The Patient Health Record: A Tale of a Two-Brained Beast
Why an IHR should be an equal partner to the EHR

Scene from the movie Pacific Rim. Source: Warner Brothers

In the 2013 epic sci-fi thriller Pacific Rim, Guillermo Del Toro takes us into a dystopian future in which humanity fights back against Godzilla-sized alien monsters (the Kaiju) rising randomly from the depths of the Pacific ocean to terrorize and destroy large cities. To match the sheer size and power of these alien beasts required the creation of equally gigantic robots, called Jaegers, equipped with various formidable weapons to fight these unusual creatures.

The striking concept I found when watching this movie, is that the Jaeger robots were so complex and powerful that a single pilot could not bear the neural load necessary to drive and control them. The load could be lethal for a single pilot. A second pilot would be required to share the neural load via a mental bridge (a concept called drifting).
Only together, and flawlessly synchronized, can two pilots effectively control the Jaeger and achieve perfect coordination to fight the Kaiju. Whether two pilots are drift compatible is contingent upon the depth of their connection, and their ability to establish and maintain a focused mental bridge.
To keep Health IT topics relatable and fun, I find it excessively stimulating to draw parallels between pop culture and aspects of Health IT, which can otherwise be a rather dry subject to cover. In this analogy, the Patient Health Record is the Kaiju to be tamed, and the Health IT enterprise ecosystem is the Jaeger that gets the job done.

Scene from the movie Pacific Rim. Source: Warner Brothers

Status Quo: EHR As The Cornerstone Of Patient Records

For far too long and in most cases deliberately the EHR has been positioned as the centerpiece of the patient’s record. Our collective experience as enterprise imaging professionals has historically been that any project not related to the EHR would have to wait until the EHR is in place.
Billion-dollar budgets are not uncommon in an endeavor to uproot and establish a new EHR in a health system. Imaging projects and budgets have been traditionally dwarfed by larger EHR projects, as we routinely wait (patiently) until a hospital system comes up for air after a multi-year EHR deployment. Only then can we become engaged in enterprise IT ecosystem evaluation and imaging workflow design… as an afterthought.

This sequential approach, essentially stating, “don’t bother me until I’m done with the EHR project,” is fundamentally flawed. By prioritizing the EHR over any other project, we fail to see that a vital element of the patient’s record is being demoted to play a second fiddle to the EHR. When faced with a fait accompli, imaging IT must conform to an environment that has already been established, but without vital design input from imaging.

Introducing The Imaging Health Record (IHR)

Enter the concept of the Imaging Health Record (IHR), contrasted with the EHR. Companies like Epic, Cerner (now Oracle), and MEDITECH, have long considered themselves the alpha dog in these processes, and imaging IT a distant second priority.
In our collective Health IT consciousness, the IHR must become an equal partner to the EHR. Much like the Jaeger requires two flawlessly synchronized pilots to fight the Kaiju, the EHR, and the IHR must act as one, and therefore must be designed as two equally important parts of the same entity.
The fragmentation within enterprise imaging isn’t a deliberate attempt by healthcare providers, but rather the result of decades of stratified health IT solution deployments, addressing the needs of the enterprise on an ad hoc basis. What’s been missing is a more strategic way to look at the health IT ecosystem, and inject some deliberate integrated design in our deployments.

Enterprise Imaging is a highly evolved manifestation of healthcare imaging organization that builds on decades of legacy PACS technology. Credited for pulling diagnosticians out of the physical film business and bringing them into the digital age, PACS/VNA solutions are now expected to deliver functionality that goes far beyond archiving and communicating digital images. Imaging solutions are expected to manage complex parallel workflows that coexist in real-time.

Imaging ecosystems need to capture, route, analyze, AI-orchestrate, 3D-render, view any type of imaging object, exchange, archive, prioritize, transform, prefetch, understand the distinction between relevant and irrelevant priors, integrate seamlessly with other solutions via a wide array of industry standards, embrace the introduction of digital pathology images and workflows, complement the EHR, compare, report, conform to diverging data governance priorities,
de-identify for machine learning, clinical trials, and research, and support internal and external end-users who all have different needs for data access.

Imaging ecosystems must help to support and optimize increasingly heavy workloads for diagnosticians, ensuring the infrastructure delivers high-performing networks and computing power to avoid data bottlenecks and end-user frustration. Last but not least, they must do so interchangeably on-premises and in the Cloud, all while avoiding the introduction of cybersecurity or privacy vulnerabilities for the greater enterprise.

Looking Ahead: IHR and EHR, flawlessly synchronized with each other

A vision for the Imaging Health Record brings together the majority of disciplines that utilize imaging in one form or another. The IHR, when architected correctly, unites all imaging data, eliminates fragmentation of imaging records, and provides streamlined, standardized multidimensional access to all relevant parts of a patient’s record for all pertinent end-users. End-users in the EHR should be able to conjure up any image they need, and IHR end-users should be able to look up any pertinent data in the EHR.
Some vendors today, to some extent (although suboptimally), support this vision in a single environment, delivering functionality for radiology, cardiology, breast imaging, Nuclear Medicine, and orthopedics. Some others have also dabbled in integrating ophthalmology, dermatology, POCUS, pathology, and visible light imaging (photography and videography for wound and burn care, and endoscopy). However, these vendors today reluctantly coexist with one another in an ecosystem that evolved organically over a long time. This massively parallel vendor coexistence often means unnecessary redundancy of functionality.
To avoid these costly redundancies and inefficiencies, the Enterprise Health Record and the Imaging Health Record must be considered indivisible elements of the enterprise IT ecosystem. Neither EHR nor IHR should be regarded as a vassal of the other because they are meant to complete each other to produce a complete picture of a patient’s records and care continuum.
Just for fun, I will now transpose concepts within one of the introductory paragraphs above:
Only together, and flawlessly synchronized with each other, can two pilots effectively control the Jaeger and achieve perfect coordination to fight the Kaiju. Whether two pilots are drift compatible with each other is contingent upon the depth of their connection, and their ability to establish and maintain a focused mental bridge with each other. Only together, and flawlessly synchronized with each other, can the EHR and IRH effectively control the Patient Health Record and achieve perfect coordination. Whether two IT ecosystems are compatible with each other is contingent upon the depth of their integration, and their ability to establish and maintain focused collaboration with each other.