Tom DeLuca, manager of imaging management systems, Johns Hopkins Hospitals, Baltimore, Md.

Because Johns Hopkins Hospital, Baltimore, is such a large and decentralized institution, giving clinicians timely, unfettered access to radiology images on film was once a profound challenge. Historically, the department has deployed films to 18 film libraries and reading rooms around the sprawling, 22-acre hospital campus. The purpose of this effort was to situate images near the departments or office areas of the clinicians most likely to need them. It was a good idea, but the logistical difficulties of coordinating film movement among so many branches proved greater than expected, in the end; the desired benefits failed to materialize fully.

This led the hospital to explore another, better option: taking images produced by digital modalities and, instead of printing film as before, simply embedding them within an existing, enterprise-wide electronic medical record.

Ordinarily, this approach would require integration between the electronic medical record system and a picture archiving and communications system (PACS). When this course of action was being considered, however, Johns Hopkins Hospitals’ journey toward full PACS implementation had only begun. The institution lacked anything approaching the kind of full-scale archival capability such an endeavor might appear to demand. That, however, posed no impediment. Tom DeLuca, manager of imaging management systems for the department of radiology, says, “One of the add-on components available for the PACS that we were beginning to acquire, piece by piece, was a web server; its job was to make images available to large numbers of users by way of the computers already in their possession. We found that we could take this web product and begin pushing out digital images to the enterprise through the electronic medical record even before our full PACS solution was in place.” He adds, “In other words, we tackled the problem in reverse order and, for us, it was an ideal way to go.”


Johns Hopkins Hospital is the flagship facility owned by Johns Hopkins Medicine, a $2.7-billion health delivery system that includes everything from a school of medicine to employer health plans. Launched in 1889, the institution has, in recent years, consistently topped U.S. News & World Report’s annual survey of best hospitals. 1 Contained within Johns Hopkins Hospital’s 15 floors are a number of world-renowned specialty centers providing not only diagnosis and treatment, but research and education to advance each field. Across from the hospital and connected to it by an underground concourse is the Johns Hopkins Outpatient Center, where a variety of cutting-edge diagnostic testing and imaging procedures are performed.

The department of radiology oversees imaging services in both the hospital and the outpatient center. Together, both locations account for about 400,000 imaging procedures annually. To handle this volume of service requires the expertise of 65 attending radiologists, who also participate in the supervision and instruction of 30 fellows and 27 residents. As for equipment, DeLuca says, “We have five MRI scanners in three locations and seven CT scanners in five locations. Ultrasound is offered in two locations within the department of radiology, in six locations for our diagnostic imaging division, and in two locations for nuclear medicine. Nuclear medicine has a positron-emission tomography (PET) scanner; that division also performs PET-CT. On top of this, we have an area for fluoroscopy. In addition, we have a pediatric radiology section that performs about 30,000 studies in its own separate diagnostic areas.”

All of the digital modalities channel images into the PACS. Actually, there are components of multiple PACS systems used in ultrasound, general radiology, MRI and CT, and nuclear medicine. The IMPAX Web1000TM EPR Suite integrates the images from all of these systems into the electronic medical record. It operates using a four-processor server.

In a more conventional PACS implementation, clinicians throughout the enterprise would gain access to images by logging into the PACS. “We anticipate a multi-tiered approach to clinician access to images. The electronic medical record web integration is an extremely important part of the process,” DeLuca says, because “providing images in the context of the patient record with the radiology report provides an important service to clinicians and may help them in providing the best of patient care.”

Records that DeLuca keeps indicate that, at present, the electronic medical record system receives about 700 requests per day from users who want to see images in the course of providing care. Physicians can access the electronic medical record at any of the many public workstations deployed on all floors, or they can enter the system from their own desktop or laptop computers.


Populating the electronic medical record with radiology images through the PACS web server was a fairly straightforward proposition, DeLuca says. “The way that it is set up calls for a Health Level 7 (HL7) message to be created each time a study is received by the web server. The message then is disseminated through an interface engine linking it with a database on our mainframe, the location of our electronic medical record data,” he says. “That HL7 message includes the patient’s medical record number and the accession number of that study. Once the database receives the message, it enables an icon in the electronic medical record to become active. When a clinician logs onto the electronic medical record, clicks over to the section containing the radiology reports, and then selects a specific report to review, the icon lights up to indicate that an associated image is available online.” DeLuca continues, “If the clinician clicks on that icon, it launches an embedded web browser that queries the web server for that particular study. Initially, the image that comes up is displayed as a half-screen window, right next to the radiologist’s report. This is done to encourage the clinician to use that report as part of his or her clinical decision making, although the clinician can, at any time, click the window to obtain a full-screen view of the image.”

Once an image becomes available for online viewing in the electronic medical record, it remains for the next 3 months in the Agfa web product’s immediate-access, 240-gigabyte redundant array of inexpensive disks (RAID) memory. After 3 months, the image is automatically shuttled to a long-term archive. “When an image is moved from RAID, the system sends another HL7 message out to the electronic medical record; it changes the icon to indicate that the image is still available, but has been archived, which means that its retrieval could take several minutes (as opposed to the few seconds that it normally takes when it is in RAID). The clinician can have the image returned to online RAID if he or she plans to make repeated use of it at some point within the coming 3 months.” DeLuca notes that Johns Hopkins Hospital plans to increase the size of its RAID to 1.6 terabytes soon, thereby enabling the system to retain images online for a period of up to a year before passing them into long-term archival storage.

Even before that expansion, images are being held in full-resolution format. Lossy compression is not used. DeLuca explains, “We started out doing that, but the clinicians told us that they felt more comfortable with full-resolution images. Whether there is any effective difference in quality is still being debated, but there was a clinician comfort level that had to be taken into consideration. Besides, storage has become economical enough that it was both feasible and reasonable to store in full resolution.”


Perhaps the most intriguing aspect of Johns Hopkins Hospital’s electronic medical record is the fact that it was populated with radiology images long before PACS was fully deployed. “The reason that we approached this backward, making the images available first and then growing into PACS from there, was so that we could avoid letting any more time pass before we could start weaning people from film,” DeLuca says. The strategy of supplying images to the electronic medical record via web server without the undergirding of a full-blown PACS was only a stopgap measure. This was a first step. Where it was supremely effective was in introducing the use of electronic images. Once they got a taste of images available electronically, they soon started clamoring to have their prior studies available online as well.”

He continues, “At first, we did not have the budget for a PACS implementation that would permit us to do that for them. Having the clinicians wanting that capability then helped us gain the across-the-board support necessary to secure the capital budget’s dollars to proceed with the development of a full-blown PACS. It would have been more difficult to win those dollars otherwise. In an institution like this, many projects compete for capital-budget dollars. You really have to make a compelling case to the other departments that your capital-budget request will benefit them, not just you. We needed to make the case that PACS was to the clinicians’ advantage as much as it was to radiology’s advantage.”


The notion of making images available through the electronic medical record dates back about 4 years and was first broached by representatives of the hospital and radiology information technology teams. “As information technology professionals, we are always trying to anticipate needs, and this was no exception,” DeLuca says. The initial movement toward embedding images in the electronic medical record found DeLuca and his colleagues sharing their concept with the hospital’s electronic medical record steering committee, a group consisting mainly of physicians. “We sought to convince them to place this among their priorities,” DeLuca recalls. “After hearing us out, they agreed that it was a good idea and worth pursuing.” So did other decision makers whose consent had to be obtained at levels ranging from middle to upper management. “The nice thing was that this was a project that literally sold itself,’ DeLuca says.

With everyone in agreement to go forward, the only challenge remaining was purely of a technical nature: configuring the systems involved so that they could interact fluently and deliver the data. DeLuca says, “Our electronic medical record was an entirely homegrown product, so our largest challenges were the back-end customizations that had to be done in the mainframe database. For example, we had to conduct reversions in the table spaces of some 15 million records. The strategy for dealing with this was to plan, plan, plan.”

Network connection was far simpler: no major changes in the hospital’s infrastructure were necessary in order to accommodate this electronic medical record enhancement because the enterprise had, only a short time earlier, completed a major modernization and upgrade of its data network. “Our network consists of a 1-gigabit backbone,” DeLuca says. “The server itself sits on a 100-megabit connection, which offers plenty of capacity.”

An operational issue requiring a remedy was the very real possibility that radiologists might not complete their reports and post them for clinicians’ access until long after the associated images had become available in the electronic medical record. “There was concern that such a situation could result in clinicians making less-than-optimal decisions, if all they had to go by were the images and no report of findings,” DeLuca says. “The solution that we came up with was to present the image side-by-side with what we call a help sheet in the event that no radiologist’s report was yet ready to post. The help sheet is basically a list of phone numbers that the clinician can dial to speak directly with a radiologist whose expertise lies in the modality that generated the image in question. We felt that this would encourage the clinician to confer with the radiologist for necessary insights about that image prior to the written report becoming available.” Because the department also has deployed voice-recognition dictation, reports can be written and edited with vastly greater speed. “About 70% of our results are being done now via voice-recognition,” DeLuca says. “As a result, we have cut our report-turnaround time by two thirds from where it was 2 years ago.”


At Johns Hopkins, the chosen strategy for rolling out the new electronic medical record’s capability was, DeLuca says, “to start small and easy by picking off the low-hanging fruit first, which would allow us, at least, to get some images up and available online right away, and whet the clinicians’ appetites for more. We began with MRI studies. They happened to be available in the right format and with the right patient information, so we were reasonably sure that they would be the easiest of all images to put on the system. After that, over a period of a year, we moved all our CT studies online, starting with CT studies done in the hospital’s oncology center. From there, we moved to general CT and then neurological CT.”

DeLuca continues, “Our last step has been moving plain-film studies. In January 2004, we moved all our pediatric diagnostic radiology from film-based imaging to digital imaging, so we are able to bring that into it. At the same time, we brought in the adult emergency department. Now, our emergency procedures, too, are available online. The next step, in progress right now, is bringing in the rest of diagnostic radiology. so that an additional 100,000 general diagnostic procedures will be available online.” To this end, the hospital is currently deploying primarily computed radiography.”


Johns Hopkins Hospital operates a training center through which all new clinicians, whether residents or staff, are brought up to speed on various facets of the institution’s technological armamentarium, including the electronic medical record. “We provided the center with a training system (with support documentation) that the center’s staff incorporated into their electronic medical record training routine,” DeLuca says. “They train some 1,800 people every June and July, at the end of the academic year. By now, all the residents and a large majority of the staff physicians have received training in how to access images and reports from the electronic medical record. The training is not very complicated. Once someone has been shown a few mouse clicks to access the files and tools, the rest is very intuitive.”

End-user feedback has been quite positive, DeLuca reports. “We are finding that adding images to the electronic medical record has greatly diminished one of the chief complaints about our medical residents, which was that they were spending as much as 15% to 20% of their time chasing film or reports, rather than helping patients and being involved in learning,” he says. “All in all, this has been a very worthwhile effort for us, and a solid, practical solution.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.


  1. U.S. News & World Report. Best hospitals: honor roll. Available at: Accessed April 13, 2004.