Cleveland Clinic: Building the Ultimate Image-Enabled EMR Model

During the last 20 years, imaging informatics has morphed from an island owned and populated by radiology to a series of enterprise systems. The march of progress continues with widespread adoption of EMRs and the increasing role of imaging.

“We can’t have an effective electronic health information system if it can’t move images,” former National Coordinator for Health IT David Blumenthal, MD, observed in January 2011. Fast forward to 2013 as progressive facilities plan for meeting Stage 2 Meaningful Use that includes as one of its objectives: “Imaging results and information are accessible through Certified EHR Technology.”

Cleveland Clinic is one leading healthcare provider that has a very clear vision for the enterprise image management model of the future. They have embarked on a long-term process to develop an enterprise imaging  solution that encompasses all image-generating modalities and departments. Early in 2011, the health system promoted Louis M. Lannum from administrator for radiology imaging informatics to director for enterprise imaging and tasked him with locating images across the enterprise. The ultimate goal? Build a longitudinal imaging record to correlate with the EMR, providing access to clinically-relevant imaging along the continuum of care.

Cleveland Clinic is building an enterprise imaging repository that allows physicians to visualize every patient study, including ophthalmology images, tissue pathology, digital photos, radiology images and more, says Lannum, who detailed the organization’s progress toward an enterprise repository during a session at the annual meeting of the Healthcare Information and Management Systems Society (HIMSS) in February 2012.

The multiyear project started with a radiology imaging roadmap that included a vendor-neutral archive and has mushroomed to approximately 20 multi-specialty departments and a 650-terabyte spinning disk data center, which is replicated offsite.

“Imaging is no longer a radiology silo,” Lannum said. “The most important thing we did was to begin the process by setting up an Imaging Council that meets once a month to review all imaging strategies in Cleveland Clinic.”

The cross-departmental leaders have positioned imaging as a shared strategic resource. “Our strategy is ‘no image left behind’.” Lannum and colleagues devised a plan to identify and capture images regardless of the source and divided imaging data into five categories: DICOM PACS, non-DICOM PACS, standalone DICOM acquisition devices, standalone non-DICOM devices and image-based reports.

Their strategy is comprised of three related parts: an enterprise model, a longitudinal imaging record and cloud-based storage. At the center of this strategy is Agfa HealthCare’s ICIS™, the centralized Imaging Clinical Information System that manages and allows access to meaningful images in the same way that all patient information is managed: via the EMR. The system  includes a group of image management and repository solution stacks that provide a rich suite of image workflow,  capture, store, exchange and access services. The store, or repository, service is delivered via Agfa HealthCare’s ICIS Store service, deployed with an EMC infrastructure. The intelligent data center service consolidates standards-based clinical and diagnostic images and their related data into one centralized patient view. The data center—designed with a high level of availability, security and automation—consolidates multimedia images and information that support an EMR within one infrastructure that is more manageable and less complex to implement and maintain than multiple, less scalable archive technologies. It seeks to improve efficiencies, maximize storage assets and enhance service levels, while reducing overall costs.

Agfa HealthCare and EMC’s technologies within ICIS were developed and tested simultaneously to ensure seamless integration and performance. They include a purpose-built vendor-neutral archive for PACS neutral storage, a DICOM archive and physical storage.

How it works

The ICIS implementation supports the Clinic’s strategy of a single repository and point of access for all medical imaging data across the enterprise, encompassing the wide variety of image information-producing departments that provide patient care.  

Lannum and his team are taking an asset management approach and inventorying imaging including dermatology, pathology, endoscopy and point-of-service imaging. The team opted to focus on “easy” images first. These imaging departments are being equipped with an intermediate device that can produce an outbound DICOM message. Such systems can be interfaced with an EMR, and patient demographics are automatically shared and reconciled. Initial targets include women’s health, ophthalmology and the Digestive Disease Institute, which produces endoscopy images, and C-arm datasets.

As technical issues are conquered, human issues take center stage. It’s critical that providers in image-generating departments adapt workflow to image management and generate an image order to link the patient to the image. If an image is put into the archive without normalizing the demographics with the EMR, it’s nearly impossible to track the image. “This isn’t just about storage,” Lannum says, “it’s about storage and subsequent access.” Image retrieval requires that workflow is modified in a way that allows matching between imaging metadata and the EMR, which ultimately enables future viewing from the data center to any point of care via an easy to operate web-based viewer.  Agfa HealthCare’s XERO® technology viewer provides that critical access service, allowing the rapid retrieval and viewing of images and imaging information within a clinically-relevant context directly via a patient’s EMR screen.

An imaging repository differs from storage, said Lannum. “Storage is just another layer of storage area network. A repository has its own database and is independent of all systems that feed it.”

To date, the project extends across the enterprise and has engaged ophthalmology, ambulatory endoscopy, anesthesiology, anatomical pathology, orthopedic surgery, emergency medicine, women’s health and cardiology. “The list of departments we plan to bring into the effort continues to grow,” he said.

With so many departments and images, the concern over storage space grows, too. This has prompted a move to cloud-based storage as well as an analysis of image retrieval as part of a comprehensive effort to reduce the footprint of the data center.

Cleveland Clinic’s analysis has shown that legacy images from more than three years ago are accessed less than 5 percent of time and after four years retrieval drops to less than 1 percent. However, policies dictate images must be held seven years. Intelligent, cloud-based storage could help the Clinic tame its ever-expanding data center.

Making work (and images) flow

The ICIS solution is designed to deliver an enterprise approach to: imaging workflow, the imaging record, clinical imaging viewer and is fully embedded within EMRs, EHRs, and HIEs.

This system works today and is a solid building block for the future and approach of Stage 2/Stage 3 Meaningful Use, of which the proposed rule states: “more than 40 percent of all scans and tests whose result is one or more images ordered by the EP or by an authorized provider of the eligible hospital or critical access hospital for patients admitted to its inpatient or emergency department during the EHR reporting period are accessible through Certified EHR Technology.” For healthcare networks considering compliance with the goals of Meaningful Use, the time to plan for success ahead is now. Enterprise-wide strategic planning can ensure the easy and smooth access to a wide variety of clinically relevant imaging across the  healthcare system.

“Workflow is extremely important,” Lannum said. “To understand workflow across departments, we built a model that can be applied across departments and accounts for acquisition, management, reporting, storage, and visualization.” Stay tuned.