A web-based viewing system for enterprise-wide image distribution J.A. Carmichael 1 Historically, healthcare organizations are very departmentalized, relying heavily on disparate processing and information systems. In an effort to support the primary functions of the healthcare system, more and more healthcare organizations are implementing technologies to ensure timely distribution of, and access to, all electronic patient data for all departments, healthcare providers and even healthcare consumers. A major challenge in this respect is the transmission of clinical images. Solutions now commonly referred to as Electronic Patient Record (EPR) or Electronic Medical Record (EMR) systems are attempting to realize the goal of making patient records, including the clinical images, available wherever and whenever they are required. The second step, which is technically extremely demanding, is that of extending the EPR system so that images can be viewed via the worldwide web facilities. In this article, we describe the advantages and technical background of an EPR Electronic Patient Record system, and the Philips EasyWeb system which extends the advantages of EPR to include image distribution. However, the challenges facing a healthcare organization implementing an EPR system are considerable, requiring an unprecedented level of interoperability, connectivity and planning between departmental processes and different information subsystems. Effective use of available standards such as HL7, DICOM and image compression, appropriate technology and skilled technology partners is of paramount importance to the successful implementation of any EPR system. As a major supplier of both IT products and medical imaging systems, Philips is in a position to provide the support required for the wide range of images and imaging technologies in use, as well as those envisaged for the near future. The technology used in this environment is based on the current HL7 and DICOM standards. In the future, the capabilities of these standards will have to be expanded, and extended with new technologies and interface mechanisms based on XML, CCOW etc. Initiatives such as IHE (Integrating the Healthcare Enterprise), instigated by health professional organizations, health providers and the industry, will drive these technologies in such a way as to provide consolidated information at the clinical desktop. EPR systems transmit patient records, with their images, throughout the enterprise. The next step is to extend the system so that images can be viewed via the worldwide web. EPR (Electronic Patient Record) Complete EPR integration The EPR Electronic Patient Record or Electronic Medical Record system ensures enterprise-wide availability of patient records, specifically those involving medical images. Its principal application is in ward-bound healthcare, but it is also of particular value in radiology, cardiology, pathology, endoscopy and other image-producing disciplines. In addition to the image information, EPR includes all relevant data, such as patient history, lab results, and all studies and procedures the patient has undergone. EPR provides a single point of access for all healthcare professionals, and for all patient data. As an enterprise-wide solution, it enhances efficiency, giving hospitals a significant competitive advantage. Complete EPR integration requires that specialized clinical information systems are integrated through one portal EPR graphic user interface, and that image information from various DICOM and proprietary sources are consolidated through dedicated image servers. EasyWeb EasyWeb is a premier web-based distribution system for clinical images and related data. It provides cost-effective access to medical images and information throughout the department, the hospital, the institutional enterprise and beyond, including communication to physicians' home offices. Because EasyWeb uses standard internet EasyWeb provides access to medical images and data throughout the enterprise and beyond. 1 Philips Medical Systems, Best, the Netherlands. MEDICAMUNDI 46/2 August 2002 15
Figure 1. The EPR Direct framework. Figure 2. URL call. Figure 3. Embedded JAR. EasyWeb can be launched from a PC, using standard internet technology. technology, it can be launched from practically any PC running Java Runtime Environment. It easily integrates with most existing PACS infrastructures and will help customers comply with the upcoming HIPAA (Healthcare Insurance and Portability Act) regulations. The latest release, EasyWeb 4.1, was introduced at the American Heart Association Annual Meeting in November 16 MEDICAMUNDI 46/2 August 2002
2001. It is available in configurations for standalone use in radiology or cardiology, or as a shared IT solution, serving an institution's radiology and cardiology departments as well as the enterpriselevel healthcare information system infrastructure. New features and options provide increased performance, with secure, high performance and cost-effective communication of clinical information to multiple users, simultaneously and enterprisewide. Teleconferencing offers efficient communication with referring physicians, and variable image compressions give the freedom to make the optimal choice between image quality and speed. The new EPR Direct option seamlessly integrates with electronic Patient Record systems to make EasyWeb the image viewing component of the EPR. EPR Direct The initial goal of the Philips EasyWeb EPR Direct framework is to provide a simple, flexible interface to the sophisticated image viewing capabilities of the EasyWeb EPR Direct. Figure 1 shows how the EPR system maintains management of delivery of information data to client computers, and how the EasyWeb system manages image handling from one or multiple image databases. EasyWeb then delivers image data to the desktop, via the EPR, efficiently and regardless of bandwidth, due to its sophisticated image streaming capabilities. The EPR Direct interface is accessed by URL or by embedded Java Archive file (JAR), making it simple to integrate the image viewing capabilities of EasyWeb EPR Direct into other applications. Added functionality to communicate study availability to partner EPR systems allows the EPR system to effectively and accurately show what studies are available for viewing. EPR Direct is an add-on for EasyWeb 4.1 and comprises three components: EPR Direct Viewer HL7 messaging Database View. EPR Direct Viewer Essentially, EPR Direct Viewer is the image viewing component of EasyWeb, and has the same look and feel as the full EasyWeb application. It provides integrated viewing for the complete EPR application. The EPR Direct Viewer is available in two forms: URL call An embeddable JAR component. URL call (Figure 2) provides a very simple interface, allowing any EPR application to invoke the URL call regardless of the development environment. The embeddable JAR component (Figure 3) is essentially a file embedded in the EPR application. The file provides all the information required to view studies. For example, there is no need to download the image viewing software. The JAR file communicates with the EasyWeb server via the JAVA method. There are a number of JAVA method calls that are available for the EPR application to invoke. The method calls allow the EPR application to control the manner in which the JAR file interacts with their EPR application. HL7 messaging The HL7 messaging package (Figure 4) is an optional component. It can be configured to send an HL7 message to the EPR application when a study resides on the web cache or when a study is removed. Database View Database View (Figure 5) shows which studies are available on the EasyWeb web cache. Unlike HL7 messaging, Database View provides a snapshot at a timed moment and does not give continuous messages to the EPR. Figure 4. HL7 messaging. EasyWeb EPR Direct provides a simple, flexible interface to the sophisticated viewing capabilities. EasyWeb EPR Direct s viewing capabilities can be integrated into other applications. MEDICAMUNDI 46/2 August 2002 17
Figure 5. Database view. EPR Direct at the Barnes/Jewish Hospital, St. Louis, Missouri, USA An EasyWeb EPR Direct Package has already been installed in the Mallinckrodt Institute of Radiology at the Barnes/Jewish Hospital. Barnes/Jewish Hospital at Washington University Medical Center, the largest hospital in Missouri, is a unit within the BJC Healthcare System. The hospital has a premier reputation in patient care, medical education, research and community service. Barnes/Jewish Hospital receives more than 270 000 admissions, outpatient and emergency department visits each year from patients around the world. The EasyWeb EPR Direct package is integrated with the BJC enterprise-wide EPR system, known as Clinical Desktop (Figures 6-19). Figure 6. EPR Direct at Barnes Jewish Hospital (BJC). The EasyWeb server receives approximately 30 GBytes of images per day. EasyWeb allows clinicians to view medical images from up to a 250-mile radius of St. Louis. EasyWeb Brilliance, a component feature of EasyWeb, harmonizes images between two client monitors/viewers. Any image produced in the hospital or diagnostic clinic can now be electronically transferred and integrated into the patient's electronic file. With this new installation, clinicians can view radiological images together with the patient s file, and the system is currently being extended to include cardiology. Figure 7. EPR application: Clinical Workflow. Conclusion Philips EasyWeb integrates image distribution with web-based EPR data. The EasyWeb server has a functionality far in excess of that required for the EPR environment alone, and fully meets all the requirements for image integration for EPR systems. Acknowledgement We thank Professor B.B. Wein of the Klinik für Radiologische Diagnostik, Universitätsklinik der RWTH, Aachen, Germany, and Professor R.G. Jost of the Mallinckrodt Institute of Radiology, St. Louis Mo, USA, for their assistance in preparing this article. 18 MEDICAMUNDI 46/2 August 2002
Figure 8. Clinical Desktop Sign-On. Figure 9. Logon Identification (1). Figure 10. Logon Identification (2). Figure 11. Patient Search. Figure 12. Patient Search (results). Figure 13. Radiology Report. Figure 14. EPR Direct Viewer. Figure 15. EPR Direct Viewer (thumbnails). Figure 16. EPR Direct Viewer. Figure 17. EPR Direct Viewer. Figure 18. EPR Direct Viewer (structured reporting). Figure 19. EPR Direct Viewer (thumbnails). MEDICAMUNDI 46/2 August 2002 19