Patient-directed Internet-based Medical Image Exchange: Experience from an Initial Multicenter Implementation.

RATIONALE AND OBJECTIVES: Inefficient transfer of personal health records among providers negatively impacts quality of health care and increases cost. This multicenter study evaluates the implementation of the first Internet-based image-sharing system that gives patients ownership and control of their imaging exams, including assessment of patient satisfaction. MATERIALS AND METHODS: Patients receiving any medical imaging exams in four academic centers were eligible to have images uploaded into an online, Internet-based personal health record. Satisfaction surveys were provided during recruitment with questions on ease of use, privacy and security, and timeliness of access to images. Responses were rated on a five-point scale and compared using logistic regression and McNemar's test. RESULTS: A total of 2562 patients enrolled from July 2012 to August 2013. The median number of imaging exams uploaded per patient was 5. Most commonly, exams were plain X-rays (34.7%), computed tomography (25.7%), and magnetic resonance imaging (16.1%). Of 502 (19.6%) patient surveys returned, 448 indicated the method of image sharing (Internet, compact discs [CDs], both, other). Nearly all patients (96.5%) responded favorably to having direct access to images, and 78% reported viewing their medical images independently. There was no difference between Internet and CD users in satisfaction with privacy and security and timeliness of access to medical images. A greater percentage of Internet users compared to CD users reported access without difficulty (88.3% vs. 77.5%, P < 0.0001). CONCLUSION: A patient-directed, interoperable, Internet-based image-sharing system is feasible and surpasses the use of CDs with respect to accessibility of imaging exams while generating similar satisfaction with respect to privacy.

Providing formal reports for outside imaging and the rate of repeat imaging.

OBJECTIVE: The purpose of this study is to assess whether providing a formal report for outside imaging reduces repeat imaging. MATERIALS AND METHODS: From January 1, 2006, through December 31, 2011, patients transferred with an abdominal CT from another ("outside") institution that was imported to our institution's PACS within 60 days of the original CT were considered. Repeat imaging was defined as when an abdominal CT performed at another institution was followed by the same study at our institution in the 14 days after import to PACS. The rate of repeat imaging was compared between patients whose outside imaging did and did not receive a formal report from our radiologists. RESULTS: Consecutive patients (n = 10,330) who imported an outside abdominal CT to our PACS were considered. Thirty-six percent (3719/10,330) received a formal report. These patients were 32% less likely than the other patients to undergo repeat imaging (9.4% [350/3719] vs 14% [919/6611]; p < 0.001). The odds of repeat imaging were statistically significantly lower for patients who received a formal report after adjusting for potential confounding variables, including the age of the outside imaging study and the referring specialty (multivariate odds ratio, 0.53; 95% CI, 0.47-0.61; p < 0.001). CONCLUSION: Patients who received a formal report for their outside abdominal CT examinations were less likely to have repeat imaging. Institutions, payers, and policy makers should consider providing and supporting formal reports for outside imaging.

Reducing the rate of repeat imaging: import of outside images to PACS.

OBJECTIVE: Repeat imaging at the transfer of care between institutions is a potential source of overutilization. The purpose of this study was to assess whether importing images obtained at one institution to the PACS at another institution reduces the number of repeat imaging examinations performed, sparing patients unnecessary cost and radiation. MATERIALS AND METHODS: Informed consent was waived for this retrospective study, which included 267 patients who had undergone CT or MRI of the abdomen at our or another institution within 4 months before transarterial chemoembolization. Patients were divided into the following four groups based on the availability of their images from institutions other than ours (outside images): outside imaging performed but images not available; outside images available on CD or film but not imported; outside images imported to PACS; and no outside imaging, that is, all imaging performed at our institution. The rates of repeat imaging in the four groups were compared. RESULTS: When outside images were not available, 72% (13/18) of patients underwent repeat imaging; when outside images were available but not imported, 52% (14/27); when outside images were imported to PACS, 11% (9/79); and when imaging was performed only at our institution, 13% (18/143). Patients whose outside images were imported were significantly less likely to undergo repeat imaging than were both groups whose outside images were not imported (p < 0.001), and their rate of repeat imaging was similar to that of patients who did not undergo outside imaging (p = 0.79). After adjustment for potential confounders, including age, sex, referring institution, and size and number of lesions, the odds that a patient whose images were imported would undergo repeat imaging were significantly lower than those of a patient whose outside images were not imported (odds ratios, 31 for images not available and 9.0 for images available but not imported; both p < 0.001) and were similar to those of a patient who underwent all imaging at our institution (odds ratio, 0.71; p = 0.51). CONCLUSION: Importing outside images to PACS reduces the rate of repeat imaging.

Integrating multiple clinical information systems using the Java message service framework to enable the delivery of urgent exam results at the point of care.

The aim of this study is to determine if network-enabled personal digital assistants (PDAs) can be used to facilitate the timely delivery of urgent radiological exam results by reducing the interval from when the radiologist's initial interpretation is available to when it is first viewed by an emergency department (ED) physician. A web- and Java message service (JMS)-based application was built to replace the original fax-based wet-read procedure. The new system allows radiologists to enter wet-reads from the picture archiving and communication system (PACS) display station and to track discrepancies between the wet-read and final report. It also notifies the ED physicians when exam results are available via the PDAs and permits them to view the full text of the wet-read and final reports from the devices. The new system is compared to the original procedure with the results showing improvements with the wireless method. Furthermore, feedback from a qualitative survey of PDA users was positive, suggesting that PDAs may provide one means for accessing urgent clinical data at the point of care.

Integrating multiple clinical information systems using the Java Message Service framework.

This article describes an application for capturing, delivering, and tracking urgent radiology exam results. Urgent exam findings are entered using a Web form embedded within the Picture archiving and communication system (PACS) display station. The findings are then accessible via soft copy using the PACS display stations, hospital information system (HIS) terminals, or wireless-enabled personal digital assistants (PDAs) or via hard copy printouts that are generated automatically or on demand. Additionally, quality control is performed on those findings entered by radiology residents and fellows, the results of which are used for both performance tracking and educational activities. The application was developed using Sun Microsystems' Java programming language. The Java Message Service (JMS) was used to manage the delivery of findings. JMS provides a robust, flexible framework for exchanging messages between disparate applications. The application is now used for all urgent exams; completely replacing the original paper-based system. The use of JMS provides the necessary level of reliability needed by this application.

Implementing a MIRC query interface for a database driven teaching file.

This paper describes the authors' experience with integrating an existing database-driven teaching file with the RSNA (Radiological Society of North America) Medical Imaging Resource Center (MIRC). MIRC is the product of an RSNA-sponsored initiative to enable medical institutions to share their electronic medical content (images, text, and multimedia) by creating a distributed repository accessible from the Internet. An existing database-driven teaching file, developed by the authors and used extensively by the University of California San Francisco (UCSF) Department of Radiology since 1998, was retrofitted to include an interface for handling broadcast queries initiated by a MIRC query service. These queries take place through the exchange of XML documents via HTTP. After all the storage services have responded, the results are collated by the query service and presented to the user. The teaching file and MIRC interface were developed using the 4th Dimension Relational Database Management System (RDBMS). The integration process primarily involved mapping the "MIRCdocument" schema to the teaching file's schema, translating the actual MIRC query into the internal query language of the database and extending the access control mechanisms of the teaching file to allow public access. A working implementation of the interface required only 3 days of development time, with refinements taking place over several months. Interface development was greatly aided by MIRC's use of well-established Internet standards. This project has demonstrated the feasibility of implementing a MIRC interface on an existing teaching file server.

Implementing a MIRC interface for a database driven teaching file.

This poster describes the feasibility of integrating an existing database driven teaching file with the Radiological Society of North America's (RSNA) Medical Imaging Resource Center (MIRC). MIRC is the product of an RSNA sponsored initiative to enable medical institutions to share their electronic medical content (images, text, and multimedia) by creating a distributed repository accessible from the Internet. A description of MIRC's query/storage service architecture is provided along with an overview of the author's experience with implementing a storage service front end for an existing, database driven teaching file system.

RIS minus PACS equals film.

Web-based integration methods can be used to resolve a fundamental issue in the transition from film to a picture archiving and communication system (PACS): the identification of relevant prior studies only available on film. Even in the most ambitious conversions from a film-based environment to PACS, there are issues regarding prior studies not on PACS. Failure to compare with prior exams is one of the known risk factors for malpractice in radiology. While most commercial PACS systems today have some degree of RIS integration, knowledge of prior studies is usually limited to an awareness of studies in the PACS. On the other hand, most RIS systems today do not or cannot distinguish between studies on film and those in PACS. We made the observation, from a set theory perspective, that in general: Therefore we sought to create a system that would query both the RIS and PACS and reconcile the results using the above set operation. The query is initiated from a display station via the invocation of a Web browser installed on that station. The process of starting the browser is implemented using a scripting language provided by the workstation vendor, though the use of other mechanisms, such as the CCOW (Clinical Context Object Workgroup) or IHE (RSNA Integrated Healthcare Enterprise) interfaces, can be supported by this architecture. The medical record number, which identifies the current patient and is the primary parameter of the query, is passed as part of the URL (Universal Resource Locator) used to launch the browser. Once running, the browser connects to a Web server that hosts a JSP (Java Server Page) page that performs a DICOM query of the PACS and an HL7 query of the RIS, and then collates the results using the set operation described above. Both the DICOM and HL7 functionality are provided by Java-based toolkits developed in house. The results are returned to the client's browser as a standard HTML page with a tabular format detailing which studies are on PACS and which are available only on film. The responsiveness of the system in terms of time required to complete the two queries and display the results was measured. In addition, the number of diagnostic reports, whose retrieval was triggered by the results of the queries, was monitored to determine the overall performance and use of the system. This project demonstrates that, with minimal modification of commercial software, Web-based integration methods exist to enable patient-context sensitive queries from the diagnostic workstation that identify relevant prior studies that exist only on film and are unknown to the PACS. As a result radiologist workflow is enhanced by the elimination of the need to consult a physically separate system for this type of information. In addition, quality of service is improved by providing more accurate and easier identification of relevant prior studies.