Imaging Informatics: Essential Tools for the Delivery of Imaging Services David S. Mendelson, MD, Daniel L. Rubin, MD, MS There are rapid changes occurring in the health care environment. Radiologists face new challenges but also new opportunities. The purpose of this report is to review how new informatics tools and developments can help the radiologist respond to the drive for safety, quality, and efficiency. These tools will be of assistance in conducting research and education. They not only provide greater efficiency in traditional operations but also open new pathways for the delivery of new services and imaging technologies. Our future as a specialty is dependent on integrating these informatics solutions into our daily practice. Key Words: Radiology Informatics; PACS; RadLex; decision support; image sharing. ªAUR, 2013 he health care environment is undergoing rapid A BRIEF LOOK BACKWARD change, whether secondary to health care reform Radiology information systems (RIS) and picture archiving (1–3), natural organic changes, or accelerated T and communications systems (PACS), commonplace tools, technological advances. The economics of health care, are relatively recent developments. In 1983, the first American changes in the demographics of our population, and the College of Radiology (ACR)–National Electrical Manu- rapidly evolving socioeconomic environment all contribute facturers Association (NEMA) Committee met to develop to a world that presents the radiologist with new challenges. the ACR-NEMA standard (5), first published in 1985. In New models of health care, including accountable care 1993, the rapid rise in the number of digital modalities organizations, are emerging (4) . Our profession must adapt; and the parallel development of robust networking technol- the traditional approach to delivering imaging services may ogy prompted the development of digital imaging and not be viable. Despite the challenges, there are new opportu- communications in medicine (DICOM) 3.0 (6). nities presenting themselves in parallel. There are new and Before RIS and PACS, consider how one viewed images, exciting information technologies (ITs) to offer our patients including cross-sectional exams of several hundred images. that can contribute to improving their health and that can How were they displayed, archived, and moved about a position our profession to better tackle the challenges that lie department? We had film, dark rooms, light boxes, multi- ahead. changers, and film libraries requiring numerous personnel. We will argue that new informatics tools and developments How were copies provided for consultation? How did can help the radiology profession respond to the drive for clinicians see the exams they ordered? Historical exams were safety, quality and efficiency. New research realms, both often stored off site and not available for days. Exams were clinical and molecular, require sophisticated informatics tools. often ‘‘borrowed’’ and out of circulation or out right lost. The health of the individual and an emerging focus on popu- How did one manage an office or a department, schedule lation health require IT solutions. Wewill start with a descrip- exams, and bill for one’s services? These steps took place at tion of some fundamental informatics building blocks and a much slower pace than today. progress to explore new and rapidly evolving applications Our new technologies have been ‘‘disruptive’’. Certain jobs of interest to radiologists. have disappeared (eg, file room clerks). The number of ‘‘schedulers’’ has usually diminished. The number of radiol- ogists required to read a defined volume of exams has Acad Radiol 2013; 20:1195–1212 diminished, as PACs has resulted in increased productivity. From the Department of Radiology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029 (D.S.M.); Department of Radiology and Medicine (Biomedical Into the Future! Informatics), Stanford University, Stanford, CA (D.L.R.). Received May 22, 2012; accepted July 11, 2013. Based on a lecture delivered at the Annual meeting of the Associations of University Radiologists 2012 titled: Imaging We are in the midst of another paradigm shift. The rapid Informatics: Essential Tool for Regional Models and Increased Efficiencies emergence and improvement of networking technologies (Clinical Environment in 2020). Address correspondence to: D.S.M. e-mail: [email protected] are fostering this change. ‘‘Cloud computing’’ encompasses ªAUR, 2013 new technologies and services that are often the basis for http://dx.doi.org/10.1016/j.acra.2013.07.006 the developments that we will discuss here (7–9). This term 1195 MENDELSON AND RUBIN Academic Radiology, Vol 20, No 10, October 2013 encompasses a wide variety of services that are available over a existed, computed tomography (CT) and magnetic reso- network, often the Internet, and can include access to nance imaging, before the firm entrenchment of DICOM. hardware platforms and applications. In health care, security However, the archival and transport of those images were and confidentiality are of particular importance. Cloud manual and chaotic until vendors uniformly subscribed to computing has started to strongly influence the world of this standard. The same applies to radiology information radiology. In addition, wireless technologies, including systems (RIS). Health Level Seven (HL7) is the means of smartphones and tablets, are quickly becoming tools used communicating much of the textual and numeric data, daily by radiologists and clinicians. Though we will not deal including demographics and reports. One vendor’s system extensively with portable devices, one should recognize that can be interfaced to another’s because of these standard many of the applications we describe here will find their protocols. way onto such platforms. While HL7 and DICOM 3 are probably the best known There is also a rapid increase in processing power available standards in our industry, there are other standards that systems at a reasonable cost. This has enabled several technologies use to provide interoperability. Sometimes there are multiple to appear at our desktops as well as on portable devices. standards available to accomplish a given task. Engineers A standard desktop computer can deploy voice recognition are familiar with all the relevant standards but historically dictation systems with self-editing. Postprocessing solutions have needed to build custom interfaces to allow systems can be run on off-the-shelf equipment. These are services to exchange information because the standards were not that required extremely expensive processing 15 years uniformly adopted. Integrating the Healthcare Enterprise ago and were affordable to only a few. Many applications (IHE) (10) is an organization with the goal of achieving are being delivered as ‘‘server-side’’ solutions. Here, the transparent interoperability. IHE has multiple domains that workstation (or local client computer) almost becomes a examine common health care workflows and the available ‘‘dumb terminal,’’ with most of the processing performed standards. Voluntary collaboration on the part of vendors on a more powerful central server. The end-product is and end-users results in the development of ‘‘IHE profiles.’’ distributed to the local workstation. Server technology These profiles describe a means of applying a group of stand- itself is rapidly changing. We are in the era of the ‘‘virtual ards to a given workflow. When vendors agree to follow these machine’’; one server hosts the equivalent of multiple stand- profiles, the result is transparent interoperability between alone servers, optimizing the processing power of that single systems (11). This is true plug-and-play functionality resulting device. in reduced costs for everyone. Radiology Practice: Current State and into the Next Standardized Terminology Decade We need a standardized vocabulary (also called terminology We order, schedule, interpret, report, archive, bill, and share or lexicon) if we are to develop smart systems capable of (exchange) the data we generate. We then close the circle by executing transactions, interpreting reports, and performing performing quality analytics and research on this data to data mining. Some examples will illustrate the need for a radi- improve our performance and advance our knowledge. We ology lexicon/terminology. educate trainees and certified radiologists. Table 1 lists these How can we measure the report ‘‘turnaround time’’ for processes and some of the informatics tools used to perform radiologists in a practice? Today, this is difficult without a these tasks. We will review each of these activities, starting standardized terminology. Does ‘‘turnaround time’’ refer to with the informatics tools that enhance our abilities to address the time from order entry to final signature or exam comple- the challenges we face. tion time to the time of a preliminary dictation or some other combination? INFORMATICS TOOLS: THE FUNDAMENTAL This became a problem for the ACR in establishing its BUILDING BLOCKS Dose Index Registry. The ACR wished to collect and com- Here we will discuss the technologies used to build radiology pare dose data regarding ‘‘head CTs’’ from participating radi- IT solutions. Many of these will reappear later as we discuss ology practices. The ACR discovered that more than 1400 specific solutions and their role in a radiology department or names were associated with ‘‘head’’ or ‘‘brain’’ and