Keep open mind on image review in EHR

June 16, 2005

One year ago, the French government announced its intention to provide a national shared pa-tient electronic health record (the DMP Project). Invitations to tender for this EHR are expected to be issued this summer. The French Radiology Society (SFR) would like the tendering requirements to include provision for access to radiological images, and the society has been lobbying accordingly for the past six months.

One year ago, the French government announced its intention to provide a national shared pa-tient electronic health record (the DMP Project). Invitations to tender for this EHR are expected to be issued this summer. The French Radiology Society (SFR) would like the tendering requirements to include provision for access to radiological images, and the society has been lobbying accordingly for the past six months.

The SFR has produced a position paper outlining how images could be integrated into the French national shared patient EHR. These are our four key principles:

- Standards. The standards of the national shared patient EHR should integrate DICOM, Integrating the Healthcare Enterprise, and HL7. These standards are applicable not only in radiology, but also in cardiology, ophthalmology, nuclear medicine, and endoscopy.

- Decentralized image storage. The shared EHR should contain only information about the location of stored images. A query from the shared EHR would allow the user to retrieve images from the relevant repository.

- Image review. Network traffic overload could be avoided by use of a hierarchical image access strategy. The images themselves need not be stored in the shared EHR. On review of a report, a referring physician could access relevant images in an appropriate format by using a link to the image repositories locator.

- Deployment of image repositories. Deployment should involve regional or inter-regional strategies (such as the system chosen by the U.K. National Programme for IT), healthcare enterprise strategies (as in the Assistance Publique-Hopitaux de Paris), or professional strategies. The solution should be flexible and also promote quality, security, and continuity of care.

Our plan would ultimately allow any doctor in France to access images from any French hospital or imaging center. But the problem of digital imaging access is actually more far-reaching. We are part of Eur-ope. What would happen, for example, if a French patient decided to undergo treatment in a German hospital?

The true problem at the moment, however, is how to manage data storage and provide access to images all day, every day. In France, DICOM images must be stored for 25 years for legal reasons, and offering free-for-all access to all these DICOM images would seriously strain the network. In most cases, physicians do not need to review every image from a CT or MR series. Radiologists should select significant images to be saved in a "lighter" format, such as JPEG. Physicians can then be given access to these key images, reducing the potential network load.

Access to DICOM images and full imaging series should be restricted to radiologists and certain referring physicians according to clinical need. Once the system is up and running, all specialists will want access to all images, so we have to educate them about why this is not possible.

We have presented our paper to French medical societies that represent specialties concerned with the production and consultation of imaging: oncology, cardiology, neurology, orthopedics. All these organizations have approved the SFR's position. We are also supported by the French Federation of Public Hospitals, the French Federation of Private Hospitals, and the National Federation of Cancer Centers. This wide-reaching support is very important, because the SFR represents people from across the radiological community, not just specialists in informatics.

The paper has been sent to medical imaging companies in France and to companies working in the field of informatics. All of them support the SFR's position. We have also submitted it to the IHE committee, with a view to receiving the group's formal endorsement.

We do not know whether questions of funding will present an obstacle to the government's agreement to the SFR's proposal. My hope is that the system is kept open to images, even if they are not included in the EHR at the start. There will not be sufficient funds to create a completely comprehensive system from the beginning. If we are able to build an open system that permits acquisition of images in the future, we will have been successful. Our goals are really quite modest.

The SFR has sent its position paper to those involved with the DMP Project at the French Ministry of Health, and we are now waiting for their decision.

PROF. FRIJA is secretary general of the French Society of Radiology (SFR), secretary general of the European Association of Radiology (EAR), and chair of radiology at the European Hospital Georges Pompidou in Paris.