging methods and infrastructure for big data analysis. This gives an exciting opportunity to gain new information about the development and progression of heart disease across population groups. However, the large amount of image data and prohibitive time required for image analysis present challenges for obtaining useful derived data from the images. Automated analysis tools for cardiac image analysis are only now becoming available. This paper reviews the challenges and possible solutions to the analysis of big imaging data in population studies. We also highlight the potential of recent large epidemiological studies using cardiac imaging to discover new knowledge on heart health and well-being.

Image sharing: evolving solutions in the age of interoperability

Interoperability is a major focus of the quickly evolving world of Health IT. Easy, yet secure and confidential exchange of imaging exams and the associated reports must be a part of the solutions that are implemented. The availability of historical exams is essential in providing a quality interpretation and reducing inappropriate utilization of imaging services. Today, the exchange of imaging exams is most often achieved via a compact disc. We describe the virtues of this solution as well as challenges that have surfaced. Internet- and cloud-based technologies employed for many consumer services can provide a better solution. Vendors are making these solutions available. Standards for Internet-based exchange are emerging. Just as radiology converged on DICOM as a standard to store and view images, we need a common exchange standard. We will review the existing standards and how they are organized into useful workflows through Integrating the Healthcare Enterprise profiles. Integrating the Healthcare Enterprise and standards development processes are discussed. Health care and the domain of radiology must stay current with quickly evolving Internet standards. The successful use of the "cloud" will depend on both the technologies and the policies put into place around them, both of which we discuss. The radiology community must lead the way and provide a solution that works for radiologists and clinicians with use of the electronic medical record. We describe features we believe radiologists should consider when adding Internet-based exchange solutions to their practice.

Big heart data: advancing health informatics through data sharing in cardiovascular imaging

The burden of heart disease is rapidly worsening due to the increasing prevalence of obesity and diabetes. Data sharing and open database resources for heart health informatics are important for advancing our understanding of cardiovascular function, disease progression and therapeutics. Data sharing enables valuable information, often obtained at considerable expense and effort, to be reused beyond the specific objectives of the original study. Many government funding agencies and journal publishers are requiring data reuse, and are providing mechanisms for data curation and archival. Tools and infrastructure are available to archive anonymous data from a wide range of studies, from descriptive epidemiological data to gigabytes of imaging data. Meta-analyses can be performed to combine raw data from disparate studies to obtain unique comparisons or to enhance statistical power. Open benchmark datasets are invaluable for validating data analysis algorithms and objectively comparing results. This review provides a rationale for increased data sharing and surveys recent progress in the cardiovascular domain. We also highlight the potential of recent large cardiovascular epidemiological studies enabling collaborative efforts to facilitate data sharing, algorithms benchmarking, disease modeling and statistical atlases.

Impact of cross-enterprise data sharing on portable media with decentralised upload of DICOM data into PACS

Objectives

To evaluate portable media utilisation for image data sharing between enterprises. To predict the costs required to keep up with the trend. To identify related problems.

Methods

A software package was developed to include patient image data from CD into our normal workflow. The trend in the workload of CDs that were uploaded into a Picture Archiving and Communication System (PACS) over 89 months was analysed. The average number of images per month (and per investigation) was calculated to provide the estimation of storage and cost required in the whole process.

Results

All Digital Imaging and Communications in Medicine (DICOM) files can be read from compact disc (CD) on any workstation in the hospital, processed quickly to the central server and checked after storage using the software tool. A total of 33,982,404 images from 88,952 CDs have been stored into the PACS system. In recent years, the stored images have reached an average of 4.2 terabytes (TB) uncompressed annually.

Conclusion

Integrated information about patients is clearly needed to provide easy and timely access to these data. The steadily growing storage can be solved by a more automated approach to portable media handling or the installation and acceptance of network-based transfer using cross-enterprise document sharing (XDS).

Key points

• Rapid assimilation of external imaging into a PACS system is essential.

• But data distribution using portable media also carries some disadvantages.

• A DICOM data uploader incorporates studies from portable media to hospital workflow.

• Automated media handling or XDS should solve the steadily growing storage problem.

• Software improvements will facilitate the steady increase in the amount of CDs processed.

Imaging informatics: essential tools for the delivery of imaging services

There are rapid changes occurring in the health care environment. Radiologists face new challenges but also new opportunities. The purpose of this report is to review how new informatics tools and developments can help the radiologist respond to the drive for safety, quality, and efficiency. These tools will be of assistance in conducting research and education. They not only provide greater efficiency in traditional operations but also open new pathways for the delivery of new services and imaging technologies. Our future as a specialty is dependent on integrating these informatics solutions into our daily practice.

Using the Internet for image transfer in a regional trauma network: effect on CT repeat rate, cost, and radiation exposure

PURPOSE

The aims of this study were to evaluate an Internet-based and compact disc-based image transfer system and to compare this system with others in the literature, specifically regarding effects on repeat imaging rate, cost, and radiation dose to patients transferred to a level I regional trauma center.

METHODS

Five hundred consecutive trauma patients transferred to a level I trauma center between June 1 and July 15, 2009, were included in the study. Images were transferred from an outside facility to the trauma center using the Internet and compact discs and uploaded to the trauma center's PACS. Radiographic studies and CT scans at the trauma center were classified as outside studies, completion studies, or repeat studies. Repeat rate, costs, and radiation doses of transferred and repeated CT scans were calculated.

RESULTS

Four hundred ninety-one patients met the inclusion criteria. The patients' average age was 40.5 years, and 70% were men. The average Injury Severity Score was 14.7. Three hundred eighty-three patients had 852 CT studies and 380 nonextremity radiographs imported into the trauma center's PACS. At the trauma center, 494 completion CT scans and 2,924 radiographic studies were performed on these patients. Sixty-nine repeat CT scans were performed on 55 patients, equalling a 17% repeat rate. The total value of imported CT studies was $244,373.69. Repeat imaging totaled $20,495.95, or $84.65 per patient with transferred CT studies.

CONCLUSIONS

Using a combination of the Internet and compact discs to transfer images during inter-hospital transfer is associated with much lower repeat rates than those in the literature, suggesting that regional PACS networks may be useful for reducing cost and radiation exposure associated with trauma.

Insight into the sharing of medical images: physician, other health care providers, and staff experience in a variety of medical settings

BACKGROUND

Scant knowledge exists describing health care providers' and staffs' experiences sharing imaging studies. Additional research is needed to determine the extent to which imaging studies are shared in diverse health care settings, and the extent to which provider or practice characteristics are associated with barriers to viewing external imaging studies on portable media.

OBJECTIVE

This analysis uses qualitative data to 1) examine how providers and their staff accessed outside medical imaging studies, 2) examine whether use or the desire to use imaging studies conducted at outside facilities varied by provider specialty or location (urban, suburban, and small town) and 3) delineate difficulties experienced by providers or staff as they attempted to view and use imaging studies available on portable media.

METHODS

Semi-structured interviews were conducted with 85 health care providers and medical facility staff from urban, suburban, and small town medical practices in North Carolina and Virginia. The interviews were audio recorded, transcribed, then systematically analyzed using ATLAS.ti.

RESULTS

Physicians at family and pediatric medicine practices rely primarily on written reports for medical studies other than X-rays; and thus do not report difficulties accessing outside imaging studies. Subspecialists in urban, suburban, and small towns view imaging studies through internal communication systems, internet portals, or portable media. Many subspecialists and their staff report experiencing difficulty and time delays in accessing and using imaging studies on portable media.

CONCLUSION

Subspecialists have distinct needs for viewing imaging studies that are not shared by typical primary care providers. As development and implementation of technical strategies to share medical records continue, this variation in need and use should be noted. The sharing and viewing of medical imaging studies on portable media is often inefficient and fails to meet the needs of many subspeciality physicians, and can lead to repeated imaging studies.

Patient-controlled sharing of medical imaging data across unaffiliated healthcare organizations

BACKGROUND

Current image sharing is carried out by manual transportation of CDs by patients or organization-coordinated sharing networks. The former places a significant burden on patients and providers. The latter faces challenges to patient privacy.

OBJECTIVE

To allow healthcare providers efficient access to medical imaging data acquired at other unaffiliated healthcare facilities while ensuring strong protection of patient privacy and minimizing burden on patients, providers, and the information technology infrastructure.

METHODS

An image sharing framework is described that involves patients as an integral part of, and with full control of, the image sharing process. Central to this framework is the Patient Controlled Access-key REgistry (PCARE) which manages the access keys issued by image source facilities. When digitally signed by patients, the access keys are used by any requesting facility to retrieve the associated imaging data from the source facility. A centralized patient portal, called a PCARE patient control portal, allows patients to manage all the access keys in PCARE.

RESULTS

A prototype of the PCARE framework has been developed by extending open-source technology. The results for feasibility, performance, and user assessments are encouraging and demonstrate the benefits of patient-controlled image sharing.

DISCUSSION

The PCARE framework is effective in many important clinical cases of image sharing and can be used to integrate organization-coordinated sharing networks. The same framework can also be used to realize a longitudinal virtual electronic health record.

CONCLUSION

The PCARE framework allows prior imaging data to be shared among unaffiliated healthcare facilities while protecting patient privacy with minimal burden on patients, providers, and infrastructure. A prototype has been implemented to demonstrate the feasibility and benefits of this approach.

A DICOM-based 2nd generation Molecular Imaging Data Grid implementing the IHE XDS-i integration profile

PURPOSE

A Molecular Imaging Data Grid (MIDG) was developed to address current informatics challenges in archival, sharing, search, and distribution of preclinical imaging studies between animal imaging facilities and investigator sites. This manuscript presents a 2nd generation MIDG replacing the Globus Toolkit with a new system architecture that implements the IHE XDS-i integration profile. Implementation and evaluation were conducted using a 3-site interdisciplinary test-bed at the University of Southern California.

METHODS

The 2nd generation MIDG design architecture replaces the initial design's Globus Toolkit with dedicated web services and XML-based messaging for dedicated management and delivery of multi-modality DICOM imaging datasets. The Cross-enterprise Document Sharing for Imaging (XDS-i) integration profile from the field of enterprise radiology informatics was adopted into the MIDG design because streamlined image registration, management, and distribution dataflow are likewise needed in preclinical imaging informatics systems as in enterprise PACS application. Implementation of the MIDG is demonstrated at the University of Southern California Molecular Imaging Center (MIC) and two other sites with specified hardware, software, and network bandwidth.

RESULTS

Evaluation of the MIDG involves data upload, download, and fault-tolerance testing scenarios using multi-modality animal imaging datasets collected at the USC Molecular Imaging Center. The upload, download, and fault-tolerance tests of the MIDG were performed multiple times using 12 collected animal study datasets. Upload and download times demonstrated reproducibility and improved real-world performance. Fault-tolerance tests showed that automated failover between Grid Node Servers has minimal impact on normal download times.

CONCLUSIONS

Building upon the 1st generation concepts and experiences, the 2nd generation MIDG system improves accessibility of disparate animal-model molecular imaging datasets to users outside a molecular imaging facility's LAN using a new architecture, dataflow, and dedicated DICOM-based management web services. Productivity and efficiency of preclinical research for translational sciences investigators has been further streamlined for multi-center study data registration, management, and distribution.

MIDG-Emerging grid technologies for multi-site preclinical molecular imaging research communities

PURPOSE

Molecular imaging is the visualization and identification of specific molecules in anatomy for insight into metabolic pathways, tissue consistency, and tracing of solute transport mechanisms. This paper presents the Molecular Imaging Data Grid (MIDG) which utilizes emerging grid technologies in preclinical molecular imaging to facilitate data sharing and discovery between preclinical molecular imaging facilities and their collaborating investigator institutions to expedite translational sciences research. Grid-enabled archiving, management, and distribution of animal-model imaging datasets help preclinical investigators to monitor, access and share their imaging data remotely, and promote preclinical imaging facilities to share published imaging datasets as resources for new investigators.

METHODS

The system architecture of the Molecular Imaging Data Grid is described in a four layer diagram. A data model for preclinical molecular imaging datasets is also presented based on imaging modalities currently used in a molecular imaging center. The MIDG system components and connectivity are presented. And finally, the workflow steps for grid-based archiving, management, and retrieval of preclincial molecular imaging data are described.

RESULTS

Initial performance tests of the Molecular Imaging Data Grid system have been conducted at the USC IPILab using dedicated VMware servers. System connectivity, evaluated datasets, and preliminary results are presented. The results show the system's feasibility, limitations, direction of future research.

CONCLUSIONS

Translational and interdisciplinary research in medicine is increasingly interested in cellular and molecular biology activity at the preclinical levels, utilizing molecular imaging methods on animal models. The task of integrated archiving, management, and distribution of these preclinical molecular imaging datasets at preclinical molecular imaging facilities is challenging due to disparate imaging systems and multiple off-site investigators. A Molecular Imaging Data Grid design, implementation, and initial evaluation is presented to demonstrate the secure and novel data grid solution for sharing preclinical molecular imaging data across the wide-area-network (WAN).