What is Enterprise Imaging?

The most commonly accepted definition of enterprise imaging is, “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.”

Enterprise imaging in its broader framework is typically achieved through a single archive. Medical images include standard DICOM images from traditional imaging modalities, such as CT or MRI, as well as visible light images, such as photographs, images from arthroscopes and endoscopes, fundal examinations, and any examination in which the data are displayed as an image and not as text, a graph, or a diagram. All of these images are a part of the comprehensive longitudinal medical record. Incorporation of images into the EMR/EHR supports the concept of the EMR as a single source of truth about the patient’s medical care.1

Evolution of Enterprise Imaging

Healthcare delivery has evolved for the better due to many technological advances that continue today. For some time, the medical sector has been pivoting away from traditional picture archiving and communications systems (PACS, now known as MIMPS) and cardiovascular information systems (CVS) in favor of enterprise imaging and data management systems. The advent of vendor-neutral archive technology (VNA), and especially its accelerated adoption over the past decade, has been an important aspect of enterprise imaging.

Many departments within healthcare organizations such as Dentistry, Pathology, Dermatology, and Gastrointestinal (GI) Endoscopy, produce images in the visible light spectrum. However, in many healthcare enterprises, these images are not easily available through the standard electronic health record, and frequently departments fail to securely digitally archive them. This oversight represents a failure to consider the full effect on patient care and patient experiences, the caregiver’s quality of work, and other factors impacting the quality of service. However, in healthcare enterprises where VNAs have been adopted, the availability of images through a single login has been shown to help improve the quality of interpretation by clinicians, reduce the number of duplicate exams, and improve overall efficiency.

Enterprise imaging refers to the conglomeration of multiple hospitals or radiology departments into a single imaging system that allows the routing of images for the interpretation of examinations. It also has been defined as the incorporation of all medical images into a single archive, frequently integrated into the EMR. While these two practices are different, they are by no means mutually exclusive. The field will continue to evolve, and the practices will converge. Rather than a productivity tool primarily used by radiologists, enterprise imaging has the potential to become a platform of communication for the medical community.

Healthcare’s reimbursement model is changing, as is the role of radiologists. Other departments are incorporating radiology equipment into their own practice. Luckily, the adoption of an enterprise approach to imaging technology instead of a narrow focus on radiology will encourage internal collaboration to face external pressures. Care coordination requires the exchange of clinical care among providers. The ordering of imaging data, the reduction of costs, and the increase in efficiency help improve patient outcomes. Connectivity will help facilitate these leaps forward.

Enterprise Imaging for Clinicians

Enterprise imaging has different connotations for different specialists. Traditionally, each department had its own specialty PACS/MIMPS, but now these disparate systems are connected via a single electronic patient record. The medical imaging records of Cardiology, Oncology, Pediatrics, or other specialties can be accessed by Radiology, as healthcare data is exchanged between different vendor software. The popularization of VNAs has expedited connectivity across healthcare enterprises. Imagine it in a similar light to how the Internet suddenly enabled connectivity between millions of people worldwide, despite different operating systems.

Vendor-neutral connectivity is not the only advantage for clinicians. Automation of complex imaging workflows, including automatic upload and delivery of images from remote locations, provides a substantial efficiency boost. Enterprise mobile imaging, ensuring timely access to clinical resources and patient summaries at point of care, is also a substantial improvement. Mobile medical imaging capabilities mean that clinicians can quickly capture and integrate visible light images, as well as videos and corresponding notes with patient health records. Another substantial boon to clinicians of various stripes in the age of enterprise imaging is the availability of cognitive intelligence and analytics. Some enterprise imaging solutions come with built-in analytics engines, that extract crucial health information from a variety of complex data sources. They can also identify high-risk patients and provide intervention via understanding unstructured clinical notes in appropriate contexts.

From a compliance perspective, well-implemented enterprise imaging platforms are able to securely store and distribute clinical contents in standardized healthcare data formats, while supporting the gamut of clinical specialties. These platforms can also reduce storage costs and provide tools for information life cycle management while offering business continuity solutions and disaster recovery options in the event of catastrophes. Overall, an enterprise imaging platform that is suitably furnished with clinical collaboration and synchronization tools can facilitate substantial leaps forward in efforts towards care personalization and patient-centric service.

Enterprise Imaging for IT Professionals

Building and implementing a successful enterprise imaging platform represents a significant undertaking for an institution. Even a highly-skilled IT team may need help from consultants to implement and complete this type of project.

An IT professional working in a healthcare enterprise should be able to advocate for enterprise imaging as a means of improving patient care and operational efficiency with the following benefits:

  • A patient-centric view of all clinical information on a patient, including images, accessible from the point of care, enables the care provider to make better and quicker clinical decisions. The patient can more easily be kept up to date on their condition and treatment.
  • The availability of imaging data in the electronic health record (and its accessibility by imaging analytics and AI applications) has positive repercussions for macro-level preventative efforts: essentially, managing health on a population-wide level.
  • There are also financial savings that can be achieved as a result of consolidating imaging data into a smaller number of repositories, even with the initial investment required to purchase a new system. Centralized data management cuts maintenance costs significantly, reducing or entirely eliminating the necessity of data migrations.

Healthcare costs continue to rise for the average American, and so do patient expectations related to the convenience of care. A Kelton Global survey found that 94% of patients were of the opinion that their medical data and records should be centrally stored and electronically accessible. Patients are used to having their financial details available at their fingertips and are often dissatisfied when their personal health records are not similarly easy to access and share.

Enterprise Imaging Challenges

Enterprise healthcare providers use medical images to help diagnose disease, document abnormalities or interventions, and guide treatment for their patients. As a point of reference, nearly 40 million MRI scans are performed annually in the United States. In addition to MRI scans, medical imaging includes CT scans, PET scans, ultrasounds, X-rays, arthrograms, myelograms, and several types of mammography. Together, these images help to tell the story of each patient’s clinical journey. Unfortunately, the majority of images are not visible to the team of doctors, nurses, therapists, technologists, and other clinicians caring for a patient. This is true for a number of reasons, most importantly including a lack of systems and workflows required to acquire, upload, and view images. While historically, the radiology and cardiology services have done a good job creating automated workflows for image acquisition and information systems for image distribution, these practices have not been adopted by other services in the hospital.

As images have increased in importance, hospitals have struggled to effectively store, display, and
distribute these images throughout the enterprise. This has remained a struggle because of inefficient workflow and incomplete solutions.

Imaging Workflow Challenges

By analyzing clinical and informatics workflow challenges, enterprise imaging companies can identify potential solutions and opportunities for improved workflow and, ultimately, better patient care. Workflow challenges are usually caused by one or more of the categories below:

  • Workflow
  • Patient Identification
  • Information Needed in an Image
  • Reporting
  • Metadata
  • Legal Concerns
  • Mobile Devices

Every imaging study begins and ends with a workflow. An imaging workflow is the sequence of steps required for the image to be ordered, requested, read, evaluated, and stored. While each medical specialty acquires and uses images differently, most begin with an order placed by a referring physician. Once the order is placed, it is transferred to the Radiology Information System (RIS). The RIS uses the information contained within the order to create a worklist for the imaging modality. Technologists select the patient from the worklist, ensuring that all demographic and order information is correct. After the images are obtained, they are sent to PACS/MIMPS for storage and viewing. Even though this workflow is fairly simple, it is not standard. There are numerous variations to the workflow, depending on the ordering physician and their specialty, the differential diagnosis, the time and location of the clinician’s evaluation, and many other factors.

Hospitals have taken one of two approaches to accommodate the numerous variations of workflows. They either use an order-based workflow or the encounter to drive the workflow. In an order-based workflow, the physician order initiates an automated workflow which includes the unique study identifier and a PACS worklist of patient studies that require review. If an order for imaging is not needed by other specialties, an encounter to drive workflow method is used which creates a unique study identifier and patient worklist. Encounter-based imaging is defined as medical imaging that is intentionally performed during a patient encounter without an associated imaging order. Images are generally acquired at the discretion of the provider.

Healthcare organizations can also experience workflow challenges related to: patient identification, information needed in an image, reporting, metadata, legal concerns, and mobile devices.

Enterprise Imaging and Patient Data Security

One of the most pressing health IT concerns in the industry is patient data security and keeping patient information protected. Healthcare providers represent significant targets for cyber attackers. Digital security threats are constantly emerging from unexpected avenues. One potential downside of an enterprise imaging solution is that a centralized network, while offering substantial efficiency gains and savings on storage solutions, is more vulnerable to cybersecurity threats than networks acting individually. Cyber attacks can quickly spread malware and compromise vital operations. Security must be taken seriously by any enterprise that implements an integrated care delivery network. If a hacker is able to penetrate a network to interfere with a medical imaging acquisition device, its safe operation can be jeopardized, which in turn endangers patient safety. Organizational cybersecurity requires a unified effort from departmental staff and the rest of the enterprise. In a 2014 statement, IBM identified ‘human error’ as a contributing factor in over 95% of all cybersecurity incidents.

Preventing cybersecurity risks involves a delicate, closely monitored, system of people, processes, and technologies. IT departments must work closely with imaging service lines to develop operational plans and strategies that are practical and robust. Imaging staff must be kept aware of best practices and cybersecurity threats. Healthcare organizations are now looking at Artificial Intelligence (AI) to rise to the challenge to help ransomware victims fight back.

Another challenge is the use of different data standards for medical imaging as opposed to non-imaged data. Perhaps the most well-known standard is Digital Imaging and Communications in Medicine (DICOM), which was specially developed by the American College of Radiologists (ACR) and National Electrical Manufacturers Association (NEMA). The DICOM standard applies to imaging equipment, printers, and PACS/MIMPS. This format focuses on the workflow of images, as well as provides protocols for the integration of image data. It also allows functions like film printing or CD burning. 

Enterprise Imaging and HIPAA

Patient privacy is another challenge for enterprise imaging. is patient privacy. In accordance with federal law, all patient data must be protected and HIPAA-compliant. However, one of the main advantages of enterprise imaging is the possibility of sharing significant data banks with other enterprises for the purpose of medical research, AI training, and similar projects. It is essential that, whenever data sharing is offered, identifying information is stripped away to protect individuals’ medical data. De-identification is the most common method of performing this information removal for DICOM data in Cross-Enterprise Document Sharing (also known as XDS-I). DICOM files consist of the image and the header, which contains meta-elements containing patient information, as well as institution and study data. The patient name and number must be obscured in order to prevent the patient from being identified. Hence, de-identification. There are two main approaches to de-identification: anonymization and pseudonymization. Anonymization is considered to be more secure, as it involves removing all sensitive information from the header. The aim of this method is to irreversibly remove any probability of revealing the patient’s identity. Meanwhile, pseudonymization instead replaces identifying fields in the data record with artificial identifiers. The intention of this process is to make the data record less identifying. However, this process is used when there is considered to be a potential for the necessity of tracing the actual identity of the subject involved. Typically, the principal investigator or data manager of a research project would be able to obtain the real identity of the subject, while direct attempts to identify the patient would be avoided. Fields not necessary to this process are instead anonymized.

HL7 Interoperability in Enterprise Imaging

A format that is seeking wider acceptance is Health Level Seven (HL7), intended for general use of electronic health information in hospitals. This format manages non-imaging data, and provides protocols for exchange, management, and integration of clinical and administrative electronic health data. It allows interoperability between different systems including patient administration, laboratory information systems, billing systems, electronic medical record and health record systems, and more.

Looking Ahead: Enterprise Imaging Innovations

The field of enterprise imaging is one with a great deal of potential, but also challenges to be surmounted. It took the U.S. healthcare industry almost a decade to adjust after its investment in enterprise EHR. What’s more, the changing legislative environment and consolidations of hospital infrastructure have quenched enthusiasm for pursuing the kind of complex implementations enterprise imaging needs. There are certain departments and care areas that are, as a general rule, more enthusiastic about converting to enterprise imaging than others. Radiology is obviously one of them, but dermatology, non-invasive cardiology, and standard mammography are also typically receptive to the shift. Departments with which progress for the adoption of enterprise imaging is generally less keen include Core Pathology, Genomics, Multimedia Endoscopy, and Oncology. The reasons why vary, but may involve a lack of leadership, a reliance on committee or cross-department decision making, adherence to a broader contract involving non-software equipment and services, or a desire to use a dedicated best-of-breed functionality in a specific care area.

The long-term impact of enterprise imaging will be substantial and measurable. From small community hospitals to large institutions, enterprise imaging is an essential component of information technology infrastructure that can promote interoperability between different sites. Communication, via image sharing and other means, within the hospital and beyond, is made easier along different points of the care continuum. As a result of healthcare increasingly being absorbed into the Cloud, data migrations will become obsolete. This in turn will reduce the image management role of healthcare IT vendors and place more power in the hands of the providers. Vendor-neutral data will give providers the freedom to innovate their own solutions to progress, rather than obeying the strictures of the vendors. The most tangible benefit of this shift in imaging structure will be better patient care, by virtue of faster diagnosis and imaging orders.

AI In Enterprise Imaging

One of the biggest innovations that widespread enterprise imaging will facilitate is the ‘on-ramp’ of artificial intelligence for diagnostics. Thanks to AI, radiologists foresee a future in which machines enhance patient outcomes and reduce misdiagnosis. As more departments and enterprises consolidate their image management into enterprise imaging health systems, AI developers’ ability to source the terabytes of deidentified images necessary to train their machine learning diagnostician algorithms will increase. The ability of machines to, in a split second, assess a mammogram, MRI, or other medical scan and accurately (more accurately than any human diagnostician) diagnose a patient will represent a significant leap forward in the efficiency of medicine as a whole.

Cloud Computing Solutions for VNA

A Vendor Neutral Archive (VNA) is highly beneficial to the average healthcare enterprise. The ability to switch PACS/MIMPS vendors regardless of image data migration/conversion is highly significant. A cloud-based archive can remove one of the biggest impediments to implementing a VNA: how to store all that data? Data migrations within a cloud are far more painless, and operational and maintenance costs for data storage drop off considerably. There are additional benefits, including flexibility in terms of archive size, and the capability to homogenize data from disparate systems. Data stored on a cloud is much more affordable to recover in the event of a disaster. Furthermore, many solutions are capable of expanding the capability and longevity of a client’s current PACS/MIMPS. In addition, these solutions de-identify personal and healthcare information contained in DICOM metadata and pixels helping protect patients’ confidentiality and offering greater research possibilities.

Imaging on Mobile Devices

In the time since DICOM became one of the imaging data standards, cell phones and other mobile technologies have gone from being unwieldy and limited-use machines to highly sophisticated personal electronic devices capable of not only communication, but imaging, analysis, and more. Healthcare Organizations deserve solutions that make clinical communication and collaboration easier and more efficient. Certain enterprise imaging options on the market also provide opportunities to utilize mobile medical photography and collaboration solutions. These users can capture images, label and organize data, collaborate with colleagues, and import data into the PACS/MIMPS while complying with HIPAA and compliance audit reporting. Data is encrypted on devices at all times and transmitted, processed, and stored on encrypted systems. Photos are automatically organized by patient encounters, and all data can be seamlessly integrated via DICOM or any of the other prevalent data standards. Users are not restricted to capturing medical images; they can also use a smart document scanner to scan printed orders. Additionally, they can use the device to search across PACS/MIMPS and EHR systems from a single search field, loading images for comparison. Nicklaus Children’s Hospital, a leading pediatric hospital in Florida, implemented a mobile medical photography and collaboration tool, which resulted in a faster, more intuitive viewing workflow for clinicians. Images captured at the point of care were automatically added to the EHR. Multidisciplinary teams found it far easier to collaborate, thanks to their straightforward access to all types of imaging through the EHR. The vast compatibility of the system meant that all staff were able to use the mobile devices they were comfortable with while at the same time ensuring a compliant and secure remote solution.

Enterprise imaging is a complex and ever-evolving universe with an important role in enhancing patient care. As the number and rate of imaging studies grows, enterprise imaging enables diagnostics, research, AI-based innovations, and increased productivity. While there are challenges and limitations from legacy protocols to compliance and security, the future looks bright, and we expect enterprise imaging to continue playing an ever-expanding part in the clinical and operational aspects of healthcare systems.

Want to see Enterprise Imaging in action? Learn more about the Unifier platform by Dicom Systems.

References:

1 Petersilge CA. The Evolution of Enterprise Imaging and the Role of the Radiologist in the New World. AJR Am J Roentgenol. 2017 Oct;209(4):845-848. 

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