When it comes to building imaging systems for healthcare clients, there are many obstacles to overcome. Only a few of these are technical. The rest are complex needs that relate specifically to the healthcare industry.
While document imaging and workflow have made major inroads in the corporate world, things are more disjointed in healthcare. The biggest concern at the moment is reducing costs by increasing efficiency.
Technology can reduce administrative costs, improve provider-to-payer communications and improve the quality of patient care.
Common design problems include:
1. Islands. Most hospitals are seen as islands of automation. They use imaging technologies to streamline departments and eliminate mountains of paper. The problem is that most departmental systems don't talk to each other. They use separate, not distributed, databases. This is changing, slowly. As larger vendors enter the market, and the industry consolidates, a large number of big customers are awakening to the benefits of wide-scale integrated automation.
The ultimate goal is the "electronic patient record." This has no direct analogy in the corporate world. The ideal electronic patient record lets any authorized person access any portion of a patient record. The radiologist can see the patient's history and medical / surgical records. The internist could access an abdominal CT scan.
2. Radiology. This is different. If you think image and fax files are large compared to text files, they're nothing compared to medical images. A chest X-ray is about 10 megs. A comprehensive CT scan (with 100 images at 1/4 MB each) is huge. Legal and medical issues prevent files being compressed if there's the slightest chance data integrity could be compromised. Radiology has unique and demanding requirements on storage space, network bandwidth, display characteristics and desktop processing power.
3.Performance. This is key. Medical professionals are used to getting their information instantly. Their paper-based records are usually delivered by an assistant in advance. They expect imaging systems to do this as well. While the advance arrangements are different, doctors expect the computer to access and display information immediately. Many imaging system designers write algorithms so a patient's records are downloaded to the viewing station as a background task before appointments. This helps eliminate processing bottlenecks.
4.Interface. In healthcare (like most industries), the user interface is crucial when it comes to getting the system accepted. The situation is more complicated because the interface has to handle text (name and address), chart data (EKG results -- this year and last year), image data (before and after X-rays), etc.
The most successful designers have spent time with radiologists, internists, nurses and back-office personnel to make their software work the way these professionals work. When looking at systems, find a site already doing document imaging that wants to expand by adding a radiology information system or a picture archiving system. Another path to success is to look for customers who are already doing "soft-copy" viewing of radiology images, instead of film.
You'll find the user interface is usually well accepted and the corporate culture is on the way to becoming networked-computer tolerant. Several imaging vendors and users are now experimenting with "browser-based" tools. Browsers remove many of the platform and network specifics from the user equation. Add-ons and plug-ins often add functionality to a LAN, intranet or the Internet. Dome Imaging Systems (Waltham, MA, 617-895-1155) has released a Web browser optimized for medical imaging.
5.Authoring tools. These are important because any imaging system for the radiology department that generates reports should let a physician non-destructively mark up images as well as reference regions of interest in any clinical study. Being able to reference only the most relevant two or three X-ray images in a diagnostic report is important. Newer computer-based imaging tools let you include cine-loops (little movies replaying spatial or temporal sequence of images -- a common application in cardiology and pulminology) and imaging applications that take advantage of a computer-based system's strengths.
6. Security. Privacy is a major concern. This comes up often in meetings with clients. While an integrated patient record system makes all records available to appropriate users, these records are also available to inappropriate users. Many medical imaging systems offer security and have several levels of access to protect patient privacy.
7. Shifting buying influence. In the past, individual departments bought imaging systems. Today, healthcare providers are centralizing control. Decision-making is moving from departmental (physicians) to corporate (management and IT professionals). Vendors must address compatibility, support and interoperability issues concerning different departments. Imaging systems must be open and standards-based.
While these issues seem daunting, there are products and technologies that address the needs of end-users, integrators and developers. DIMPL from Dome Imaging Systems is a powerful, extensible software architecture specifically designed to image-enable a wide variety of medical applications.
DIMPL pipelines let you create runtime efficient, reusable and customized image-processing applications consisting of producers which feed data into the pipeline and filters which process the image and send the results to display, memory or other output devices. DIMPLX is a newer version of the C-callable library which uses Microsoft's ActiveX to provide an easy interface to an underlying DIMPL library.
ActiveX controls let you create a high-level, reusable object with useful generic behavior. The control can be passed to another developer who can use it as a building block inside a programming tool. Most major Windows-based tools for C/C++, Basic, Pascal, etc. provide this support. General purpose ActiveX tools for image enabling high-level applications are available from AccuSoft (Westborough, MA 508-898-2770) and Lead Technologies (Charlotte, NC 704-332-5532).
Applicare's (Alphen aan den Rijn, Netherlands, 31-0172-449111) RadWorks is a modular line of medical imaging software applications for Windows NT. Different modules address image acquisition (scanning and frame grabbing), transmission across WANs and image display on many high- and low-resolution workstations.
Imnet's (Alpharetta, GA 770-521-5600) Electronic Information Warehouse is a three-tiered, open architecture that consolidates all of the information within a healthcare enterprise, and includes facilities to capture, store, retrieve and display documents electronically. Imnet's MedVision module provides for the exchange of image information between radiology systems and a corporate health/patient information system.
ISG Technologies (Mississauga, Canada 905-672-2100) offers the Imaging Applications Platform, a set of visualization building blocks for both radiology applications and surgical planning. The radiology software addresses a range of viewing needs from more simple nursing workstations to complex manipulation stations in the radiology department.
Mitra (Waterloo, Canada, 519-746-2900) focuses on applications and toolkits for image archiving, gateways to hospital information systems and products for telemedicine. PACS Broker is the suite of server-based company tools for integrating radiology imaging systems to the rest of a hospital's information systems.
DICOM (Digital Imaging and Communications in Medicine) compliance is required for hardware and software systems in the radiology department. The DICOM 3.0 standard, sponsored by the American College of Radiology and the National Electrical Manufacturers Association, lets medical imaging devices exchange images and associated patient information in a digital format. Unfortunately, DICOM is complicated and still not "plug-and-play".
The base document describes a standard way of formatting images, associated text, and a hardware "plug" to connect to the imaging device. The good news is that you don't have to develop your own DICOM code. Commercially available DICOM tool kits (as well as consulting services) are available from several vendors, including Accusoft (Westborough, MA 508-898-2770) Appli- care, Merge Technologies (Milwaukee, WI 414-475-4300), DeJarnette Research Systems (Townson, MD 410-583-0680) and ALI Technologies (Richmond, Canada 604-279-5422). Let these companies maintain your software library while you concentrate on other tasks.
Wayne Threatt is an image processing specialist at Wainhouse Consulting Group (Brookline, MA 617-975-0297).
