Patients are at the center of control in an ongoing effort by the RSNA to standardize the way that medical images are shared on the Internet. In August 2011, The RSNA Image Share Network started enrolling its first patients to have images and reports stored electronically, through an online network accessible anywhere in the world.
The program began in 2009, with a $4.7 million grant from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) within the National Institutes of Health. The goal, within two years, is to enroll 300,000 patients and expand from the five university medical centers currently involved to 28 institutions.
David Mendelson, MD, is chief of clinical informatics at Mount Sinai Medical Center (New York, New York) and is the project’s chief investigator. He says, “We are deliberately going slowly with this first version because we want to find out what bugs there are and what little things we need to fix and patch. I’m very pleased with what we’ve accomplished so far.”
Mendelson says that the program has succeeded in creating a uniform set of transaction and communication standards. The application has been released as open-source software to promote communication among systems. The consortium also has created a series of security layers similar to those in place for bank transactions.
In this case, each institution houses a local server that transmits studies to the cloud. Using the Internet, patients have complete access to their reports and can share them with their physicians. The effort marks the first attempt to build a system for image exchange among disparate systems by leveraging existing technologies and the personal health record (PHR).
Breaking Down Barriers
One of the barriers to the adoption of image sharing has been the question of who would finance intersystem exchange. When the pilot has been completed, its organizers expect the vendor community to sustain the network mostly through fees paid by physicians and health-care institutions. Compared with the current system of sharing images by burning CDs, it should be less expensive and should improve care.
Whether patients will take control of their medical records as expected remains a big unknown. The program only has about 100 patients signed up, so far, and two of the five institutions have yet to receive approval from their boards of regents to participate.
Roderic Pettigrew, MD, PhD, director of the NIBIB, says, "This pilot project is a major step forward and a significant contribution to the sharing of electronic images. With the long-term goal of universal image sharing, this work will address the technical hurdles” and allow image sharing to be done more broadly.
Pettigrew was among those who urged national leaders to include medical imaging in the federal standards for a uniform electronic health record. Until the Continuing Extension Act of 2010 revised the definition of an eligible professional, radiologists appeared to be exempt from the rules (and subsidies) issued by the Office of the National Coordinator.
Pettigrew notes that imaging studies are typically shared today on a CD, which is then delivered by mail, courier, or the patient. This approach can create many problems. In some cases, the data might be incomplete, or physicians might be unable to read them using their viewing systems. Electronic image sharing, made possible through this project, “would circumvent the types of obstacles that exist now because of variations in standards and formats and approaches to making and storing images," Pettigrew says.
Mendelson notes that the current effort should reduce unnecessary medical tests, improve quality, and lower costs, while keeping patients in control of their medical records. “By virtue of using the IHE profiles, which define a common set of standards that all vendors can employ to make interoperability easier to achieve, we begin to move the vendor community away from a proprietary solution,” he says. “We felt we could drive down the cost, so vendors could make an honest living, but it wouldn’t be so restrictive that you had to use a private, proprietary solution. We wanted an open solution.”
The Open-source Component
In essence, the open-source aspect allows software from any provider to communicate with the network. Several image-sharing vendors, as well as Microsoft’s cloud-based PHR, were chosen to provide software and technical support, but having a nonproprietary general solution was chiefly important, according to David Avrin, MD, vice chair of informatics at UCSF Medical Center (San Francisco, California). “We’re supportive of vendors developing products along this line,” Avrin says. “We just want them to be able to talk to one another.”
So far, project leaders have proven that vendors can incorporate open-source code for security purposes, which doesn’t interfere with a competitive market. Mitchell Goldburgh, business-development executive for Dell Healthcare and Life Sciences (Round Rock, Texas), says, “While it’s in the public domain, it still means that any participant has to incorporate that software into its solution. We incorporated the logic and code into our version” of a patient-centered image PHR.”
Goldburgh adds that the project is unique for giving patients the power to manage and archive their PHRs. “Different models are mostly physician driven,” he says. “There are not a lot of patient models. Now, the question is adoption.”
The traditional barriers to image exchange include the will of competitive institutions to cooperate and a strong privacy lobby that (in many cases) resists unique patient identifiers, Avrin says. “We have a triple storm of truly identifying patients, combined with the fact that many community hospitals consider their patient information to be their commercial property,” he explains. “They are not really interested in making it easier for patients to cross care boundaries between them.”
Avrin observes that there’s no reason that medical records can’t be exchanged safely. “You can walk up to an ATM in Italy, identify yourself, and get money out,” he says, “but there’s no equivalent thing for patients in our country—and we’re unique in the developed world.”
David Rosenfeld is associate editor of Radinformatics.com.