EAS 5850:

EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Enterprise
Imaging
Informatics

Dr. Tessa S. Cook

Introduction to Module 4

Lesson 1: What is Enterprise Imaging?

Lesson 2: Enterprise Imaging

Governance and Strategic Planning
EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

What is
Enterprise
Imaging?

Dr. Tessa S. Cook

 What is Enterprise Imaging?
Strategies, initiatives, workflows
Implemented across a healthcare enterprise
Applies to all clinical imaging & multimedia
Enhances the EMR

Roth CJ et al. J Digit Imaging (2016) 29:530–538

This Photo by Unknown Author is licensed under CC BY-NC-ND

Why We Need Enterprise Imaging
Radiology has solutions for digital imaging
The EMR is not image-friendly
Other subspecialties have unique needs
Different workflows
Images of sensitive body parts Why not
DICOM?
Vulnerable populations This is why!
Patient privacy
Requirements for Enterprise Imaging
Governance
Strategy
Infrastructure
Single
Enterprise viewer Separate unique enterprise-
systems wide
Content
system
Image exchange

Roth CJ et al. J Digit Imaging (2016) 29:530–538

EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Enterprise
Imaging
Fundamentals

Dr. Tessa S. Cook

EI Fundamentals

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Requirements for Enterprise Imaging
1) Governance
2) Enterprise Imaging Strategy
3) Enterprise Imaging Platform (Infrastructure)
4) Clinical Images and Multimedia Content
5) EHR Enterprise Viewer
6) Image exchange services
7) Image analytics

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Enterprise Imaging Governance
Decision-making body
Variety of stakeholders – clinical, administrative, IT, (research)
Individual departments
Unique culture
Infrastructure, maybe?
Separate IT support
Custom workflows
Enterprise Imaging Strategy
On paper!
Strategy & roadmap including all
requirements
Critical look at existing systems
Department approach 🡪
enterprise approach
(Culture)
Enterprise Imaging Platform

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Enterprise Imaging Platform
Vendor neutral
archive (VNA)
Agnostic to
Modality
Modality vendor
Specialty
Service line
Viewer

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Enterprise Imaging Platform
Standards-based
image acquisition &
transfer across
departments

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Enterprise Imaging Content and Use Cases
Diagnostic imaging
Procedural imaging
Evidence imaging
Image-based clinical
reports

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Viewers, Image Exchange, Analytics
Different stakeholders need Users Capabilities
viewers with different levels of
functionality Reporting +
Diagnostic
advanced
imagers
features

Image exchange – both import

Advanced
and export Surgical
image
subspecialists
manipulation

Analytics – of both image data Patients, Basic image

and meta-data referrers, etc. viewing
Enterprise Imaging: An Unsolved Problem

No single right way – multiple wrong ways

DICOM vs. non-DICOM
Governance & strategy
EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Enterprise
Imaging: 10
Strategic Steps

Dr. Tessa S. Cook

Enterprise Imaging: 10 Strategic Steps

Primo H et al. J Digit Imaging (2019) 32: 535-43

If You Had to
Build An
Enterprise
Imaging
Solution, How
Would You Do
It?
The Challenge for Radiology

Perceived as experts in imaging

”Radiology already did it; we’ll do it for

you too”

”Radiology faced this problem too; can

we help?”
Step 1: Access to
all the Images and
Documentation for
Better
Decision-Making
to Impact Patient
Outcomes
Step 2:
Demonstrate
How EI Is a
Powerful
Strategy
Step 3:
Understand the
Specialties and
Their Clinical
Workflow
Challenges as It
Relates
to Imaging
Step 4: Create a
High-Reliability Healthcare
Strategy to Improve
Quality of Care
and Patient Safety with EI
Step 5:
Demonstrate
How EI Can
Reduce Costs
Step 6: Show How EI Can Help Enhance Patient
Experience
 Placeholder for PiP on
camera

Step 7:
Enhance the
Work Life of
Caregivers
Step 8:
Develop EI
Governance
Step 9: Implement an EI Project
Step 10: Understand Cybersecurity
for EI
Conclusions
Imaging informatics is not exclusive to
radiology

Enterprise imaging can impact care delivery,

caregiver experience, patient experience

Return on investment (ROI) in many forms

EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Orders- vs.
Encounters-Based
Imaging

Dr. Tessa S. Cook

Orders- vs. Encounters-Based Imaging

Cram D et al. J Digit Imaging (2016) 29:559–566

Orders- vs. Encounters-Based Imaging
Orders-Based Imaging
Order for
Patient goes Exam Images to
radiology
to radiology performed PACS
exam

Encounters-Based Imaging

Non-radiolog
Patient goes Non-radiolog
y imaging Images
to outpatient y imaging
deemed go...where?
encounter performed
necessary
Orders-Based Imaging
What we’ve been discussing so
far in the course
More traditional approach
Imaging in a separate location
from other care

Cram D et al. J Digit Imaging (2016) 29:559–566

Encounters-Based Imaging
Performed during an office/clinic
visit
Imaging not the primary purpose
of the visit
Complements other
documentation

Cram D et al. J Digit Imaging (2016) 29:559–566

Universal Goals of Imaging Workflow

Unique identifier associated with all images

acquired
Images connected to the correct patient
Any necessary image manipulation capabilities
Image viewing within EMR or associated viewer
Identification of imaging type and anatomic location
Associated report/note
Necessary meta-data Cram D et al. J Digit Imaging (2016) 29:559–566
Unique Challenges in Encounters-Based Imaging
If you had to place an order, how would you do it?
Which body parts are you imaging, and how do you
describe them?
How does that metadata get linked to the
images/index/accessed later?
Where are the images stored?
How are they indexed/searched/accessed/viewed later?
Who reports these studies and where?
How does the clinician bill for these images?
Cram D et al. J Digit Imaging (2016) 29:559–566
EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Enterprise
Imaging
Governance

Dr. Tessa S. Cook

Enterprise Imaging Governance

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Enterprise Imaging Governance

Roth CJ et al. J Digit Imaging (2016) 29:539–546

The Goal of Enterprise Imaging
Governance

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Requirements of the Governance Group
Stated mission & charter
Long term strategy
Authority to make & communicate decisions
Accountability to leadership groups and stakeholders
Clearly defined scope
Links to medicolegal, risk management, credentialing, radiation safety,
other relevant policy/regulatory groups

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Centralized Enterprise Imaging Governance

MODEL A

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Distributed Enterprise Imaging Governance

MODEL B

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Culture of the EI Governance Group
Requires alignment between senior leaders in different areas of the
organization (clinical, IT, etc.)
Spectrum of tech maturity levels & use cases
Variety of stakeholders - may not have the best pre-existing
relationships
“We did it this way and it works so you should do it also”

Roth CJ et al. J Digit Imaging (2016) 29:539–546

EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Four Arms of
Enterprise
Imaging
Governance

Dr. Tessa S. Cook

Four Arms of EI Governance
Technology
Information
Clinical
Financial

Unique but intersecting aspects

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Enterprise Imaging Technology Governance
Everyone associated with technology – EMR,
PACS, interface, modalities, network, etc.
Weigh migrations/ongoing IT activity against
KTLO (keeping the lights on)
Cost/benefit of solutions for storage, backup,
business continuity, disaster recovery
Lifecycle management – data, hardware, software
Capital requests vs. operational requests

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Enterprise Imaging Information Governance
Managing information to support the
organization’s strategy & operations
Image data + metadata
Association to standards (LOINC,
SNOMED-CT, CPT, ICD-10, etc.)
Clinical, research, education use cases
Patient privacy
Data security

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Enterprise Imaging Clinical Governance
Important stakeholders to inform experience of working
with images daily
“Death by a thousand mouse clicks”
ROI not necessarily measured in cost savings
More effective multidisciplinary conferences
Image-enriched patient record
Straightforward billing, regulatory compliance, etc.
Accessible data for accreditation & medicolegal needs
Roth CJ et al. J Digit Imaging (2016) 29:539–546
Enterprise Imaging Financial Governance
Project prioritization towards highest yield
Scoring rubric – cost, revenue, patient/worker satisfaction, safety,
Not just ROI but also ROH (return on health)
Who bears the cost?
Individual departments – potentially unfair
Enterprise as a whole – “the cost of doing business”

Roth CJ et al. J Digit Imaging (2016) 29:539–546

Enterprise Imaging Governance
Enterprise imaging is tricky!

Governance is critical
Stakeholders
Scope
Priorities
Transparency
EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Technical
Challenges of
Enterprise
Imaging

Dr. Tessa S. Cook

Technical Challenges in Enterprise Imaging

Clunie D et al. J Digit Imaging (2016) 29:583–614

Technical Challenges in Enterprise Imaging

Hospital workflow designed around DICOM

Visible light images (photos, digital path, etc.) do
not neatly fit
Need enterprise imaging platform

Clunie D et al. J Digit Imaging (2016) 29:583–614

This Photo by Unknown Author is licensed under CC BY-SA

Enterprise Imaging Platform

Roth CJ et al. J Digit Imaging (2016) 29:530–538

Integration with Departmental Imaging Systems
Central archive removes burden Departments using endoscopes,
from individual departments microscopes, digital cameras
DICOM-based departments Not natively DICOM – either need
Will have PACS, DICOM to be DICOM wrapped or collect
Modality Worklist, well-defined demographics via HL7 ADT
metadata Pre-existing medical
photographs
DICOM wrapped or imported with
metadata
Clunie D et al. J Digit Imaging (2016) 29:583–614
Source Devices
Imaging modalities Technical considerations
FDA-regulated Data fidelity
Image compression
Digital photography Appropriate displays
Viewing environment &
Technical considerations affect ambient light
interpretability and clinical
decision-making
Clunie D et al. J Digit Imaging (2016) 29:583–614
Visible Light Imaging Devices
Consumer devices Medical photography
Turn off automatic correction Dedicated team with specific
White balance equipment and training

Red eye Important for high volume

services, e.g., ophthalmology
Blemish removal
Standard protocols by clinical
Use flash
service line

Clunie D et al. J Digit Imaging (2016) 29:583–614

EAS 5850:
EAS 5850:
IMAGING
IMAGINGINFORMATICS
INFORMATICS

Workflow
Challenges in
Enterprise
Imaging

Dr. Tessa S. Cook

Workflow Challenges in Enterprise Imaging

Towbin AJ et al. J Digit Imaging (2016) 29:574–582

Workflow Challenges in EI
1. Workflow
2. Patient identification
3. Information needed in an image
4. Reporting
5. Metadata
6. Legal concerns
7. Mobile devices

Towbin AJ et al. J Digit Imaging (2016) 29:574–582

Workflow in EI
Unique to each imaging
department in the enterprise
Radiology: RIS, PACS,
orders-based
Elsewhere: EMR, ?archive,
encounters-based
Reconciling different workflows
into one cohesive system

Towbin AJ et al. J Digit Imaging (2016) 29:574–582

Patient Identification in EI
Images must go to the right Non-DICOM images – no header
patient record – now what?
Workflow reminders to add
DICOM header patient info to images

Fields for various patient Sticker/bar code on every

demographics image

EMR 🡪 RIS 🡪 DICOM modality Use HL7 ADT to mimic DICOM

worklist 🡪 images modality worklist

Towbin AJ et al. J Digit Imaging (2016) 29:574–582

Information Needed in an Image for EI
Measurements Patient positioning
Standardized in DICOM (pixel Standardized in diagnostic
sizes) imaging specialties (e.g.,
Rulers for non-DICOM images? radiology, cardiology)

Color Others should at least annotate

images with body site
Less critical in nuclear medicine
Very important in dermatology!

Towbin AJ et al. J Digit Imaging (2016) 29:574–582

Reporting in EI
What’s the purpose? Requirements
Interpretation of images Bidirectional linkage
Functional data during procedure No report duplication
Description of patient visit Accessible where needed in
Which comes first? the workflow

Diagnostic imaging: images

Diagnostic
Other specialties: patient imaging Documentation of
encounter patient findings
Towbin AJ et al. J Digit Imaging (2016) 29:574–582
Metadata in EI
Body Part Department
Radiology body part descriptions Less important in radiology
don’t work for EI Across enterprise – critical!
”Humerus” rash? Need standardized names
“Abdomen” infection? Imaging Source
Procedure Description Modalities are well defined
Radiology study & series names Digital cameras?
Equivalent in encounters-based Patient-generated images
imaging?
Towbin AJ et al. J Digit Imaging (2016) 29:574–582
Body Part Labeling for Enterprise Imaging

Towbin AJ et al. J Digit Imaging (2021) 34:1-15

Legal Concerns & Mobile Devices in EI

Patient privacy & access control

Maintaining images
Video
Image fidelity
File format
Clinicians with PHI on their smartphones

Towbin AJ et al. J Digit Imaging (2016) 29:574–582