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Technical Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper

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Technical Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper J Digit Imaging (2016) 29:583–614 DOI 10.1007/s10278-016-9899-4 REVIEW PAPER Technical Challenges of Enterprise Imaging: HIMSS-SIIM Collaborative White Paper David A. Clunie1 & Don K. Dennison2 & Dawn Cram3 & Kenneth R. Persons4 & Mark D. Bronkalla5 & Henri “Rik” Primo6 Published online: 30 August 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract This white paper explores the technical challenges Enterprise imaging . Enterprise imaging platform . Enterprise and solutions for acquiring (capturing) and managing enter- Image Repository . Enterprise PACS . EXIF . FHIR . Image prise images, particularly those involving visible light appli- file format . Integrating the Healthcare Enterprise (IHE) . cations. The types of acquisition devices used for various Image compression . Image distribution . Interoperability . general-purpose photography and specialized applications in- Medical image sharing . Metadata . Migration . Multimedia . cluding dermatology, endoscopy, and anatomic pathology are PACS . PACS implementation . Photography . Vendor neutral reviewed. The formats and standards used, and the associated archive (VNA) . Visible light . Whole slide imaging . XDS . metadata requirements and communication protocols for XDS-I transfer and workflow are considered. Particular emphasis is placed on the importance of metadata capture in both order- and encounter-based workflow. The benefits of using DICOM to provide a standard means of recording and accessing both Scope metadata and image and video data are considered, as is the role of IHE and FHIR. This paper is one of a series of white papers on Enterprise Imaging developed by HIMSS-SIIM workgroups [1–6]. It focuses on describing and solving the technical challenges Keywords Anatomic pathology . Archive . Dermatology . of enterprise imaging, and does not dwell on the rationale Digital image management . Digital Imaging and for enterprise imaging except to the extent that the use cases Communications in Medicine (DICOM) . Endoscopy . illustrate the technology. The primary area of focus is the inclusion of visible light imaging into an enterprise imaging strategy together with ra- * David A. Clunie diology and cardiology, such as might be found in clinical (as [email protected] opposed to research) use in a typical large adult or pediatric patient care facility, or an integrated group of ambulatory fa- 1 Pixelmed Publishing LLC., 943 Heiden Rd, Bangor, PA 18013, USA cilities that share a common infrastructure. It does not address 2 Don K Dennison Solutions Inc., 205 Fern Cres, Waterloo, ON N2V several other areas that might well be considered appropriate 2P9, Canada candidates for inclusion, but which have highly specific 3 Department of Information Technology, University of Miami Health workflow requirements and are reviewed elsewhere, specifi- System, Miami, FL 33136, USA cally radiotherapy [7] and dentistry [8]. 4 Mayo Clinic and Foundation, 200 First St. SW, Pb 2-58, This paper provides insight into the type of devices, for- Rochester, MN 55905, USA mats, and standards involved, along with the associated meta- 5 Merge Healthcare, 900 Walnut Ridge Drive, Hartland, WI 53029, data needs and communication protocols for transfer. It also USA reviews alternative methods of managing these images and 6 Digital Health Services, Siemens Healthineers, 65 Valley Stream their associated information (metadata), and the common Parkway, Malvern, PA 19355, USA types of systems used. 584 J Digit Imaging (2016) 29:583–614 The companion white paper on enterprise viewing [2]pro- are already present in the vast majority of hospitals, the infra- vides a high level overview of the requirements, technical structure, backup, disaster recovery mechanisms, and gover- challenges, and solutions for query and retrieval of images nance policies can be shared with other departments using VL for display. This paper elaborates on the available standard imaging for whatever purpose [9–11]. protocols and formats that support viewing use cases, but does The technological challenges of enterprise imaging are es- not address the tools necessary for user interaction or specific sentially those of how to leverage, consolidate, or replace to a particular clinical use, nor such issues as color consisten- existing PACS infrastructures with systems using standards cy, speed and responsiveness, appropriate choice of display and technologies that provide access throughout the infra- hardware, or the importance of the viewing environment, structure for all imaging specialties, using the most efficient whether for desktop or mobile devices. and reliable mechanisms. The term “enterprise imaging” was In the interest of interoperability, throughout this paper a initially used to describe extending support for traditional ra- strong emphasis is placed on the use of standards, both formal diology and cardiology modalities to the enterprise [12–14], and de facto. Interoperability between systems from different but today, it is recognized to include all potential sources of vendors is a prerequisite for successful Enterprise Imaging. images, what early pioneers referred to as “multimedia imag- The use of closed, proprietary systems that lack standard open ing” [15, 16]. interfaces, formats, and protocols is eschewed. The enterprise imaging strategy is the roadmap with gov- There are different approaches, patterns, and practices for ernance that defines the approach, the supported services, data acquiring, storing, and displaying enterprise imaging data. formats, and acquisition methods, and provides the underlying These need to be reviewed and understood before making a infrastructure for storing, indexing, and accessing the images choice for a particular deployment. Considerations include the when and where they are needed. installed base of equipment, software, formats and standards, There is no single correct strategy, but there are some com- the relative priority of different use cases and the mixture of mon themes. The first is that there needs to be an enterprise medical specialties, existing workflow practices, the size of imaging platform of some sort. the enterprise, and extramural integration partners. Given the diversity of users, a mixture of different approaches is often needed and centralized components may have to support sev- Enterprise Imaging Platform eral alternative standards in order to be successful. Accordingly, this white paper attempts to be descriptive rather An enterprise imaging platform provides the reliable infra- than prescriptive in its exploration of the possibilities. structure, and integration points, on which the enterprise im- The use of APIs to access image data and metadata will aging strategies and initiatives can be based. A high level view also be considered, as an alternative to handling images (or of a generic enterprise imaging platform is illustrated graphi- sets of related images) using a document-oriented paradigm. cally in an accompanying white paper [3]. At the center of an A comprehensive set of references is provided, since one enterprise imaging platform is an Enterprise Image Repository white paper cannot do justice to the entire field; the lessons (EIR), which provides standards-based image archive infra- learned by both early adopters and mature practitioners are structure and services for storing and retrieving DICOM and expected to be useful to readers. non-DICOM clinical imaging content. It includes an index of the images and content in the archive, along with related meta- information that was recorded when the images were initially Architectural Considerations for Enterprise Image stored. It also usually includes a viewer for viewing the imag- Management ing content in the archive. An Enterprise Image Repository may be a single system or This section makes reference to various source devices, stan- a system that provides a federated view of multiple underlying dards, protocols, services, and formats that will be described components. An Enterprise Image Repository may or may not in more detail later in the paper. be implemented (or branded) as a so-called Vendor neutral An enterprise imaging strategy is needed for acquiring, archive (VNA). To the extent that a VNA may have features storing, indexing, and viewing images from many sources. that may not be required for this application, and to the extent Historically, radiology and cardiology have managed im- that the requirements for an Enterprise Image Repository may ages at a departmental level, though have used PACS and be satisfied by other systems that do not claim to be VNAs, the related systems to provide access to them throughout the en- Enterprise Image Repository terminology is used here. The terprise, and to some extent, beyond the enterprise. Other spe- word “repository” is used in a general sense and should not cialties, particularly those creating visible light (VL) images, be confused with the IHE Document Repository actor (indeed have until recently been less concerned with providing access in IHE XDS-I, images are served by an IHE Imaging outside the department. Since radiology and cardiology PACS Document Source actor, and the Document Repository stores J Digit Imaging (2016) 29:583–614 585 only the manifest of images). The term also serves to empha- content to present information and links to the EMR user to size the enterprise-wide utility of the system. access the content. Surrounding this core infrastructure are standards-based It can be a common discussion,
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