In the early days of radiology, data entry errors by radiology technologists were common. Their attention, after all, was on the patient and the modality, not the clerical task of typing. To address this, DICOM Modality Worklist (aka DMWL) was adopted.
DMWL took the textual patient and imaging procedure order information entered into the HIS or RIS and made it available within the DICOM image objects, without retyping. The productivity and information quality gains were significant.
The order provides other value than just eliminating duplicate data entry. It represents a work instruction, and is used in scheduling and billing. Where image acquisition is not scheduled or billed for, orders are typically not created.
Enter Enterprise Imaging
As we enter the era of enterprise imaging, there are lessons that we can learn from areas like radiology.
For example, when a photo is captured in a wound care clinic, it has to be associated with the correct patient, but there is other pertinent information that should be captured, such as the anatomical region imaged and any physician observations.
In enterprise imaging, orders are often not placed. In many areas, the imaging is often not the primary task, but one that is used to support clinical work. If orders are not placed, how can we provide the benefit of passing textual patient data to the image capture device or application to reliably associate patient data?
Even if orders are placed, most of the devices and applications used in enterprise imaging cannot accept an HL7 message and do not speak DICOM.
Enterprise Information Interoperability for Enterprise Image Capture
One hope is the adoption of the new HL7 FHIR standard. A Web API, HL7 FHIR is easier to integrate with different devices (e.g. mobile) than HL7 v2.x messaging and DICOM interfaces.
A URL from the EMR that launches the image capture application/device, with information in the parameters, in context can also work. Another method is to use HL7 messaging to populate the vendor neutral archive (VNA) database with patient information, and use an API to get the necessary information.
Metadata and Supporting Information
This still leaves the issue of how to reliably capture the information that goes with the image(s) — notes, anatomy info, findings, etc. In DICOM, the header of the SOP Class object specifies where all this metadata goes. A primary principle of interoperability is a defined format and data scheme, with a clear meaning.
Without the information structure that DICOM provides, the definition of the metadata schema is left to be defined by the implementing vendor. Operational data, for use in analytics and process improvement, should also be captured.
Even when we have a common schema, if the terms used within the scheme are not consistent, we end up spending time doing mappings or integrating terminology services.
To Acquire or Not to Acquire
When enterprise imaging is not “ordered,” what triggers the acquisition of an image? Is it up to the individual care provider to make the judgment? Should a published set of best practices define this? Would the EMR have logic, based on the patient’s condition or care pathway, to prompt the user to acquire the image(s)?
Enterprise Imaging Acquisition Protocols Needed?
If we consider the different types of digital content that can be captured (still, video), the subject in frame (cropping, zooming), and the ability to capture a single image or a set of images, do we need some form of a book of protocols to guide the acquisition? Should certain images contain a ruler to allow the image to be calibrated for measurements?
The Cost of Doing Nothing
If we consider the impact of not having methods to avoid data entry errors, or not having a common schema and terminology, and finally not having a common communication protocol or best practices for acquisition workflows, what hope does enterprise imaging have?
The Future is Now(ish)
This is why the joint HIMSS-SIIM Enterprise Imaging workgroup1 is so important. The space needs to be better defined, with acquisition workflow practices, data formats, schemas, terms and protocols outlined.
If we copy radiology practices into enterprise imaging, it will create too much of a burden on the clinical staff, and they are unlikely to adopt these practices. Clinical staff have little incentive to spend the extra time to capture, index and upload images to the EMR when they are focused on the patient.
But if we ignore the benefits that come with the methods developed over years in radiology, we risk having to relearn all the same lessons again.
With increasing need to share data across different enterprises, the importance of data interoperability is critical.
The knowledge developed by imaging informatics professionals, through on-the-job experience and membership in societies like SIIM, will be crucial in determining the right mix of proven concepts that apply, along with new methods and innovations.
When dealing with such an under-defined space, people often relish the idea of “doing it right this time.” I would urge anyone involved in this space to reflect on what has been accomplished in mature fields like radiology, as there are a lot of “right things” that we may be taking for granted. With a little modernization, we can still get continued value out of what we have already achieved.
1http://siim.org/?page=himss_siim_ei_workgr. Accessed Sept. 10, 2015.
Don Dennison has worked in the medical imaging informatics industry for over 14 years. As a consultant, he is a speaker on medical imaging record interoperability, integration of imaging data within the EMR, and multi-facility integration. He currently serves on the Board of Directors of the Society for Imaging Informatics in Medicine (SIIM) and as chair of the American College of Radiology (ACR) Connect Committee.