Like an airline pilot’s instrument panel, EMRs strive to give you an overview of your patient’s condition, treatment and progress. The EMR’s text narratives and numerical data help you understand your patient’s history and discern progress.
But text and numbers, as valuable as they might be, omit a major clinical element. Without images, your understanding of a patient’s status will likely be incomplete.
Today, you can review clinical images in a variety of ways. You can see them on the imaging device itself, such as an OCT, or print a copy of the image. You can also use a separate image management system, which consolidates pictures from various devices into a central repository. Alternatively, you can view images within an EMR system.
While each of these methods has its advantages, using an EMR provides distinct benefits. For example, it can aid in diagnosis and assist in patient education; it can also leverage the investment that you’ve probably already made in a big-ticket EMR, as some 72% of ophthalmologists currently use such a system, according to a February 2018 report in JAMA Ophthalmology.
In this article, you will learn how EMR systems integrate images from various types of imaging equipment and get a better sense of how this can improve your diagnostic abilities, aid efficiency and promote patient education
VARIETY OF IMAGES
A large variety of imaging types can be included in today’s EMR systems. For instance, one EMR vendor, Compulink Healthcare Solutions, supports more than 350 equipment interfaces. Another vendor, Modernizing Medicine, asserts that its EMR, called EMA, can connect to more than 80 imaging devices. These instruments need to be networkable and have a database of images the vendor can monitor, along with an option to export images, DICOM files or text-readable PDFs.
Dan Montzka, MD, retinal specialist and owner of Gulf Coast Retina Center, Clearwater, Fla., imports images such as fundus photography, OCT, fluorescein angiography and B-scan ultrasonography into his EMR — IntelleChartPRO, by Nextech, a company for which he serves as chief medical officer.
DIRECT AND INDIRECT
Various methods exist to get images from an imaging device into the EMR, but the method can vary based on the systems used and how the data is exported.
The main idea, says Josh Koontz, associate product manager at Modernizing Medicine, Boca Raton, Fla., is to make the process “super simple” for the user so that image management doesn’t impose major changes on anyone’s workflow.
Paul Gallogly, MD, Retina Care Specialists, LLC, Palm Beach Gardens, Fla., is the ophthalmology team lead for the posterior segment at Modernizing Medicine. “You don’t want to have a lot of clicks” to get to the image, he notes.
Generally, methods can be categorized into direct and indirect, says Heather Bush, Ophthalmic and ASC EHR product director at Compulink. With the direct method, the user clicks a button and then the image is loaded directly into the EMR. With the indirect method, which typically requires more clicks, the image is first placed into a file, which can then be uploaded to a DICOM worklist or perhaps rendered as a PDF, and is imported into the EMR, Ms. Bush notes.
AIDING DECISIONS AND DIAGNOSIS
Viewing an image in the EMR can aid diagnosis. For instance, using a “compare mode,” Dr. Gallogly says he can view an image from a previous visit for a patient and analyze it next to the present image. Also, a “sync mode” provides the ability to pan and zoom two pictures in the comparison viewer at once, thus honing in on the same anatomic location on both. Dr. Gallogly uses these functions on Modernizing Medicine’s EMA EMR. Users can access the “compare mode” in various ways, including clicking on thumbnail images or clicking on a button when the user is already in full-size view mode.
The ability to view, with the click of a mouse, the last few visual fields for a patient is a huge benefit, notes Ms. Bush. Dr. Montzka says it’s important to “look at the efficiency and speed that you can review past data, because that really dictates our decision making.” Images in the IntelleChartPRO EMR, for example, are “very much totally integrated into the clinical information,” he says, appearing along with text on a single summary screen.
And reviewing the image has benefits that notes alone do not. For instance, in a patient with macular degeneration, Dr. Montzka says he can review a previous fundus image for a subtlety that now has become more pronounced. “Whereas in the past I might have looked at what I wrote about an image, now I’m looking at the actual image,” he says. “I really prefer looking at the raw data than my interpretation of that data.”
For physicians with multiple practices or office locations, EMRs with integrated imaging can offer the capability to share images across different locations. Dr. Gallogly uses his EMR at three offices. If it’s more convenient for a patient to see him in one of the other facilities, he can bring up the patient’s image at any of them.
Another example is Nextech’s “Shared Care” feature that allows a physician who uses the IntelleChartPRO EMR to exchange clinical information, including images, with other providers who also use IntelleChartPRO. For instance, if Dr. Montzka is seeing a patient with wet AMD and wondering if the finding is new or old, he can see the actual image from another practice.
On a related note, some EMRs allow you to view images on a mobile device such as an iPad. Dr. Montzka says that can be helpful if he wants to view an image on evenings or weekends.
Besides aiding diagnosis, having images available within your EMR can improve your patient education efforts.
Dr. Montzka regularly reviews images with his patients using a large-screen monitor. “Patients really love to see these images,” he notes. For instance, with a patient with macular degeneration, the patient can see fluid resolve over time from multiple injections. “It really gives them understanding of why they’re getting all these treatments,” he says.
Dr. Gallogly, who also shows patients images on monitors, agrees. “Part of imaging a patient is to make the correct diagnosis, but part of it is to educate the patient as well.” Showing them the improvement by using images gets a lot of buy-in from the patient. “It’s really a powerful tool to use.”
Vendors also provide the ability to annotate images, a feature that Dr. Gallogly praises. With his EMR, he can make notes on a fundus photo indicating the location of a lesion and send that version to the referring doctor. He can also mark up the image and save a copy of the original, unedited file, as well.
IMAGE SIZE AND QUALITY
Since image files can be large, does this pose a problem in transferring one from an imaging device to the EMR? It appears that EMR vendors have worked hard to ensure that speed of transfer is not an issue. Christina Lantz, Compulink Specialist at Vision Care Specialists Inc., Denver, Colo., estimates that it may 30 seconds from the time an image is taken to when the doctor can view it with a patient.
Ms. Bush admits that large image files “can tax an EHR system.” Depending on how the files are stored, the more images you have can increase backup time and slow the system. However, you can avoid such issues with a well-structured system setup. Compulink, says Ms. Bush, provides a way to place images in a separate “background file” so there is no slowdown in processing speed or backups.
Another concern involves the quality of the images themselves. Jeremy Wolfe, MD, owner, Associated Retinal Consultants in Royal Oak, Mich., says that his EMR doesn’t give him the picture resolution that he needs for patient care, so he still views images on his practice’s image management system. For the physicians in his practice, “we like to have the richer data set.”
An EMR, notes Dr. Wolfe, may compress an image and degrade the quality he needs to see details. It also may not offer the ability to scroll, magnify, pan or compare files, as he can with an image management system. And storing an image in a uncompressed format could cause the EMR to load slowly.
Dr. Gallogly notes that not every EMR prevents a loss of resolution when the image is viewed in the EMR.
Dr. Montzka, the originator of the IntelleChartPRO, said that he wanted to create a more physician-centric EMR and one that was focused on the point of care. Instead of spending a great deal of time looking at a computer screen, he wants to “maximize the eye contact with my patients.” With images integrated into the single “instrument panel” of your EMR, he says that is a more achievable goal.
Those who have invested in EMR systems, or are looking to do so, may consider integrating this technology with their imaging devices in order to increase both efficiency and diagnostic ability. OM