Wednesday, June 4, 2008

Enterprise Image Management

To me, the basic components of a medical record are Problems, Medications, Allergies, Notes/Reports, Lab/Micro Results, and Radiology results including images. Of all of these, image exchange between different vendor systems and among organizations is the most problematic. Standards exist to transmit the outputs of CT, MRI, Ultrasound and digital xray machines to PACS systems, but most vendors customize or extend the standards to meet their own proprietary needs. Sharing images among providers is essential for coordination of care and efficiency. The path forward to enable image sharing across vendors, modalities, and imaging technologies is not entirely clear.

Creating an archive of all image types used within an organization seems like a logical first step. I've written about the technologies to do this (Cool Technology of the Week ), which involve placing images from all departments into centralized storage devices (NAS, Data Domain appliances, tape or optical disk juke boxes) then storing metadata about the images in data repository which can be accessed by an image viewer which works with all image types.

However, there are multiple possible approaches. General Electric offers an Enterprise Archive product that is capable of managing images from multiple modalities as long as they are DICOM-based. (GE's product can manage multiple image types: jpeg, jpeg2000, DICOM, etc. in the long-term archive. However, if using their PACS Workstations, and/or Web viewer, it must be converted into a DICOM image, if it was not originally acquired in DICOM.) Teramedica's product uses a Service Oriented Architecture to retrieve DICOM and non-DICOM files from storage devices.

Joe Marion, a consultant at BIDMC working on developing a roadmap for cardiology applications and image management recently wrote a blog about these competing approaches.

It's an interesting issue. On the one hand GE is correct - DICOM is the universal standard for image management in healthcare. Utilities are available that can turn other image formats, such as JPEG, GIF and TIF, into DICOM objects. A standard DICOM viewer from GE, Merge-Efilm, or other third party should work reasonable well with DICOM formats.

On the other hand, are Flickr, Facebook and Myspace using DICOM for image management? In the world of web 2.0, you'll find technologies like SOAP/XML for managing metadata and industry standard image formats such as JPEG for storing images.

Who will win - DICOM for all healthcare images OR a flexible service oriented approach to using DICOM for some images and JPEG for others?

We're continuing to investigate the pros and cons. My prediction is that as more and more hospitals discover the importance of unified image management, multiple companies with various technology approaches will enter the marketplace. Teramedica is an early entrant with technologies that enable migration of images among different storage devices, compression based on business rules, and image deletion by replacing large DICOM objects with a small object that when viewed presents a simple graphic stating "Image deleted by policy". GE claims its approach is high performance and ensures data integrity. IBM has its GMAS product which offers a grid of storage for image management. I'm sure that Siemens, McKesson and other PACS vendors will follow soon with their products.

My advice is to assess the features needed in your institution to accomplish image viewing and archiving within the built and bought systems you have. Define the workflow needed by your users. Determine what dependency the archive creates on a single vendor i.e. if the vendor goes out of business or discontinues its product, what will your options be? Joe Marion's blog entry will help you understand the issues.

In the meantime, I'm working at the national level via the 2008 HITSP "Consultations and Transfers of Care" use case which requires we constrain the optionality of DICOM to enable exchange of images as part of a patient's lifetime medical summary. Reducing variability of DICOM will better support plug and play interoperability of images among different vendors.

In 2008, BIDMC's plan is to learn about all the approaches, convene the vendors together, and determine what is possible. You can be sure I'll share those vendor discussions with you via my blog as they happen.
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