Enterprise Imaging: Enabling true image exchange

An effective image-sharing framework is essential to truly functional and clinically meaningful electronic health record (EHR) deployments.

Liberating your clinical images and associated reports from the clutches of your legacy systems and clinical information silos will enable a much broader, patient-centric health delivery paradigm. The good news is that today’s challenge is less about technological limitations and more about defining priorities. How do you meet the mandates of Meaningful Use, prepare for ICD-10, and take on countless other priorities—all while pushing ahead with image exchange as a core strategy?

Clinical data exchange

If we take a step back and look at our illustrious journey toward embracing the EHR, we realize that while moving from analog to digital, paper to paperless, and film to filmless were all critical points on the trip, these systems become so much more valuable if they can “talk” to one another. That is when the true value to clinical workflow can be exponentially realized. The ability to effectively integrate disparate clinical information systems and enable them to exchange clinical data sets the stage for truly patient-centric workflow, as opposed to merely application-centric workflow.

So the battle is not just about moving from analog to digital but about integrating health information systems.That will facilitate access to and retrieval of valuable clinical data, and streamline a robust workflow focused on a broader, longitudinal care record. Such clinical data exchanges could potentially reduce medical errors and lower costs through improved care coordination among all stakeholders— providers, care teams, payers, and patients.

Cloud-based image exchange

Cloud computing is often misunderstood and, particularly 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 providers can choose to embrace these solutions.1

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

It is common knowledge that we need to better define the approach to exchanging medical images and their associated reports. Whether within hospitals, across various provider locations (eg, trauma, transplant, and cancer centers, and radiology clinics) or across wider health information exchanges (HIE), interoperability across disparate silos is critical from a patient care perspective. Without interoperability, we will continue to merely treat one series of images at a time, and not the patient as a whole.


Compared to other industries, such as banking, health care still has a way to go when it comes to adopting clinical data exchange standards and common data frameworks. There is a wide variety of standards. The problem is the way those standards are interpreted.

Indeed, health care organizations, regulators, vendors, and consultants have created numerous standards that vary widely in their purpose and function. There are document standards, such as clinical document architecture (CDA); and conceptual standards, such as Health Level Seven version 3.0 (HL7 V3 RIM). Radiology has worked with the Digital Imaging and Communications in Medicine (DICOM) image standard for years. But attempts to implement and streamline these standards have resulted in many different local, regional, and national clinical data exchanges.

IHE developed a small group of profiles relevant to the exchange of medical documents, including cross-document sharing (XDS) and a profile specific to the sharing of images known as XDS-I. The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC) have pushed for Meaningful Use guidelines that encourage the adoption of these standards.

Although these standards have generally been a tremendous boon to imaging, unlike data exchanges for medications, for example, not enough has been done to encourage true image exchange.

RSNA image share network

Through a grant from the National Institute of Biomedical Imaging and Bioengineering (NIBIB), the Radiological Society of North America (RSNA) created the RSNA Image Share Network, a secure, patient-centric medical image-sharing network based on common, open-standards architecture. The network enables patients to control access to their images and imaging reports through personal health records (PHRs) without having to depend on CDs. RSNA Image Share currently provides services to patients at 5 major medical centers across the United States, and plans are under way to expand the network.

Empowering clinical workflow

Providing true image exchange not only empowers streamlined and coordinated clinical workflow but also improves patient care by ensuring access to prior studies and reports. Ready awareness of and ready access to these studies directly correlates to appropriateness in image study ordering.

Furthermore, almost any connected PACS today can streamline connectivity to electronic medical record (EMR) systems and health information exchange (HIE) platforms via local edge devices or more elaborate cloud servers. Coupled with the emergence of zero-footprint client viewers, this has greatly facilitated access, retrieval, and viewing of images and reports from any application and end-user device, including mobile tablets. An emergency department physician can immediately retrieve an outside study via the cloud, and submit it for an imaging consult to a specialist radiologist on call.

A call to action: Meaningful Use 3

While radiology received the cold shoulder in Stage 1 of Meaningful Use, there was some saving grace in Stage 2, including a menu-set measure for diagnostic image accessibility, clinical quality measures relevant to radiology, and more flexibility in defining encounters. But for a clinical specialty so integral to the running of a health system, radiology measures for now are deemed only optional, not mandatory.

There is no doubt that the ONC could do more to encourage widespread support for an image exchange. Since imaging is critical to all clinicians, the ONC should make accessibility of radiology results through the EHR a core objective. Stage 3 of Meaningful Use should ideally encourage health care providers to offer patients at least the option to have their images and related information (such as dose) transmitted to other health record systems. Image-enabling the HIE should be a priority driven by clinical needs, technology readiness, and regulatory incentives.

Furthermore, many opportunities exist to leverage broader national networks. Surescripts, an electronic prescribing network used by 95% of U.S. pharmacies, could be used by national networks not just to send pharmacy orders from the EHR but also to share imaging reports and links to images across the nationwide network.

The time to enable true image exchange is here, and there is no time like the present.


  1. Shrestha RB. Imaging on the cloud. Applied Radiology. 2011;40:5.
  2. Alford T, Morton G. The economics of cloud computing: Addressing the benefits of infrastructure in the cloud. s.l: Booz A, and Hamilton, 2009.
  3. Rangan K, Cooke A, Dhruv J, et al. The cloud wars: $100+ billion at stake. Technical report. Merrill Lynch. 2008.
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