DICOM is considered the predominant standard for communication of medical images.

Kowa’s DigiVersal Image Viewing Solution is DICOM compliant.

Even as more optometrists have shifted their medical records from written or typed words on paper to digital information management, a key challenge remains: How to integrate diagnostic testing and imaging results with systems designed to gather, organize, and store EMRs.

That effort requires extensive collaboration between medical device makers, eyecare practitioners, and experts in medical information technology. And it’s happening right now thanks largely to a broad-based and loosely bound organization called Digital Imaging and Communications in Medicine or DICOM.

Originally designed for radiology in 1983 when the American College of Radiology teamed up with the National Electrical Manufacturers Association (NEMA), what would later be named DICOM aimed to create a standard method for transmitting digital medical images and their related information, according to NEMA. An early fruition of their joint efforts came in 1993 with the adoption of its first standard for communicating digital image information.

Fast-forward to today, and DICOM is now considered the predominant standard for communication of medical images, according to the Radiological Society of North America. Many subspecialties have gotten into the act. Some 750 technical and medical experts contribute to more than 20 DICOM working groups, according to the organization.

The American Academy of Ophthalmology’s Working Group on

Carl Zeiss Meditec’s FORUM Ophthalmic Data Management System integrates all instruments
for a centralized, paperless record
of all relevant clinical data.

Ophthalmic Standards is one of numerous subspecialty committees devoted to setting standards for vendors of diagnostic instruments as well as EMR system makers to ensure that their machines are optimally compatible.

That’s important, not only because EMRs are a significant long-term investment, but also because they are of limited value if not operatively linked with the instruments that gather critical diagnostic data, especially those which capture anatomical and physiological images.

“EMR interoperability is not a major requirement for most smaller independent optometry clinics—yet,” says Alan Golata, an interoperability consultant with Ophthalmic Tools, Westland, MI. “It will be though within stage two and stage three of ONC requirements for government funds.”

The Office of the National Coordinator for Health Information Technology

Kowa Optimed, Inc., Optovue, Inc., and Lumenis, Ltd., have teamed up to form the AZ-Alliance. Each alliance partner brings extensive resources and expertise that practitioners can access for a connectivity solution that offers simultaneous image viewing from these technologies within their practice, as well as the ability to purchase a suite of best-of-class products from any and all alliance members at significant savings. The AZ-Alliance will also be hosting educational seminars across the country on topics such as diagnosis, treatment, and charting.

(ONC) authorizes certification of EMR systems as a first step for hospitals and providers to demonstrate “meaningful use” of the technology and thereby obtain federal incentive funding from the American Recovery and Reinvestment Act.

While still a work in progress, DICOM’s Ophthalmology Working Group has made considerable strides in stipulating interoperability standards for multiple ophthalmic diagnostic instruments. These standards extend not only to images but also to so-called structured data for the information associated with those pictures.

“The diagnostic modalities for which DICOM has defined (standards) include external photography, fundus photography and angiography, stereoscopic display, visual fields, optical coherence tomography, macular thickness and volume, and ophthalmic refractive measurements data,” says Working Group co-chairman P. Lloyd Hildebrand, MD, a professor of ophthalmology at the University of Oklahoma’s Dean McGee Eye Institute.

In terms of putting into practice DICOM-stipulated interoperability standards, hospitals have taken the lead while individual practitioners who use EHRs are poised at the starting line. “DICOM is still a standard for the future when it comes to communicating with colleagues,” says Jorge A. Cuadros, OD, PhD, director of Informatics Research at the University of California, Berkley Optometric Eye Center, and a member
of DICOM’s Ophthalmology Working Group.

Satisfying DICOM’s interoperability standards is not yet a practical concern for individual optometrists, Dr. Cuadros says. “Electronic medical records used in eyecare are just beginning to deal with DICOM,” he says. “Most of the time, we don’t deal with DICOM. A lot of the electronic medical records that are used in outpatient medical care—which is the bulk of the type of communication that we do—is actually done through HL7 interfaces.” That’s a data- interchange standard for medical records that is mostly textual.

Many vendors are getting on board with EMR-diagnostic modality interoperability. The FORUM Ophthalmic Data Management System by Carl Zeiss Meditec, Inc. connects Zeiss and other companies’ ophthalmic DICOM compliant instruments. FORUM also has an HL7 interface that is compatible with most EMRs. FORUM enhances practice and workflow, communication, and patient education by digitally integrating all instruments for a complete, centralized, paperless record of all relevant clinical data. It is scalable to the needs of practices of every size and scope.

IMAGE CAPTURE SOFTWARE Instruments for Vision’s new generation of ophthalmic imaging software is RETINAphile XP. Practitioners can import various data from other instruments using the comprehensive DICOM and PDF formats. Plus, there is no upgrade or conversion charge from its predecessor iMACAM.

The OIS WinStation from Ophthalmic Imaging Systems (OIS), which was recently acquired by Merge Healthcare, is DICOM compliant. OIS provides a range of WinStation systems to specifically meet various needs. Its WinStation 11K™ provides high-resolution 11 megapixel film size CCD to eliminate the need to optically reduce the image. It offers instant fundus autofluorescence and color fundus imaging in one compact digital camera that connects directly to most fundus cameras for easy interfacing. The OIS WinStation 11K also offers AutoMontage™, PDT planning, and automatic overlay software.

Another vendor getting on board with EMR diagnostic modality interoperability is Topcon Medical Systems, Inc. It offers IMAGEnet, which has significantly increased the functionality of the retinal camera without sacrificing patient work flow or ease of use. It offers ample selection of image analysis and measurement functions for precise diagnosis. Easy navigation and comparison functions let practitioners check each step of the exam.

In addition, Kowa Optimed Inc. also offers the DigiVersal™ Image Viewing Solution that is DICOM compliant.

In its contribution to DICOM’s most recent “Strategic Document,” the Ophthalmology Working Group notes among its key challenges: “Implementation of existing standardized objects in ophthalmic applications and devices is just beginning. While there has been heightened awareness of DICOM in the vendor and user communities, several major vendors still do not participate in the standard-development process or use the standard in their products.”

Why not? In theory, you might think that coming out with DICOM-compatible products would be a significant competitive advantage. In practice, retrofitting sophisticated diagnostic instrumentation to interface with EMRs is an expensive and resource-intensive process. “Somehow there needs to be an easier and less-expensive way for companies, particularly smaller companies, to be able to conform to DICOM standards and bring their products to market,” according to the Ophthalmology Working Group. That somehow alludes to a bar set at dauntingly lofty heights.

Undeterred and doggedly optimistic, Dr. Hildebrand sees significant progress and achievable goals. “This is the classic chicken-and-egg question,” he says. “The EMR-vendor community is adopting DICOM more rapidly than the modality-vendor community. However, this last year we have seen rapidly expanding interest on both sides. We are still a ways from having a fully integrated environment, but it is progressing rapidly. I’d say we’re probably 50% of the way to broad adoption on both the EMR and modality-vendor ends.”

Even now there are steps to take to prepare for the day when you may elect to participate in DICOM standardization of EMRs and diagnostic modalities—not only as a means toward obtaining meaningful-use authorization and CMS incentive payments, but also for better clinical-
decision support and patient-management efficiency. DICOM-compatible technology may also play a key role in expanding and enhancing telemedicine’s capabilities and scope.

“Evaluate the modalities that you need in your practice,” Dr. Hildebrand says. “If there is imaging and image-intensive data required for your practice, request DICOM-compliance statements from your vendors. If you are implementing an EMR, make sure it can accept DICOM modalities and can interface with DICOM Picture Archiving and Communications Systems, where DICOM objects are typically stored.”

So what’s all the fuss over DICOM about? The bottom line is it all comes down to getting your optometric EMR and image-capture capabilities to “talk” to each other.

Robert Murphy is a freelance writer with over 20 years’ experience writing for the optometric industry.

Carl Zeiss Meditec, Inc. 800-342-9821 • meditec.zeiss.com/usa

Instruments for Vision • 800-323-4382 • eyeimg.com

Kowa Optimed Inc. • 800-966-5692 • kowa-usa.com

Lumenis, Ltd. • 408-764-3000 • lumenis.com

Ophthalmic Imaging Systems (OIS) 800-338-8436 • oisi.com

Optovue Inc. • 866-344-8948 • optovue.com

Topcon Medical Systems, Inc. • 800-223-1130 topconmedical.com


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