Linking Your Images to Each Other — And to You

What to consider about image management systems in the age of interconnectivity and interoperability

Linking Your Images to Each Other — And to You

What to consider about image management systems in the age of interconnectivity and interoperability.


The two great technology trends of the previous decade — digitization of imaging devices and a ubiquitous connection to a networked world — developed independently of each other, and were surprisingly slow to merge. But the past few years have been a robust period in which diagnostic instruments, and the medical practices that rely on them, have expanded their capabilities thanks to better use of digitization and connectivity. Software that improves instrument networking both within the practice (interconnectivity) and beyond its walls (interoperability) can yield patient care benefits and practice efficiencies that were previously un available in the analog era.

As you anticipate future uses of ocular imaging, it's necessary to consider how the images you capture will integrate with your electronic medical records — and your busy schedule. Will you be able to access images while away from your instruments? Can colleagues be consulted remotely? What clinical insights could be had when considering the gestalt of a patient's diagnostic data in toto rather than each test result in isolation?

The 2009 Health Information Technology and Clinical Health Act passed into law various carrots and sticks intended to prod greater technology adoption by medical practices. Although the regulatory picture remains opaque, both interconnectivity and interoperability will be essential to success in the digital domain. Several software solutions have emerged and are sure to flourish over the next decade.


A network operated by a Mac is used to remotely control a Windows XP workstation running OCT review software. The configuration allows indirect viewing and analysis of instrument data while the instrument is being used.

Methods of Linking Images

Even if you choose a system that provides interoperability you still have to choose a method of accessing images on a network. Consider these two approaches:

Direct access. This method auto-populates your medical records with data obtained from your diagnostic instruments; you and your staff directly access patient images through the EMR system.

Indirect access. As an alternative, you can view, control or manipulate diagnostic data within your instruments using a system that provides indirect access to your patient records. The indirect system doesn't allow access while someone else is using the instrument, however.

You can, however, circumvent this limitation by using workstation review software, available for many instruments. This allows you to load the software onto exam room computers, providing access to diagnostic data while a staff member or colleague is using the instrument on a different patient.

Another work-around for an indirect access system is to create a remote-controlled workstation that allows you to access data on a server at any time without affecting the use of your instruments. Each doctor can have a remotely controlled computer, permitting access to all data through the configuration of remote desktop connection software on exam room PCs. “I prefer this approach because it doesn't require you to maintain review software for each computer in each exam room,” says retinal specialist Vincent R. Vann, MD, PhD, of Edinburg, Texas.

Dr. Vann operates a Mac-based network but uses easily-obtained software to interact with his PC-based instruments.

He will soon use the iTap software on the iPad to access data produced by OCT, perimetry, ultrasonography, fundus photography and angiography while out of the office.

Below is an overview of systems for linking images and diagnostic data, based on information provided by the companies that sell the systems. Consultation with independent and knowledgeable experts is recommended.

EyeRoute (Topcon)

The EyeRoute system lets you view, compare, organize, annotate and transmit patient images from more than 100 instruments manufactured by Topcon and by other companies. Data from the instruments flow into the Capture Station Gateway, which sends the information to the EyeRoute host server. The server makes the images available quickly via a Web browser, allowing you to view them on a desktop computer, laptop, iPhone or iPad. The browser also can provide data to an EMR system.

The system's AutoSync technology automatically imports exam data from remote locations with seven-point data validation to prevent database errors. You can drag and drop images into referral letters, emails and presentations. Other characteristics include redundant, fail-safe servers that eliminate down time; HIPAA compliance; encryption; latest firewall protection; and usage tracking. EyeRoute's Flash networking software permits instant remote access to all stored information.

Workflow centers around an exam screen list that allows you to select types of images, dates of image captures and patient histories. The screen displays selected images in one window and lets you enlarge images and use measuring tools. With the AnyUp feature, you can compare and enlarge specific images from varying instruments in the same window. EyeRoute also features a diabetic retinopathy telemedicine reading module, iReports, PDF report and other modules to enhance workflow.

Forum (Carl Zeiss Meditec)

Forum, a data management system, integrates data from Zeiss and non-Zeiss instruments to produce a complete, centralized and paperless record. Forum complements EMR systems by providing a robust viewing platform for viewing clinical images and reports. It makes clinical data instantaneously available to you in your office and off-site.

Connectivity is established through an optional EMR license, which creates a seamless link between Forum and an existing EMR system. The interface enables transfer of diagnostic images and reports from Forum to the EMR system. Patient demographic data also can be transferred from the EMR system back to the instrument.

The system is both Mac and Windows compatible. Forum eliminates the need to key patient demographic data into each instrument, preventing charting errors. The Archive component links your instruments, diagnostic images, reports and raw data for synchronization, remote access and data backup. The DICOM-compliant design allows integration of instruments into a single digital data flow that can be seamlessly extended — even into the OR.

The Forum Viewer, a Web-based application, provides immediate remote access to diagnostic data from any computer within your network. This tool is designed to support eyecare workflow by allowing flexible and efficient viewing of diagnostically relevant data.

DigiVersal (Kowa)

All image formats can be stored in the DigiVersal image and data management system from Kowa, regardless of platform. The software compresses images, but not to the point of interfering with DICOM compliance. The system, which interfaces with medical records and non-Kowa instruments, processes slit-lamp, retinal and OCT images.

The system comes with a series of annotation tools, including a feature that lets you mark a copy of an image while maintaining a pristine original version of the image. You can measure cup-to-disc ratio or the distance of a lesion from the macula. The software also provides image-processing capabilities, including a filtering system that allows viewing of the original image and three other filters (red, green, blue) at the same time. Filtered images are linked so you can view the same section of multiple images simultaneously.

The DigiVersal system allows you to search through a patient's records by diagnosis, a series of diagnoses, or by type of image capture. For example, you can search by slit-lamp only or visual fields only, or look at all central images for glaucoma. The system has a Flex option for multiple locations, allowing all images to be stored in a central database.

Symphony Web (OIS)

OIS Symphony takes data captured by a variety of manufacturers' instruments and integrates the data into one format, enabling you to view all of a patient's information on a screen from anywhere instantly. The system, providing access through Web functionality, links with EMR software. Once patient data is entered into the EMR, it flows into the image management system and attaches to each new image that is added to the database. There's no need to input patient information into the instruments, which provide images to the system at full resolution.

To ensure efficiency, images and diagnostic reports are stored separately from the EMR on a server. You can review history, images and diagnostic reports for a patient and, using an instrument's native viewing software, analyze 3-D data. The PerfectView feature combines images from multiple retinal viewing technologies, such as fluorescein angiography and optic nerve head photography, or serial images from the same technology over time. With AutoHistory, you can page through multiple diagnostic reports. The Montage feature combines fundus images into a single color image. The system also lets you search and sort through all images associated with each patient. You can also download images to a computer hard-drive for email communication of patient data.

iViews (Chace & Associates Technologies)

iViews is a premier informatics system for eye care. It allows advanced diagnostic review of images and text via any desktop, wherever the imaging, electronic reports and data are needed for review. The system integrates more than 160 instruments for viewing. iViews works with MS Terminal Services, Citrix and all mobile devices, such as the iPad.

Once processed through the iViews Imaging System into Digital Imaging and Communications in Medicine (DICOM) files, all images and e-PDFs are available for viewing in iViews. The system allows user-customized viewing options, multiple visit dates, serial analysis, side-by-side views and device-specific viewing. Assorted buttons in the viewer can be used to simplify the viewing experience. Once the exams are retrieved, users can easily display, annotate and print all available images and maps.

The instrument databases can be located on the image server and manipulated by review software. You can create buttons for custom grouping, layout and appearance at any time. Custom summary sheets are ready for discrete data tracking. This discrete data can be presented graphically to track changes to data, such as intraocular pressure, nerve fiber layer thickness, central macular thickness or other measurements. iViews can be launched from within most EMRs with preselected patient information. OM

The DICOM Difference

Interoperability suffers greatly if instruments lack a common, universal language. When data formatting varies from system to system, incompatibilities are inevitable. That's why the DICOM standard has recently emerged and continues to grow in prominence. Below are a few advantages:
• Images are no longer confined to a specific system; they remain available even after a device is replaced.
• If the originating system's database gets corrupted, images can still be identified by metadata such as patient demographics retained in the files.
• Images can be stored in an enterprise image archive, making them accessible to authorized personnel via a facility's EMR system.
• Tight integration with an EMR system (e.g., creating a Modality Worklist) simplifies patient progress in the exam lane, to save time and avoid error.
• Image quality obtained by direct DICOM storage is superior to that of screen-capture methods used by non-DICOM storage techniques.

Courtesy of MedFlow, Inc. To learn more, see Case Study in EMR of this issue.