A Message from Seth Koeppel.

If you haven’t already heard the phrase “Image-Enabling the EMR,” you will. Now that the Federal Government has provided incentive payments to eligible professionals, hospitals and critical access hospitals (CAHs), “Image-Enabling the EMR” is all the buzz.

Through the American Recovery and Reinvestment Act of 2009 (ARRA) and Medicare and Medicaid EHR Incentive Programs, incentives are paid out for adopting, implementing, upgrading or demonstrating Meaningful Use (MU) of certified EHR technology. Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program.

This has driven the referring physician community, which controls the referral and ordering of diagnostic imaging procedures, to adopt Electronic Medical Records at a fevered pace. As a result, imaging providers are now inundated with requests from their referring physicians to have reports made available within their EMRs.

Interestingly, Stage 1 MU did not require medical images to be part of an EMR in order to meet meaningful use qualifications, and while the recently defined Stage 2 includes it only as a menu option, it’s hard to understand why any medical facility or healthcare provider would not want to include medical images as part of their EMR.

When we discuss medical imaging with physicians, they are nearly unanimous in their opinions that medical imaging is necessary to clinical diagnosis and treatment, not to mention prevalent in the patient care cycle. Furthermore, they tend to agree that the lack of access to imaging studies in the EMR often means that diagnostic imaging is repeated, exposing patients to unnecessary doses of radiation, increasing patient care costs and extending treatment times, and sometimes even delaying referral processes.

Most medical practitioners would be happy to add medical imaging to their EMR with their stage 2 meaningful use implementation. The benefits are obvious, and the medical practitioners can use this as one of their 3-5 menu options that are required for reimbursement.

However, many healthcare professionals and imaging providers are uncertain just how to add medical imaging to their EMRs. Often the question we hear is: “can eRAD send the medical report to this EMR?” While technically feasible using standard HL7 interfacing, is that really the best way to accomplish it? As always, the devil is in the details.

There isn’t any support for report formatting in HL7; so when they do arrive in the EMR, the reports are often not visually clear and don’t represent the sending institution very well. Besides the cost and technical challenges, sending the report to EMR via HL7 doesn’t do anything to address access to the images-a critical point that impacts both patient care and MU Stage 2 requirements. The old adage “a picture is worth a thousand words” certainly rings true in medical imaging, and clinicians want to be able to show their patients the images and discuss treatment.

This is where the term “Image-Enabling the EMR” comes into play. In the past there has been no easy way to access images or medical reports through the EMR without expensive upgrades or wholesale system replacements. Early on, the advent of Web-based systems like eRAD addressed this challenge by allowing clinicians to gain outside access.

They could simply log onto a browser from any computer or device connected to the Internet, and even receive automated notifications via emailed links or text messages that gave providers even easier access. But these all required the provider to leave the EMR, open a browser, and enter a username and password into a separate system, search for the patient and then drill down into the reports and images. Not the most efficient method.

Today there are more technically advanced methods to link the images and reports directly into the EMR within the context of the patient. This allows the provider to have seamless, one-click access to both the reports and images from within the patient’s record in the EMR. These are called Application-Programming Interfaces or APIs, which is a set of commands for accessing an application or system. A software company publishes its API so that other software developers can design products that are powered by its systems and services.

An API is a software-to-software interface, not a user interface. With APIs, applications talk to each other without any user knowledge or intervention. When you buy movie tickets online and enter your credit card information, the movie ticket Web site uses an API to send your credit card information to a remote application that verifies whether your information is correct. Once payment is confirmed, the remote application sends a response back to the movie ticket Web site saying it’s okay to issue the tickets.

As a user, you only see one interface-the movie ticket Web site-but behind the scenes, many applications are working together using APIs. This type of integration is called seamless, since the user never notices when software functions are handed from one application to another.

[source: TConsult, Inc.]

In the world of medical imaging, APIs are often used to integrate image management (PACS) systems directly into EMR systems, often referred to as “Image Enabling the EMR.” This is a more seamless and robust method than the traditional way of sending just the results of the radiology report via HL7 to the EMR-which then could offer only a blob of text viewed in the EMR. The API negotiates the security in the background and retrieves both the images and report for that patient-presenting it in a single view that is a very powerful combination of text and images for the user.


Third-party applications can use the eRAD API (a collection of HTTP commands) to access and modify PACS data. The commands include arguments identifying exam details such as the accession number, MRN, patient name and date of birth, study ID, etc. Data is secure and access can be restricted as needed. These are some of the commands available in the eRAD PACS API library:

  • Search the database: Query the database for study, order and report details.
  • Edit study data: Create and modify study demographics, order information and clinical reports.
  • Launch the eRAD PACS viewer: Invoke the diagnostic and web viewers, including the tools to organize and manipulate images.
  • Retrieve report contents: Download report text, addenda, key images and other report details.
  • Download system activity logs: Request heuristic data for dashboards, summary reports and other event analysis.

In addition to image enabling EMRs as described above, eRAD PACS API can be used to integrate radiology order systems, so that physicians can seamlessly request and send imaging requests to eRAD PACS.

Advanced Radiology, Baltimore MD, uses eRAD’s API to provide referring providers access to reports and images in their online web portal. APIs allow the portal to display a real-time worklist that allows providers to launch studies using eRAD’s zero footprint web viewer.

Data-mining is also possible from the eRAD PACS API-as all logging and statistical information is available to be used in applications such as third-party dashboards and management reporting. For an example of an eRAD dashboard available from a third-party company see this video on YouTube.

With the right cloud-imaging solution for the EMR, all images can be stored and archived in the cloud and made available with a simple icon or pull-down menu  within the EMR. Make sure that the cloud solution you choose meets all HIPAA-required compliances, so patients’ privacy is assured and security is provided.

Distribution of radiology data to such a wide network of users is not a simple task and presents its own set of challenges due to the size and complexity of the images. This is why using a simple embedded solution within the EMR allows the EMR to make use of the cloud and advanced imaging technology and protect the investment in the current EMR’s software capabilities.

For radiologists and referring physicians alike, image access in the EMR can be a game-changer-boosting clinical collaboration, enhancing patient education and care and shaving minutes from every patient encounter throughout the day.

Seth Koeppel
Senior VP of Sales
Cell: 617-821-4175
[email protected]