Enterprise Imaging: Cloud-based image exchange

 Dr. Shrestha is the Vice President of Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA, and the Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.

Imagine this: Your recurrent headaches are back, this time with a vengeance. The constant right-sided headache and diplopia for the last 2 weeks has you worried. Your neurologist just ordered a contrast-enhanced magnetic resonance imaging (MRI) scan of the brain and orbits. You then recall that when you had an exacerbation some time back, the other location where you had been treated had done a computed tomography (CT) and magnetic resonance angiography of the head, along with a lumbar puncture.

You log on to your personal health record (PHR), click a button and securely transmit the prior studies along with related reports and history to your current physician. The radiologist on call reviews your priors and related history, and compares these to the current contrast-enhanced MRI. The neurologist reviews the images and reports, and confident that you do not have a worrisome lesion, you are discharged with prednisone 60 mg orally daily for 6 weeks, tapered over 4 months. Even before you have left the hospital, your most current imaging studies are available online in the hospital’s tethered PHR, and you are able to, at the click of a button, automatically transfer these over to your own PHR. Your symptoms soon subside, but you are prepared if things deteriorate.

So what just happened here? Did we just actually focus all of our attention on the clinical conditions at hand, with full awareness of clinical history and effortless access to priors? Did we not have to burn CDs back and forth, worry about proprietary image standards, embedded image viewers, lost disks, and—yikes—let’s not even go there: printed films shipped back and forth between patients and care providers? Did we actually not even have to fret over the possible existence of prior studies and related history, whether within the facility or anywhere else the patient may have been seen before? Did we just empower the patient and give the patient control over his images and clinical content?

Mark yes to all of the above. Mark yes, too, to the power of cloud-based image exchange.

In this day and age of rampant EMR adoption, Meaningful Use and proliferation of Web 2.0 technologies, creating true interoperability that is patient-centric and image-enabled is a virtue that needs to be fully realized.1

Regardless of what PACS (picture archiving and communications system) you have and regardless of the scale of your needs, cloud-based image exchange must be exploited further to meet the needs of an increasingly integrated healthcare delivery environment. Despite some simmering concerns around security, privacy and true costs,2,3 the truth is that we now have the right technologies at hand to enable much more sophisticated, yet simpler ways to enable image exchange—and rid ourselves of the archaic imaging practices of printing film and burning CDs. There is no reason for us to be handcuffed to physical transport, lost media, and proprietary file formats.

There is a clear recognition of the need to better define means to exchange medical images and associated reports. Whether within hospitals, across various provider locations (eg, trauma center, transplant center, cancer center, and radiology) or across a wider Health Information Exchange, interoperability across the growing number of disparate electronic medical silos is critical from a patient-care perspective. Without this, we continue to just treat one series of images at a time, and not the patient as a whole.

Cloud computing is often misunderstood, and of late, over-hyped. However, it offers dynamic scalability, better performance, and economic sense. The availability of different cost models, including pay-per-usage models, opens up possibilities in how deeply and how quickly you want to embrace these solutions.1

There is little doubt that with the advent of accountable-care organizations (ACOs) and initiatives, such as the Medicare Shared Savings program, there is growing momentum to literally reshape healthcare delivery within the next decade. Imaging appropriateness leads the charge in the transformation of volume to value-based medical practice. Radiology’s ability to communicate more effectively around the treatment of care will increase its influence on the appropriateness of the recommended studies and the follow-up studies. Cloud-based image exchange offers a smart way to leverage existing information technology (IT) investments and embrace newer business models.

Cloud-based technologies are liberating images not just from the PACS vendors but from the provider organizations too. Done right, the vendor-neutral capabilities that are enabled can also be extended well beyond radiology to the other “ologies,” such as ophthalmology, pathology, and otolaryngology.

So, resolve this year to explore the most appropriate solution to embrace cloud-based image exchange—and make life simpler for everyone: IT, clinicians, and, most of all, patients. With reasonable cost models enabled by cloud-based deployment options, and maturity in standards (such as IHE/XDS-I)4 as well as actual solutions that have shown their mettle, this is one technology whose time has truly come.


  1. Shrestha, RB. Imaging on the cloud. Applied Radiology. 2011;40:8.
  2. Alford, TA, Morton, G. The economics of cloud computing: Addressing the benefits of infrastructure in the cloud. Booz, Allen, and Hamilton. http://www.boozallen.com/media/file/Economics-of-Cloud-Computing.pdf. Updated October 26, 2009. Accessed January 3, 2012.
  3. Rangan K, Cooke A, Post J, Schindler N. The cloud wars: $100+ billion at stake. Mendeley. http://www.mendeley.com/research/the-cloud-wars-100-billion-at-stake/. Updated May 7, 2008. Accessed January 3, 2012.
  4. IT Infrastructure Technical Framework. Vol. 1 (ITI TF-1): Integration Profiles, Revision 4. 2007;1. Integrating the Healthcare Enterprise. IHE Technical Frameworks. http://www.ihe.net/Technical_Framework/. Accessed January 2, 2012.
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