DIGITAL REPRESENTATION Images are sometimes more important than the written report. A visual with a narrative creates a more comprehensive patient record.

If a picture is worth a thousand words, what is an image in an electronic health record worth? For your surgeons, who nowadays rely on still images and video clips for most every patient, the ability to add crisp, detailed visual information to the clinical narrative is priceless. The inclusion of images into the EHR provides a complement to the operative narrative that results in a more robust summary of the care episode. Photographic documentation improves coordination of care among caregivers and reduces subjective interpretation of the written report.

"Before, you'd get a paper chart and a jacket full of images that would be the story of the patient," says one physician. "Now, with integrating the images into the electronic record, you get a much more comprehensive view of the patient's surgical history."

Challenges of video integration
Your job is to manage the clinical imaging workflow, to make sure your surgeons can view and manipulate the images and video that they capture both during and after the case. Displaying images in operative and endoscopic suites is the easy part. Storing and routing those images to the patient's EHR — and ensuring that your docs have secure on-demand access — is the real challenge.

You'd think it'd be easy to find a comprehensive image management solution that lets surgeons view and manipulate video and images intra-operatively and post-operatively. But there are 4 major hurdles we're still trying to clear.

• First, there are dozens of different image-capture devices in your ORs — scope video, X-rays, ultrasounds, MRIs and CTs. Importing all of these different imaging modalities is technically difficult. You want to find an image management vendor that can get all of these devices to "speak to each other" and store all of these images into one central storage depository.

The whole process is much easier to manage if you funnel all of your image-capture devices into a single integration point.

• Second, you want your system to associate the appropriate patient demographics to the images at the time of room setup. You don't want your OR staff typing patient demographics on the image acquisition device. This needless step creates the potential for data entry error (mistyped medical record number or name, for example). You want a system that supports the integration of multiple image-capture devices regardless of the vendor. Most of today's image management solutions can decipher imaging from a variety of vendor devices, but they can't interpret the patient demographic data unless it's generated from their own device.
• Third, the current processes to share and retain selected images and video are manual. For example, saving video is only possible when written to a DVD at the local acquisition device. This provides limited accessibility and uses disparate storage methods that are often unsecure and unmanaged.
• Fourth, you want to enable secure image access to all caregivers throughout the continuum of care.

Consider a solution that's going to communicate with your scope devices, and store the imaging information as well as patients' demographic information directly into a vendor-neutral archive so that information can be seamlessly integrated into patients' EHRs. Instead of each video-capture device having its own integration path, you want each device to communicate to a single solution and have a direct communication line to the archive. The whole process is much easier to manage if you funnel all of your image-capture devices into a single integration point.

I'd advise against sending images directly to the EHR. For one, it's important from a caregiver perspective to have a longitudinal imaging history so that you can see the patient's history in chronological order. For another, it lets you have a single point of access into your EHR. If you're integrating all vendor solutions directly to the EHR, oftentimes you'll only see the history associated with that communication path or interface.

We've come a long way
"I want that image I want that image." Before video integration, a surgeon viewing video in real time would click the foot pedal to capture an image, and 2 copies would print: 1 for the paper chart and 1 to take to the lobby to show the patient's family. Not long ago, it was considered high-tech to print surgical images, and then scan them on a document scanner for integration into the EHR. Labor and cost-intensive, yes, but it was better than having only still images in the paper chart. What's more, with scanning you can't perform accurate measurements or magnify the scanned image without losing resolution. With image-capture systems, the surgeon goes into the waiting room after cases with his iPad and shows families dynamic images.

We recently implemented a surgical imaging management system in a 5-suite ortho surgical center that does about 4,500 cases a year. They were printing images during the case and scanning them into the EMR. When we were through, they projected we'd save $18,000 and $75,000 in printing and scanning costs, respectively, in the first year. Plus, they decreased room turnover times by an average of 38 seconds. The image management system is able to export the images in a DICOM format — the industry standard. It's stored on a vendor-neutral archive and can be viewed universally. Patient demographics associated with those files are stored in a way that any system can read and interpret them. The image management system is also able to receive a feed of all the scheduled procedures, so staff doesn't have to manually input the patient's information. Once staff pick the correct patient from the worklist, all patient data matches to the EHR. Not only is this faster, but it also eliminates errors.

What's goes into the EHR should be clinically relevant. When you must edit images and video, ideally you'll want to be able to perform it remotely rather than locally on the individual acquisition devices. Providing access to the video and images via a secure centralized image management solution and the EHR eliminates the need to transfer images to portable media or to print images, thereby reducing the likelihood of a HIPAA breach.