Q&A: Secure image exchange may be closer than you think
Exchanging diagnostic images presents a new dimension of interoperability challenges. However, if all goes according to plan, there will be a secure, open-source image exchange framework on display at RSNA next month, said David S. Mendelson, MD, FACR, who is principal investigator for a National Institute of Biomedical Imaging and Bioengineering/National Institutes of Health contract to set up the framework through RSNA using IHE (Integrating the Healthcare Enterprise) profiles.

Based on results of an IHE mini-connectathon held earlier this month, the demonstration at RSNA is "on target," said Mendelson, chief of clinical informatics and director of radiology information systems at the Mount Sinai Medical Center in New York City. He recently spoke with CMIO about the initiative.

CMIO: How will this image exchange work?
First and foremost, this is to find a way to take images done in any radiology department or imaging center and get them into the cloud, so they are accessible to the patient from a transient cloud archive—or a clearinghouse—and are transferred into a patient’s PHR [personal health record]. From there, a patient would have complete control over the distribution of images and reports, so that whenever any physician or other provider needs to look at a report or images, the patient can sign onto the PHR where they can look at it on-the-fly or can do a full transfer of the DICOM data into a local archive or another PACS system.

There are three parts to this. First is the edge server—ideally, PACS should be able to talk to the cloud, but the reality is none of them can do that in a secure fashion right now, or without adjustment; legacy systems do not ‘talk’ to the outside world.

Second, the clearinghouse, built on an IHE infrastructure, includes an IHE registry, repository and PIX manager.

Last is the PHR. We’ve tried to leverage as much as possible the IHE XDS-I.b (cross-document enterprise sharing-images) profile as the transport mechanism between the imaging center and the edge server. The edge server [is] meant to take images out of your PACS and reports out of a RIS, package it and ship to this clearinghouse in a secure fashion using IHE XDS-I.b.

The clearinghouse is a transient repository. We’re estimating we’ll keep the exams and images there for about 60 days. During that 60 days, it provides the patient with an opportunity to go to register with a PHR if they don’t already have one—they’ll need one that participates in this project—and pull images and reports into their PHR account.

CMIO: What are security components of the project?
We’ve gone to extraordinary lengths for this pilot project. … The XDS profile would permit one to use the patient name and med record number, some demographic information as long as all access is secure. We’ve encrypted those things; instead every patient will be assigned a cryptic multi-digit RSNA ID number. Then we’ll ask the patient to type in a PIN number that’s hidden from us. When they go to their PHR, they will then have to re-enter the RSNA ID and the PIN number to enable  the PHR to be able to go out to the clearinghouse and grab the images.  This is in addition to whatever security the PHR provides.

In principle, you shouldn’t have to do these things, but we didn’t want the patient to have any concern about privacy and confidentiality. In a secure environment, they should be able to use their names to identify these things, and it should be clean. We’ve just gone an extra step here.

CMIO: Are patients looking for this level of security?
Yes. [There are] a significant number of patients out there that say they don’t want any of this going forward because they’re concerned about privacy and confidentiality. We don’t want that to be the show-stopper. We want to put out there a pilot from which nobody can crack the code and find your information.

CMIO: Can you walk us through the RSNA demo?
Attendees will need to register at the IHE showcase booth. At the showcase, we [will] have an instrument that generates (simulates) an exam and attaches [an] attendee’s name for the purposes of demonstration. Once they’ve done that, they stop at the next desk and see what the patient would see in their department. They will register for image sharing at an edge server, just like a patient, and get an RSNA ID and a PIN, and march through the clearinghouse infrastructure. Then we will take them to the PHR on the other end, let them sign into the PHR, enter the RSNA ID and PIN, and get back their report and images. We’ll show them what they can do with the individual PHR vendors.

The goal of the mini-connectathon is to stage the RSNA showcase. Within the last five years of the project, we get partial successes every year, but we find the gaps that people have to clean up between now and the annual meeting. We were about 80 percent successful in what we had hoped to achieve technically. It positions us to do our [RSNA] demonstration.