Cloud-based image and report sharing continues to expand as standards emerge and security improves.Well connected

About a year ago, 45-year-old Anna Schafer moved from Maine to South Carolina for her job. As she settled into her new home, Anna made an appointment with a highly recommended gynecologist at her local hospital.

At her appointment, Anna filled out the new patient paperwork and as part of her medical history indicated that it had been more than a year since her last mammogram. Seeing this, the gynecologist referred Anna to the hospital's breast imaging center.

Anna had been getting annual mammograms for five years and knew what to expect from the screening exam. But when the radiologist told her about a suspicious spot on the images, Anna welled with anxiety. Her mother had battled breast cancer, and she worried that heredity wasn't on her side. The radiologist would know more once she compared the new exam to Anna's previous breast images. It would take just a few days for Anna's former provider to put the images on a CD and send it through the mail. In the meantime, all Anna could do was wait — and worry.

While Anna is a fictional character, her story is all to real. Every day, patients experience anxiety, delayed care, and sometimes repeated imaging due to inefficiencies in image sharing among health care institutions. But imagine if patients and providers didn't have to obtain CDs for comparison studies. Imagine if hospitals could instantaneously share images while a transfer patient was en route or if patients could send their images electronically to authorized providers. Some health systems have made such rapid image transfer a reality through the use of a platform that many people already use to store and share other types of data — the cloud. And the technology's use in medical imaging is only expected to rise.

Improving Care

Cloud computing involves sharing information through integrated networks over the Internet, making it possible to access the information from any location. Most people regularly use cloud services in some capacity, even if they don't realize it. One of the most common uses is through email programs, like Gmail and Yahoo Mail, which store messages and make them shareable using cloud servers. "In general, people have grown accustomed to cloud services just kind of taking care of data storage and sharing without them having to think about it," says David S. Hirschorn, MD, director of imaging informatics at Staten Island University Hospital in Staten Island, N.Y.

When it comes to sharing radiology images and reports through cloud services, most systems follow one of three models: incorporating image and report sharing into health information exchanges, electronic systems for moving clinical records among institutions; facilitating point-to-point image and report exchanges through PACS connections; or configuring personal health records so radiologists can share images and reports directly with patients and patients can share their records with providers. David S. Mendelson, MD, FACR, senior associate of clinical informatics, vice chair of radiology IT, and professor of radiologist at the Icahn School of Medicine at Mount Sinai Health System, notes that other models, including provider-to-provider exchanges and secure email programs, also exist. "But those programs don't seem to have taken off," says Mendelson, who is also the principal investigator of the RSNA Image Share project, a personal health record-based image- and report-sharing network.

Each image- and report-sharing model has pros and cons, but generally all of the systems carry benefits over CDs. Jonas Rydberg, MD, radiology professor at Indiana University School of Medicine and radiology director at Indiana University Health Methodist Hospital, led the development of the hospital's tristate image transfer system, through which it receives about 10,000 exams and sends about 5,000 exams each month. (Read an Imaging 3.0® case study about the exchange, which now includes Health Level-7 standards for coordinated report sharing) Rydberg says, "Sharing images and reports through the Internet is much faster, cheaper, and safer than with a CD, which can easily be lost or damaged." He adds that, in addition to streamlining care in general, on several occasions Indiana University Health radiologists have used the health information exchange system to triage patients prior to and during transfer for significantly improved care.

Every day, patients experience anxiety, delayed care, and sometimes repeated imaging due to inefficiencies in image sharing among health care institutions.

Overcoming Hurdles

While sharing images and reports through cloud services sounds innovative, it's actually been possible for more than a decade. In fact, Canada and some European and Asian countries, have had exchanges in place for years. Systems have been limited in the United States, though, because each image exchange vendor has traditionally transported its digital data by employing different internet protocols. As a result of these proprietary methods, different vendor systems couldn't talk to one another, Mendelson explains.

"Finally, organized radiology took a stand in the early 1990s and said, 'All vendors must observe a single set of standards' — which ultimately became DICOM3," he says. "Now we're encouraging vendors to also adopt Cross-enterprise Document Sharing for Imaging (XDS-I) standards, which will allow each institution to pick the vendor it thinks is best without having to worry about interoperability for image and report sharing. We believe that using these standards as a common starting point will enable safe, secure, and transparent exchange with a pathway for intelligent technical evolution as internet technology advances." To that end, the RSNA has extended its Image Share project to include a technical validation program.

Security is another reason cloud-based image and report sharing has been slow to proliferate. Especially with the Health Insurance Portability and Accountability Act (HIPAA), institutions are sensitive about anything that could compromise patient data. But Rydberg contends that multilayer encryption makes sharing personal data through the internet safe and points to banking as a model. "Banks are constantly sending information and people are constantly logging into their bank accounts and buying stocks and bonds through the internet," he says. "Digital image and report sharing is no less secure."

For Gary H. Dent, MD, president of South Georgia Radiology Associates, security was a primary concern when his group developed its image and report exchange in 2008. "Obviously, security was in the forefront of my mind because when you do 400,000 exams a year, any breach is going to be huge," Dent says. "But we feel confident in our system's security because our platform partner performs a risk analysis and audit every year. They think about HIPAA probably even more than I do — it's their entire business."

Crossing Borders

As the hurdles associated with web-based image and report sharing fall, more exchanges are expected to form. Ideally, a national exchange would allow institutions to easily share medical data, so patients, like our exemplar Anne, could take comfort in knowing their medical records are easily accessible anywhere. But Mendelson thinks state laws may hinder the development of a national exchange. "In the worst case, we'll have statewide networks," he says. "So, as a patient, you would join the one in your state, and it would talk to the networks in other states — making it possible for you to share your records with institutions across the country."

By Jenny Jones, Imaging 3.0® content specialist

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