In the late 1990s, radiology societies helped encourage vendor adoption of the DICOM 3.0 standard, a milestone that ultimately sparked a revolution in digital image management. Now, RSNA hopes its Image Share project will do the same for the nascent field of image sharing.
"This is the next revolution from our perspective, enabling standards-based image sharing," said Dr. David Mendelson, chief clinical investigator for Image Share and chief of clinical informatics at Mount Sinai Medical Center. Mendelson is also a member of RSNA's radiology informatics committee, which developed the Image Share concept.
Working with five pilot sites and vendor partners, the project has implemented a patient-centric model for sharing images and reports. Image Share recently began signing up patients at Mount Sinai Medical Center and the University of California, San Francisco. The other three Image Share pilot sites -- the Mayo Clinic in Rochester, MN; University of Chicago Medical Center; and the University of Maryland Medical Center -- are set to begin enrolling patients in the next couple of months.
Image Share had its genesis in discussions a few years ago by RSNA's radiology informatics committee, which would frequently discuss mechanisms for image sharing at its meetings. Attention during those talks focused on CDs and their associated problems and workflow issues, Mendelson said.
At the same time, the Integrating the Healthcare Enterprise (IHE) initiative yielded a number of relevant integration profiles for image sharing, including portable documents for imaging (PDI) and import reconciliation workflow (IRWF).
"Lots of work had gone into identifying the right way to do things, but people weren't always doing things the right way," Mendelson said. "In the course of those [radiology informatics committee] discussions, we often talked about [how it would] be wonderful to do Internet-based sharing through what has now become called the cloud. And these conversations were going on four or five years ago, before the cloud was an idiom."
With the enactment of the American Recovery and Reinvestment Act (ARRA) in 2009, the committee members realized that the U.S. National Institutes of Health (NIH) would be receiving some of those funds, and thought that their ideas would fit well with the healthcare information exchange concept that was being promulgated at the time, he said.
The RSNA then submitted a proposal to develop an image sharing network that would be based on standards using IHE profiles and that would be consumer-directed through personal health records (PHRs). Realizing that more than half of the U.S. was capable of shopping online or banking online, the committee believed it could develop an application that was equally easy to use to give patients ownership of their images and reports.
"We were really answering the call [to provide] greater patient control of their health record," he said.
In 2009, the NIH's National Institute of Biomedical Imaging and Bioengineering (NIBIB) decided to provide $4.7 million in funding for Image Share to build a secure, patent-centric image sharing network based on open-standards architecture. As work began, RSNA subcontracted elements of the project to several academic sites and a few vendors.
Ultimately, the success of Image Share will depend on adoption by the vendor community, Mendelson said.
"It's not something in the long-term that we want the RSNA to own or control," Mendelson said. "It's something that we'd like to set guidelines for and substantiate the activity, and let the vendor world run with it, pretty much like what happened with DICOM 3 and PACS."
How it works
There are three elements to Image Share: an Edge Server at each local radiology site, a clearinghouse in the cloud, and a PHR to receive the images and reports.
The process works in a similar fashion to a banking transaction performed at an ATM. The Edge Server and local PACS represent the bank, while the PHR serves as an ATM, allowing users -- after identifying themselves in a secure fashion -- to receive their images and reports. In a similar approach as used in the banking industry, a clearinghouse serves as the middleman; it retrieves the information from the originating site using IHE's Cross-enterprise Document Sharing for Imaging (XDS-I.b) profile, and provides it when needed to the PHR.
Built by an Image Share development team at the five principal sites, the Edge Server functions as a buffer between an institution's PACS and the Internet, Mendelson said.
"We realized pretty early on that nobody really wanted to attach their PACS directly to the Internet," he said. "It's too valuable a resource to expose directly."
The Edge Server also automates the Image Share process.
"If a patient walks into my department today and says, 'I need my images outside' and they're really asking for a CD, we say to them, 'we can give you the CD, but in addition, would you like to leverage this service?' " he said.
Registration is performed via a simple process on the Edge Server.
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| The patient sign-up process is handled by the Edge Server. Image courtesy of Dr. David Mendelson. |
After registration, patients check off the studies they want from a list and select a password. They are also given a document with an eight-digit code, which they can then enter at home on one of two PHR options. Two vendors are currently providing PHRs for Image Share: LifeImage and Dell InSite One (formerly InSiteOne), but other companies are also interested in participating, Mendelson said.
LifeImage is also the current subcontractor for the clearinghouse. It's possible that a second clearinghouse may also be added in the future, he said.
In developing Image Share, the biggest hurdle was addressing HIPAA and security requirements, Mendelson said. Each site's HIPAA office had different criteria and different issues that needed to be addressed, and effort was placed into making it ultrasecure, he said.
"I would hope that as the world comes to grasp healthcare security in a more uniform fashion, we can make this a little easier, as easy as an Amazon, for instance," he said.
As soon as the information leaves the Edge Server and goes outside a hospital's firewall, it remains encrypted until it arrives at the PHR, where it's de-encrypted so the patient can see it, Mendelson said.
PHR interest
While the PHR concept has generated attention in the past couple of years, the model took a hit with Google's decision to shut down its Google Health platform as of January 1, 2012. Google cited a lack of interest in its decision to exit the PHR business.
With Image Share, Mendelson said he has seen a moderate level of interest from patients since the first release launched on August 1. The service also isn't being pushed that hard yet in order to gain some initial experience and clean up any potential bugs that might pop up, he said.
Further ramp-up will take place in approximately 30 days following the release of a revised edge server package (Edge Server version 1.1), Mendelson said.
The service is paying attention to patient education. At sign-up, patients are given a variety of documents and a help-desk phone number to call if they need assistance during the process, he said.
Because it's a focused-use case and targets a service that patients need right away, Image Share may be a better way to generate patient interest in PHRs than broader PHR platforms like the former Google Health, Mendelson said.
"[The most likely users] are going to be people who have a health problem that needs a lot of imaging and know they have to move those images around," he said. "It's the same people who are using CDs. But it's a population that has a high motivation to have easy solutions."
What's next
The pilot phase of Image Share will run over the next two years. The goal is to have patients embrace the service and collect data that substantiate that success, Mendelson said. Each principal site will also identify three other local sites to get Edge Servers in the coming months.
"We think it may be a little too early, but we'd like to generate data to see if it even suggests reduction in inappropriate utilization through duplication of services due to easier availability [of images]," he said.
In other long-term goals, Image Share organizers believe that the Edge Server could turn into a platform that could aggregate services that need to be aggregated nationally, such as radiation dosimetry reporting.
"If the [American College of Radiology (ACR)] is going to provide a national registry and you just need a local box to report on to the ACR, it's possible that the [Edge Server] could provide that platform," he said.
RSNA has released the Edge Server as open-source, allowing vendors to utilize it and add to it if they want.
"We don't intend in the long-term to market the Edge Server; we think that's a vendor responsibility," he said.
In other upcoming plans, project investigators are testing an ability to provide direct transfer of images, such as in trauma cases.
"An offshoot of this is that each site could directly transfer the images if the patient brings in the same transaction information they would have put in the PHR," he said. "It's a secondary-use case because we would still, in the big picture, want for patients to have ownership of their images in the PHR."
The site-to-site transfer capability and bug fixes will be part of Edge Server version 2.0, which is targeted for a release by the RSNA meeting in November. Version 3.0, which is planned for the spring of 2012, will include a research use case. The RSNA's Medical Image Resource Center (MIRC) Clinical Trial Processor (CTP) application will be merged into the Edge Server.
