Case Exchange vs. Image Exchange – They’re different!


As we welcome the era of value-based healthcare and growing consumerism, the notion of image exchange needs to make way for case exchange… marking the new paradigm shift in clinician collaboration.

Consider this complex, though not uncommon, Case example:

Susan’s* first diagnostic mammogram with her local primary care office showed a suspicious soft spiculated mass on her left breast. A breast ultrasound detected a malignant solid mass and a biopsy confirmed the presence of an Invasive breast cancer. Susan also has a family history of Breast Cancer but at the same time, she has lupus and is also recovering from a knee surgery. She knows about her condition more than any one clinician ever can.  And now she needs a second opinion on next steps – hopefully with a leading Breast Cancer surgeon at a leading hospital elsewhere in the country.

First, there is a plethora of Susan’s medical information to sift through including several historical reports, scans, current reports, scans, pap smears, pathology reports, lupus treatment, and allergy information. Second, several physicians and specialists will need to work together to help ensure Susan gets the best care possible.

Are Exchanging Images Enough? 

In this example, meaningful clinician collaboration will depend on the ability to access medical data regardless of its file format – this must include the ability for multiple clinicians to access the information at the same time. In other words – exchanging images is not enough. What is needed is a more multi-directional exchange of patient cases which includes images and documents. A case reflects ongoing collaboration on a patient’s situation – the request from a primary care physician, the opinion of the specialist, back and forth discussion on treatment protocols, drawing co-relation from similar cases etc…and all of the collaboration happening among clinicians who may be geographically and systemically separated. That is the spirit of case exchange as opposed to image exchange.

The Intent of Case Exchange

An ideal exchange solution should have the ability to rapidly query and retrieve patient’s DICOM images and related Non DICOM medical data like results, reports, pictures, videos etc. In addition, a contextual presentation of this data can help a clinician in co-relating the images to the results and arriving at diagnosis or treatment decisions faster.

Sharing and storing patient’s data in a Non DICOM format comes with its own challenges. From a sender’s perspective this data may reside in several disconnected file folders, department owned storage media, structured text in PACS and sometimes even paper files. From a receiver’s perspective, they do not want to be tied to a specific workstation or device or need multiple viewers to view all the disparate file formats. “DICOMization” or DICOM wrapping of unstructured data may not be an ideal solution because this will restrict viewing this data from a DICOM viewer such as from your PACS. In addition, transfer of Non-DICOM data over the public internet needs to happen with secure socket layer (SSL) protocol or HTTPS. To overcome the above challenges, adherence to standards like IHE-XDS for storage of information and retrieval through HL7 protocols is important. This should be an important consideration when looking for an effective case exchange solution.

Patients – More than an Image

I’ll close by noting the most important entity in this collaboration – Susan, the patient herself. Case exchange solutions should allow patients to take control of their medical images and documents. Patients do not read images, they read clinicians comments and notes.  They understand that. But they should have the freedom to send their data to a specialist of their choice for second or third opinion if they so desire. So there should be a simple way for them to access and download not just their images, but also results and reports and subsequently send it to a clinician of their choice.

In my next blog, I will talk more about the healthcare market forces that are further driving or limiting clinician collaboration…stay tuned and thanks for reading!

*A fictitious patient example.

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