Only a decade ago, a referring physician in need of a radiology report had to wait for the film and report to be processed and sent via courier or mail. While simple, this predigital process was slow, especially for surgeons who have been known to sneak into the file room before an operation and steal film, wreaking havoc on beleaguered file room assistants.

While the dramatic growth of sophisticated PACS/RIS systems has largely stopped radiology thievery, surgeons and referring doctors still cannot grab images when and where they want. Different facilities have different proprietary PACS/RIS and/or HIS systems. Even within the same hospital, an orthopedist cannot simply view a set of images and data processed from radiology with a simple push of a button.

The good news is that vendors, researchers, and the US government are developing new technology for radiographic images and their accompanying patient data to become more portable and collaborative across the sea of proprietary digital platforms. The bad news is that it will take many years before physicians can easily share patient medical records and radiology exams across town—or across the states.

New Portability Trends

Although the sheer scope of implementing universal standards across departments, health systems, the nation, and products is daunting, vendors are still developing more efficient ways to share imaging information, especially with referring doctors.

Most modern Web-based PACS make radiology reports available to referring doctors on a secure server for viewing. Physicians then use a proprietary viewing software to view the images.

While these modern systems are filmless, a drawback is that the proprietary viewing software prevents physicians from having access to reports from any computer. Instead, they can only view images on those computers or workstations that have the PACS system’s viewing software.

Furthermore, for security and technical reasons, referring doctors who work at multiple facilities must receive permission to install the software at each facility, or only view the exam from one location.

Another complaint is that a referring doctor who uses more than one radiology provider may have to install several viewing programs and keep track of different systems for each radiology provider.

With Vision Reach from AMICAS, physicians can read reports and images from a Web-enabled PDA such as a BlackBerry or iPhone.

To address these issues, PACS companies are introducing new methods for radiologists to send final reports and key images to their referrals without the need for viewing software.

Vision Reach, a service from AMICAS Inc, Boston, is one example. Instead of viewing software, Vision Reach sends an e-mail from the radiologist to the referring doctor with a Web link. The physician then clicks on the link, logs in to a secure server, and views the final report and key images. Because there is no viewing software, physicians are able to read the report and images from any PC or MAC, laptop, or even a Web-enabled PDA, such as a BlackBerry or iPhone.

Paul Merrild, vice president of marketing for AMICAS, believes that Vision Reach’s capabilities helps referring doctors who do not want to deal with installing viewing software or who are prevented by their facility’s IT staff from doing so. He said, “With Vision Reach, radiologists can provide a much better service to that referring doc because you’re taking away those barriers.”

Merrild adds that all distributed reading models such as Vision Reach are password protected by either a virtual private networks or over an HTTPS, the secure socket version of Web-based protocols.

Different Facilities, Diverse PACS

While customer service and portability advances for referring doctors is a step toward seamless interfacing, radiologists are also seeking easier transfer of archived studies among radiology facilities that don’t share to the same PACS. Aside from the technical issues of importing noncompatible PACS systems, there are also issues with the HIPAA permissions that must be addressed when transferring old studies. Plus, there’s the risk of infecting one’s system with external viruses.

Mitchel Goldburgh, senior vice president for business development and marketing at InSite One, Wallingford, Conn, believes that security and HIPAA is a large obstacle for seamless portability.

Frequently Used Acronyms in Medical Information Standards and Portability

When information technology (IT) experts discuss the transfer of health care imaging data and nonimaging data (“metadata”) among enterprises and across different information systems, they frequently mention several common acronyms:

  • HL7 (Health Level Seven). Along with digital imaging and communications in medicine (DICOM), HL7 is the most common standard being used today for radiology information systems (RIS) and hospital information systems (HIS) to transfer nonimage patient information. HL7 is a nonprofit organization dedicated to creating an international IT framework and standards for the sharing and retrieval of electronic health information across hospital departments or across the globe. For more information on HL7, visit
  • IHE (Integrating the Healthcare Enterprise). IHE is another initiative by health care professionals and companies. While IHE is not creating new standards, it is developing ways to more widely implement and improve existing standards such as DICOM and HL7. Participating members are collaborating on making a common medical IT framework and protocols for vendors, IT departments, and clinical users. Most major health care companies are participating. For radiology, IHE has issued a number of radiology integration profiles, which are published at
  • NHIN (National Health Information Network) is an initiative proposed by David Brailer, MD, and the Office of the National Coordinator for Health Information Technology (ONCHIT). NHIN is the government entity entrusted with building a national network of interoperable health records. Visit online for more information.
  • RHIOs (regional health information organizations) are small examples of what the NHIN is trying to accomplish on a national level. RHIOs are in use across the country today in both urban and rural areas. They’re typically made up of an organization of separate hospitals that share common IT standards and architecture, and provide digital access to any relevant information about patients in their area. Some RHIOs are funded by the federal government, while others are supported by private industry and state funding. More about RHIOs can also be found on the Web at

—T. Valenza

He said, “You don’t want to have your PACS system open to receive media that could load viruses. So in many hospitals and imaging centers, PACS do not have optical disk drives or disk drives of any sort that are open to external media. That means, operationally, from a clinical workflow, you’re now viewing in your native PACS environment a current exam from a foreign PACS environment or a stand-alone workstation showing a foreign exam in their supplied viewer. That’s not optimal in the clinical workflow.”

As a nondisc and secure alternative, InSite One is offering a fee-per-study service called InDex Link. InDex Link allows multiple sites with different PACS systems to share a common DICOM server.

The service works by each facility contracting with InSite One as a HIPAA business partner first—thereby complying with HIPAA regulations. Then, when one facility requests an exam from the other facility, the exam can be digitally “pushed” or exported into the InDex Link’s shared server. Next, the receiving PACS looks at the worklist on the shared server and pulls up the exam.

Mitchel Goldburgh, senior vice president for business development and marketing at InSite One, said, “The benefit of InDex Link is that it’s in the native PACS format, and obviously is much more symbiotic of the normal clinical workflow, because they’re viewing the study on the normal clinical workstation.”

InDex Link can support up to five facilities, with access to patient data controlled by the original facility.

Sharing Images in Real Time

When radiologists want to confer with a subspecialist or a peer inside one’s group, that physician may be in another part of the hospital or at another imaging center, miles away.

Philips Medical Systems, Andover, Mass, recently introduced a suite of custom tools through its partner, Primordial, Astoria, NY, on Philips’ iSite PACS. One of these features is an instant messaging system that can share images instantly.

For example, if Dr A wants to confer with a neuroradiologist, rather than call the remote radiology center to ask if Dr B or Dr C is available, the system allows the radiologist to see which neuroradiologists are currently logged on. Dr A can then click on the neuroradiologist’s name, Dr B, and send an instant message with the image in question. When Dr B receives the message and clicks on the link, his screen will match Dr A’s screen. The two can then either confer on the phone or, if enabled, through microphones through their computers. When finished conferring, Dr B can simply close the screen and return to the exam he was reviewing before the conference.

While these new offerings by PACS vendors are helping radiologists in their current workflow, it does not address the need for truly seamless interfacing among different departments, different hospitals, and different states.

RHIOs and the Future

PACS would not be the powerful tool that it is today without government, industry, and researchers working together to create the DICOM standard.

An even more daunting effort is now under way by the National Health Information Network (NHIN). Its goal is to make it possible for a patient’s medical records to be available from anywhere and from any medical system in the United States. As part of this effort, the NHIN has provided guidelines for regional health information organizations (RHIOs).

RHIOs are essentially a small-scale model of the NHIN’s goals. They generally consist of health care providers in a particular city or rural area working together to implement a common IT standard and architecture in order to share patient information.

RHIOs have so far found it difficult to achieve their goals. A recent study by Harvard University researchers, published in Health Affairs, reveals that 25% of the initial 145 RHIOs that were formed have failed, and that only 20 of the 145 programs have successfully shared information.1

The problem appears to be poor funding. The report said that 40% of RHIOs rely primarily on grants and only 5% report posting a profit. The study’s co-author, Ashish Jha, said in a press release, “Either we have to create the right market conditions or have much greater public investment, but the vision of a national health information network is unlikely to come to fruition without one or the other.”

Julia Adler-Milstein, the study’s lead author, added, “These findings suggest that nationwide electronic clinical data exchange will be much harder than what many people have envisioned. The expectation has been that we will have RHIOs throughout the country that bring together all the providers in their region and engage in comprehensive data exchange. In reality, we’re seeing few established RHIOs, and those that are established have only a small number of participating groups exchanging a narrow set of data.”

Merrild at AMICAS is not surprised by the difficulty in making RHIOs successful. He said that the exponential growth of so many different PACS companies over the last 10 years has made it difficult for institutions—and PACS companies—to settle on one single solution.

He said, “When you think of having this nirvana of having all this data in one place or another, one of the big challenges is everybody’s got one of these systems now, and one of their critical requirements is making sure that they have access to all their historical data. As a radiologist, you want to have 5, 10, 30 years, depending on the study, at your hands. That’s a huge amount of work. Over time, I think we are going to get there, but it’s beyond the 5- or 10-year time frame.”

Tor Valenza is a staff writer for Medical Imaging. For more information, contact .


  1. Jha AK, Orav J, Li Z, Epstein AM. The inverse relationship between mortality rates and performance in the hospital quality alliance measures. Health Affairs. 2007;26(4)1104-1110.