Perceptions of Radiologists and Emergency Medicine Providers Regarding the Quality, Value, and Challenges of Outside Image Sharing in the Emergency Department Setting

Abstract

OBJECTIVE.

The purpose of this study is to assess the perceptions of radiologists and emergency medicine (EM) providers regarding the quality, value, and challenges associated with using outside imaging (i.e., images obtained at facilities other than their own institution).

MATERIALS AND METHODS.

We surveyed radiologists and EM providers at a large academic medical center regarding their perceptions of the availability and utility of outside imaging.

RESULTS.

Thirty-four of 101 radiologists (33.6%) and 38 of 197 EM providers (19.3%) responded. A total of 32.4% of radiologists and 55.3% of EM providers had confidence in the quality of images from outside community facilities; 20.6% and 44.7%, respectively, had confidence in the interpretations of radiologists from these outside facilities. Only 23.5% of radiologists and 5.3% of EM physicians were confident in their ability to efficiently access reports (for outside images, 47.1% and 5.3%). Very few radiologists and EM providers had accessed imaging reports from outside facilities through an available stand-alone portal. A total of 40.6% of radiologists thought that outside reports always or frequently reduced additional imaging recommendations (62.5% for outside images); 15.6% thought that reports changed interpretations of new examinations (37.5% for outside images); and 43.8% thought that reports increased confidence in interpretations of new examinations (75.0% for outside images). A total of 29.4% of EM providers thought that access to reports from outside facilities reduced repeat imaging (64.7% for outside images), 41.2% thought that they changed diagnostic or management plans (50.0% for outside images), and 50.0% thought they increased clinical confidence (67.6% for outside images).

CONCLUSION.

Radiologists and EM providers perceive high value in sharing images from outside facilities, despite quality concerns. Substantial challenges exist in accessing these images and reports from outside facilities, and providers are unlikely to do so using separate systems. However, even if information technology solutions for seamless image integration are adopted, providers’ lack of confidence in outside studies may remain an important barrier.

Radiologic imaging is most effective when interpreted in the context of the clinical condition and prior imaging studies of a patient. However, the fragmented U.S. health care system results in imaging often being performed at multiple institutions, with patient care provided across diverse sites being the norm [1]. Health information exchanges (HIEs) have been proposed to overcome image sharing barriers. HIEs can typically exchange basic clinical information, often but not always including radiology reports, although they generally are not comprehensive [2]. Newer mechanisms also exist for directly sharing images between institutions.

Image sharing has the potential to reduce costs, enhance patient care, and improve patient satisfaction [3]. Despite the potential value of HIEs, the clinical adoption of HIEs and other image sharing modalities remains low, with a correspondingly limited impact on clinical care. Most providers in inpatient and outpatient practice have no access to an HIE. Even when an HIE is available, it historically has rarely been used by providers [4, 5]. The primary reasons for limited use of available HIEs are inconvenience and suboptimal human factors design. Most require accessing a system distinct from the electronic health record (EHR) by use of a separate portal, interface, credential, password, or combination of these features. These are time-consuming steps for busy providers and do not easily accommodate typical clinical workflows. Furthermore, existing HIEs are very rarely truly interoperable, failing to integrate critical elements of outside records) into the usual interactions with the local EHR, such that even reports that are technically available in the EHR are likely to be overlooked by busy providers [5].

Existing HIEs also generally do not provide a radiologist with the ability to view images from other institutions. Imaging studies are more difficult to exchange than reports because they typically are stored in local PACS and because formal exchange standards historically have not been widely adopted [6]. Moreover, the significant data size of an imaging examination complicates transfer and storage. Cloud-based image-sharing solutions, such as those provided by Nuance and LifeImage, have more recently been introduced, although they do not offer full integration into local systems and, at present, their clinical adoption is limited. Although radiologic images can be transferred outside HIE mechanisms via portable electronic media such as a CD or flash drive, the rate of upload failures was found to be substantial in a study from 2011 [7]. Even when uploading is successful, a substantial delay may occur while the CD is requested, prepared, and sent from another institution. Moreover, CDs or flash drives often are cumbersome to navigate [8], may lack appropriate software, and may not be integrated beyond local viewing workstations into the patient’s clinical record for multiple providers to access [9].

In the emergency department (ED) setting, the extent and type of prior patient imaging is relevant to clinical decision making. Prior imaging may impact transfer decisions, data synthesis, diagnostic considerations, consultation, and further evaluations [3, 10]. The need to obtain a repeat or interval imaging study or to obtain an additional distinct imaging study, as well as the choice of which specific imaging modality to order (e.g., CT or MRI if radiography or ultrasound has been already performed), might be altered on the basis of the availability of prior studies. Furthermore, incidental findings for a range of organ systems occasionally are encountered in the evaluation of acute medical conditions in the ED setting. These may engender an extensive and costly downstream cascade of efforts [11, 12] to ensure adequate communication to patients and outpatient providers and timely follow-up to exclude malignancy or ensure intervention, stability, or resolution. The interpretations of such incidentalomas and recommendations for interval reimaging or referral might be substantially altered after comparison with previously obtained images.

The effectiveness of integrated image sharing as a solution to these problems is unknown. Even if seamlessly available, external data may not be trusted by treating clinicians. Particularly for advanced imaging modalities such as CT and MRI, radiologists and treating physicians might not feel comfortable trusting the technical performance of outside machines, depending on the modality or imaging protocol or the interpretations provided by external physicians. It is therefore possible that even integrated report and image sharing might not substantially reduce overutilization and duplicate testing. In the present study, we assessed the perceptions of radiologists and EM providers regarding the quality and value of imaging performed at outside institutions (hereafter referred to as outside imaging) and also assessed the perceived challenges associated with using outside imaging. Our findings are intended to help guide successful future efforts in the implementation and widespread adoption of optimal integrated cloud-based image sharing solutions.

Materials and Methods

Study Setting

The present study was conducted at a single, large, urban academic medical center. The inpatient and outpatient practices in the health care system all use a single, integrated EHR (Epic, Epic Systems). Access to radiology reports from other local medical centers using Epic can be gained through a dedicated section of the electronic health record (Care Everywhere, Epic Systems) that first requires that signed informed consent be uploaded before access is provided. A regional health information exchange (Healthix; Healthix, Inc.) includes clinical information and radiology reports from most nearby major medical centers, including non-Epic platforms, and it is accessible either through a stand-alone website or through a link in a dedicated section of the EHR. For patients who have provided prior consent, Healthix is automatically queried on patient arrival to ED triage, and data are downloaded to the Care Everywhere section of the chart. Outside images may be viewed only if a patient brought them on a CD or flash drive, in which case the outside images may be imported into the local PACS with the use of Life Image software (version 5.3.0.1, Life Image).

Subjects

Eligible participants were all radiology faculty who had interpreted at least 10 cross-sectional imaging examinations from the institutional ED in the past 3 months as well as all 2nd- through 4th- year radiology residents and all EM faculty who worked primarily in the main hospital ED.

Outcome Measures

In the absence of any previously validated survey instrument, a questionnaire related to regional image sharing was jointly designed by a radiologist, internal medicine physician, and EM physician, all of whom were in active clinical practice, and was pilot tested by several noneligible physicians. The survey consisted of a series of statements (20 for radiologists and 22 for EM faculty) in three primary domains (quality and access, impact on decision making, and HIE access mechanisms). Using a 5-point Likert scale with responses ranging from strongly disagree to strongly agree, respondents were asked to rate their confidence in the quality of outside reports and images and in their ability to access outside data. Using a 5-point scale with responses ranging from never to always, respondents were also asked to rate the perceived frequency with which outside imaging results reduced recommendations for additional imaging, changed interpretation, increased diagnostic confidence, or provided unexpected information and also rate whether they had accessed outside HIE data through any of four different methods. A free-text option was provided for general comments. The survey was distributed via a secure e-mail invitation that contained a hyperlink to a web-based version of the survey (Qualtrics). The e-mail to EM providers was sent to faculty and trainee listservs that included all EM faculty; however, many faculty do not work at the main hospital that was the target of the survey. Accordingly, the e-mail instructed EM providers not working in the main hospital to disregard the survey. Consent information was included on the first screen of the survey; completion of the survey served as implicit consent. Two reminder e-mails were provided. The surveys were completed in April and May of 2019. The full survey instrument is available in Appendix 1.

Statistical Analysis

Survey responses were summarized using standard descriptive statistics, including percentages. Responses regarding confidence in outside imaging examinations from academic versus community practices were compared using McNemar tests performed using MedCalc software (version 19.0.5, MedCalc). Responses regarding confidence in outside imaging examinations were also compared graphically between radiologists and EM providers with use of spreadsheet software (Excel for Windows 2016, Microsoft). Results for attending physicians were evaluated as a secondary analysis. Common free-text comments were identified and categorized. The study was approved by the institutional review board, which granted a waiver of signed informed consent.

Results

The radiologist survey was answered by 26 of 74 attending physicians (35.1%) and eight of 27 residents (29.6%). The EM provider survey was sent to 117 attending physicians, 51 of whom primarily worked at other facilities and were instructed not to answer, leaving an effective sample size of 66 attending physicians. This EM provider survey was answered by 23 of 66 attending physicians (34.8%), eight of 64 residents (12.5%), and seven of 67 physician assistants (10.4%). Therefore, a total of 34 of 101 radiologists (33.6%) and 38 of 197 EM providers (19.3%) responded.

Access to Outside Images and Reports

For examinations performed at outside academic facilities, 20.6% of radiologists were confident in their ability to successfully and efficiently access the reports, and 50.0% were confident in their ability to access the images, compared with 23.5% and 47.1% of radiologists, respectively, for examinations performed at outside community facilities (p = 1.0) (Table 1 and Figs. 1 and 2). For examinations performed at outside academic facilities, 10.5% of EM providers were confident in their ability to successfully and efficiently access the reports, and 13.2% were confident in their ability to access the images, compared with 5.3% and 5.3% of EM providers, respectively, for examinations performed at outside community facilities (p > 0.1) (Table 2 and Figs. 1 and 2). The percentage of radiologists who had ever accessed any patient’s prior imaging report was as follows: 90.6% had accessed a prior report in Epic (the local EHR), 21.9% in Epic Care Everywhere (a separate section within the EHR for health records from outside institutions), 0.0% in Healthix (the New York State HIE) through Epic, and 0.0% in Healthix through a separate portal (Table 1). The fraction of EM providers who had ever accessed any patient’s prior imaging report was as follows: 88.2%, had accessed a prior report in Epic, 82.4% in Epic Care Everywhere, 26.5% in Healthix through Epic, and 14.7% in Healthix through a separate portal (Table 2).

TABLE 1:

Survey Responses of Radiologists

Survey Question	Response
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
For imaging examinations performed at outside academic facilities, I am confident in…a
The quality of the images themselves	0.0 (0.0)	5.9 (3.8	29.4 (38.5)	55.9 (55.0)	8.8 (7.7)
The quality of the outside radiologist’s interpretation	0.0 (0.0)	5.9 (7.7)	35.3 (46.2)	52.9 (38.5)	5.9 (7.7)
My ability to successfully and efficiently access the reports	23.5 (26.9)	29.4 (34.6)	26.5 (19.2)	14.7 (11.5)	5.9 (7.7)
My ability to successfully and efficiently access the images	2.9 (3.8)	17.6 (15.4)	29.4 (30.8)	35.3 (34.6)	14.7 (15.4)
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
For imaging examinations performed at outside community facilities, I am confident in…a
The quality of the images themselves	2.9 (3.8)	35.3 (38.5)	29.4 (30.8)	26.5 (19.2)	5.9 (7.7)
The quality of the outside radiologist’s interpretation	2.9 (3.8)	35.3 (42.3)	41.2 (38.5)	14.7 (7.7)	5.9 (7.7)
My ability to successfully and efficiently access the reports	23.5 (26.9)	35.3 (42.3)	17.6 (11.5)	17.6 (11.5)	5.9 (7.7)
My ability to successfully and efficiently access the images	2.9 (3.8)	20.6 (23.1)	29.4 (23.1)	35.3 (38.5)	11.8 (11.5)
	Never	Rarely	Sometimes	Frequently	Always
When I have access to reports for outside imaging studies, it…a
Helps to reduce rates of recommendations for additional imaging for incidental findings	3.1 (3.8)	18.8 (19.2)	37.5 (42.3)	37.5 (34.6)	3.1 (0.0)
Changes my diagnostic interpretation of the current imaging examination	3.1 (3.8)	31.3 (30.8)	50.0 (53.8)	15.6 (11.5)	0.0 (0.0)
Increases my confidence in my diagnostic interpretation of the current imaging examination	3.1 (3.8)	6.3 (7.7)	46.9 (46.2)	37.5 (34.6)	6.3 (7.7)
Provides unexpected useful information for the patient’s care	3.1 (3.8)	12.5 (11.5)	71.9 (73.1)	9.4 (7.7)	3.1 (3.8)
	Never	Rarely	Sometimes	Frequently	Always
When I have access to images for outside imaging studies, it…a
Helps to reduce rates of recommendations for additional imaging for incidental findings	3.1 (3.8)	0.0 (0.0)	34.4 (34.6)	56.3 (57.7)	6.3 (3.8)
Changes my diagnostic interpretation of the current imaging examination	3.1 (3.8)	3.1 (3.8)	56.3 (65.4)	34.4 (23.1)	3.1 (3.8)
Increases my confidence in my diagnostic interpretation of the current imaging examination	3.1 (3.8)	0.0 (0.0)	21.9 (26.9)	68.8 (61.5)	6.3 (7.7)
Provides unexpected useful information for the patient’s care	3.1 (3.8)	9.4 (11.5)	50.0 (50.0)	31.3 (26.9)	6.3 (7.7)
	No	Yes
I have accessed any patient’s prior imaging report by reviewing it in…b
Epic	9.4 (11.5)	90.6 (88.5)
Epic Care Everywhere	78.1 (73.1)	21.9 (26.9)
Healthix through Epic	100.0 (100.0)	0.0 (0.9)
Healthix through a separate portal	100.0 (100.0)	0.0 (0.0)

Note–Data are percentage of radiologist responses (percentage of responses restricted to attending physicians only).

^aThe total number of radiologists who responded was 34, and the total number of attending physicians who responded was 26.

^bThe total number of radiologists who responded was 32, and the total number of attending physicians who responded was 26.

Fig. 1—

Bar graph shows summary of survey responses regarding confidence in imaging examinations performed at academic facilities outside respondents’ institutional network. Solid bars denote responses of radiologists, and striped bars denote responses of emergency medicine providers. Numbers above bars denote percentages of respondents.

Fig. 2—

Bar graph shows summary of survey responses regarding confidence in imaging examinations performed at community facilities outside respondents’ institutional network. Solid bars denote responses of radiologists, and striped bars denote responses of emergency medicine providers. Numbers above bars denote percentages of respondents.

TABLE 2:

Survey Responses of Emergency Medicine (EM) Providers

Survey Question	Response
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
For imaging examinations performed at outside academic facilities, I am confident in…a
The quality of the images themselves	0.0 (0.0)	0.0 (0.0)	15.8 (17.4)	63.2 (47.8)	21.1 (34.8)
The quality of the outside radiologist’s interpretation	0.0 (0.0)	5.3 (0.0)	26.3 (26.1)	55.3 (52.2)	13.2 (21.7)
My ability to successfully and efficiently access the reports	28.9 (21.7)	55.3 (56.5)	5.3 (8.7)	10.5 (8.7)	0.0 (4.3)
My ability to successfully and efficiently access the images	36.8 (39.1)	44.7 (39.1)	5.3 (8.7)	10.5 (8.7)	2.6 (4.3)
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
For imaging examinations performed at outside community facilities, I am confident in…a
The quality of the images themselves	0.0 (0.0)	10.5 (17.4)	34.2 (21.7)	44.7 (43.5)	10.5 (17.4)
The quality of the outside radiologist’s interpretation	2.6 (4.3)	10.5 (13.0)	42.1 (39.1)	42.1 (39.1)	2.6 (4.3)
My ability to successfully and efficiently access the reports	44.7 (39.1)	44.7 (43.5)	5.3 (8.7)	5.3 (8.7)	0.0 (0.0)
My ability to successfully and efficiently access the images	42.1 (39.1)	47.4 (43.5)	5.3 (8.7)	5.3 (8.7)	0.0 (0.0)
	Never	Rarely	Sometimes	Frequently	Always
When I have access to reports for outside imaging studies, it…b
Helps to reduce rates of repeat imaging in the emergency department	2.9 (0.0)	11.8 (14.3)	55.9 (47.6)	29.4 (38.1)	0.0 (0.0)
Changes the diagnostic or management plan for the patient	0.0 (0.0)	11.8 (14.3)	47.1 (42.9)	38.2 (42.9)	2.9 (0.0)
Increases my confidence in the diagnostic or management plan for the patient	0.0 (0.0)	5.9 (9.5)	44.1 (42.9)	47.1 (47.6)	2.9 (0.0)
Provides unexpected useful information for the patient’s care	0.0 (0.0)	11.8 (9.5)	52.9 (52.4)	32.4 (38.1)	2.9 (0.0)
Influences the patient’s final disposition	0.0 (0.0)	5.9 (9.5)	52.9 (52.4)	41.2 (38.1)	0.0 (0.0)
	Never	Rarely	Sometimes	Frequently	Always
When I have access to images for outside imaging studies, it…b
Helps to reduce rates of repeat imaging in the emergency department	0.0 (0.0)	2.9 (4.8)	32.4 (23.8)	55.9 (66.7)	8.8 (4.8)
Changes the diagnostic or management plan for the patient	0.0 (0.0)	8.8 (9.5)	41.2 (47.6)	47.1 (42.9)	2.9 (0.0)
Increases my confidence in the diagnostic or management plan for the patient	0.0 (0.0)	0.0 (0.0)	32.4 (38.1)	64.7 (61.9)	2.9 (0.0)
Provides unexpected useful information for the patient’s care	0.0 (0.0)	2.9 (0.0)	52.9 (57.1)	41.2 (42.9)	2.9 (0.0)
Influences the patient’s final disposition	0.0 (0.0)	2.9 (4.8)	41.2 (47.6)	50.0 (42.9)	5.9 (4.8)
	No	Yes
I have accessed any patient’s prior imaging report by reviewing it in…b
Epic	11.8 (14.3)	88.2 (85.7)
Epic Care Everywhere	17.6 (14.3)	82.4 (85.7)
Healthix through Epic	73.5 (66.7)	26.5 (33.3)
Healthix through a separate portal	85.3 (81.0)	14.7 (19.0)

Note–Data are percentage of EM provider responses (percentage of responses restricted to attending physicians only).

^aThe total number of EM providers who responded was 38, and the total number of attending physicians who responded was 23.

^bThe total number of EM providers who responded was 34, and the total number of attending physicians who responded was 21.

Confidence in Outside Images and Interpretations

For examinations performed at outside academic facilities, 64.7% of radiologists agreed or strongly agreed that they were confident in the quality of the images themselves, whereas 58.8% were confident in the quality of the radiologists’ interpretations, compared with 32.4% and 20.6% of radiologists, respectively, for examinations performed at outside community facilities (p < 0.005) (Table 1 and Figs. 1 and 2). For examinations performed at outside academic facilities, 84.2% of EM providers agreed or strongly agreed that they were confident in the quality of the images themselves, whereas 68.4% were confident in the outside radiologists’ interpretations, compared with 55.3% and 44.7% of EM providers, respectively, for examinations performed at outside community facilities (p < 0.05) (Table 2 and Figs. 1 and 2).

Impact of Outside Images and Reports

A total of 40.6% of radiologists thought that access to outside reports always or frequently helps to reduce rates of recommendation for additional imaging (which increased to 62.5% for access to outside images); 15.6% thought that outside reports change the diagnostic interpretation of the current imaging examination (37.6% for outside images); 43.8% thought that outside reports increase confidence in the diagnostic interpretation of the current examination (75.0% for outside images); and 12.5% thought that reports provide information that is unexpectedly useful for patient care (37.5% for outside images) (Table 1). A total of 29.4% of EM providers thought that access to outside reports always or frequently helps to reduce rates of repeat imaging in the ED (which increased to 64.7% for access to outside images); 41.2% thought that reports change the diagnostic or management plan (50.0% for outside images); 50.0% thought that reports increase confidence in the diagnostic or management plan (67.6% for outside images); 35.3% thought that reports provide unexpected useful information for patient care (44.1% for outside images); and 41.2% thought that reports influence the patient’s final disposition (55.9% for outside images) (Table 2).

Free-Text Responses

Free-text comments by radiologists described access to outside reports as helping to avoid “a time-consuming search process,” being “critical to quality patient care” despite needing an “easier/simpler method to access,” and being “almost never available at time of interpretation.” Free-text comments by EM providers described the process of obtaining outside reports as “long and time consuming,” “very cumbersome,” “very frustrating,” “painful,” and a “nightmare.” Numerous EM provider comments remarked on performing repeat imaging purely because they were unable to access the outside examination, doing so “often” or “on many occasions” and in turn extending the length of stay in the ED. In addition, numerous EM provider comments remarked on outside examinations often being received on CDs that were difficult and inefficient to access, if accessible at all. Examples of free-text responses provided by radiologists and EM providers are presented in Table 3.

TABLE 3:

Free-Text Comments by Radiologists and Emergency Medicine (EM) Providers

Respondents	Comment
Radiologists	A single, easy to access, and reliable location for accessing additional images AND reports is desirable. This would reduce the chances of having a time-consuming search process looking for the information and would reduce the rates of missing this available information (for example, if someone forgot to check the media tab to see if a report was available). Maybe it would be best to upload scanned reports into the “reports” tab in PACS similar to the way we review prior reports dictated at [redacted].
	Having prior imaging available is critical to quality patient care. Any initiative which will improve our ability to see prior imaging will only improve patient care.
	I never see the prior reports, which is a major limitation/stressor to reinterpreting outside imaging. The most useful thing would be to scan the report into PACS.
	Image sharing is imperative for best patient care. I would like to request that outside report sharing is also optimized. At times, outside report does not get uploaded into patient’s chart.
	Need easier/simpler method to access outside imaging reports; should upload directly to PACS
	Outside reports are almost never available at time of interpretation.
	The outside report is frequently helpful, as there is often an entirely benign incidental finding on a scan that I might not even mention in my report but that has been highlighted as potentially significant by an outside radiologist. I can therefore specifically address in my report that the finding of concern on the outside interpretation is not clinically significant (e.g., the referrer might wonder why I didn’t mention the lung nodule that was reported on the outside, when it is only an incidental fissural node that is irrelevant). Outside reports will often make reference to older comparison studies that have not been uploaded, and I can therefore ask for those to be uploaded as well—particularly useful for subsolid nodules where evolution is typically only appreciated over many years.
	The outside report should be linked to the images uploaded and I should not be searching for them.
EM providers	I have called outside institutions and asked for fax reports, which is long and time consuming for all parties.
	I have worked at institutions with and without image-sharing agreements, and I can say categorically that patient care is improved when there is image sharing. Any repeat scan solely done due to lack of access to the initial scan/report should be considered a PSI [Patient Safety Incident]-able event in the grand scheme of healthcare, and we should do everything in our power to prevent this.
	I have no idea if you have good partners to collaborate with who have implemented this, but I would say that the [redacted] folks in [redacted] did it remarkably well with a large number of community providers throughout the region.
	I’ve had to reimage patients on many occasions. Often even if they have a CD—we are unable to access it. At [redacted] many of the outpatient doctors use [redacted] imagining and then send these patients to our department for care based on these images that we do not have any access to. For many surgical diagnoses the images are done again at [redacted]. Repeating a CT abdomen pelvis is a radiation and possible financial burden we should not be exposing our patients to. We need to find an option that makes sense for this community.
	Image sharing would be immensely helpful, as would streamlining the process for uploading and getting radiology reads on images that patients have on CDs that they bring to the ED, as this can often lead to reimaging that doesn’t necessarily need to happen due to delays in the imaging being uploaded/transferred over.
	It is very cumbersome and time consuming to upload prior CTs for official [redacted] read. We received instructions in the past that no longer seem to work—this was by me following instructions and radiology night clerk trying; was told by them they were having problems for a while and advised day team to try.
	It is very frustrating when patients are sent to the ED from [redacted] after imaging. Approximately 95% of the time I have trouble uploading/accessing the images which extends LOS in the ED and often results in repeat imaging which is bad patient care.
	It’s a nightmare.
	Multiple instances in which a patient bring a CD from outside facility and the workflow is that radiologist can read it.
	The process to get an outside imaging study interpreted by radiology through the ED is not efficient. Most computers are not compatible and there are almost always complications with getting the images linked to the orders for external rad consult. Very time consuming and requires multiple telephone calls to fix.
	This is such a painful process—every time I upload anything the images will not pair with the order and therefore the radiologist cannot see that I want a consult/reading. this requires mult[iple] telephone calls to rectify. is there a way to improve this process to upload an image and have it paired with the consult order automatically?
	Under ideal circumstances, I would be able to give a CD with outside images to someone else to upload and process rather than having to do it myself.
	Usually come from CDs carried by patient.

Note—With the exception of redacted portions, free-text comments are presented as provided by the survey respondents. ED = emergency department, LOS = length of stay, rad = radiologist.

Discussion

In the present survey of EM providers and radiologists at a single, large academic medical center that participates in the largest national public health information exchange (Healthix) and uses the most prevalent EHR system, we still found persistent, substantial barriers to obtaining outside images and reports in daily practice. Radiologists and EM providers do, however, perceive outside studies to have substantial value when available. Radiologists reported that access to outside imaging examinations commonly increased diagnostic confidence and reduced rates of recommendation for additional imaging. EM providers also reported that outside imaging impacted major components of patient care, commonly increasing diagnostic confidence, providing unexpected information, influencing patients’ final disposition, changing diagnostic or management plans, and reducing repeat imaging rates. Both radiologists and EM providers confirmed that these effects were magnified when they had access to the outside images versus only the outside reports. Of the six fundamental aims of modern health care systems laid out by the Institute of Medicine more than 15 years ago [13], at least four (safe, effective, timely, and efficient) are violated by the difficulties in seamlessly accessing outside images and reports. “Shared knowledge and the free flow of information” and a “continuous decrease in waste” are cornerstones to achieving these aims [13].

Of interest, despite the substantial perceived added value of outside images and reports, respondents did not have uniformly high confidence in outside imaging examinations. Both radiologists and EM providers had somewhat lesser confidence in the outside imaging interpretations than in the actual images, and they had substantially lower confidence in outside imaging examinations performed at community facilities compared with academic facilities. Although these sentiments may not be accurate and may represent academic medical center bias, such concerns may still pose an important barrier to reducing repeat imaging in practice. Furthermore, confidence in outside images and reports was substantially lower among radiologists than among EM providers, potentially related to radiologists’ ability and desire to directly interpret the examinations themselves. These findings suggest that automated solutions for efficient outside image sharing may require reinterpretation of the outside imaging examinations by radiologists where the patient is currently receiving care in order for outside imaging examinations to achieve the same impact as prior examinations performed within the same institutional network.

Our survey also highlights substantial challenges in accessing outside imaging examinations that may also serve to undermine the potential clinical value of such examinations. Radiologists reported moderate confidence in accessing outside images and reported lower confidence in accessing the outside reports. Radiologists’ perceived level of success in accessing outside images may relate to the fact that, at our institution, once the outside images have been imported by the care team, they are then presented to the radiologist in a fully integrated and seamless fashion within the local PACS, without the radiologist needing to take specific actions to locate the outside images through a portal or other unique mechanism. In addition, the frequency with which outside images are provided via CD may increase the overall availability of outside images, even if the images cannot or are not in fact being accessed through the regional HIE or Epic Care Everywhere. However, reports are placed into the electronic health record, not the PACS, making access more cumbersome for radiologists, whose workflow is primarily PACS based. Moreover, only approximately one-fifth of radiologists had accessed prior imaging reports through Epic Care Everywhere (compared with four-fifths of EM providers). In a striking and pragmatic illustration of the limitations of the region’s HIE, not a single radiologist acquired reports through this mechanism.

In comparison, EM providers reported very poor success in accessing both outside reports and images. This may be related to EM providers being on the frontline in the initial attempts to track down the outside studies. In addition, EM providers are more likely than radiologists to turn to mechanisms beyond the traditional EHR in search of outside imaging examinations, as is indicated by the fact that 15% of ED staff had accessed reports through the stand-alone Healthix portal. Nonetheless, the number of staff using the portal remained far less than the number of EM providers accessing prior imaging reports within the EHR through Epic Care Everywhere. These observations highlight the barriers imposed on outside report access in clinical practice when use of a separate system is required.

Although not specifically probed by our survey questions, comments by the EM providers called particular attention to the challenges of accessing outside images through CDs. EM providers reported high levels of frustration in trying to directly access imaging examinations found on CDs, at times being unable to access the examinations at all through this mechanism. Our institution has made available a system for provider-driven importing of outside imaging examinations on CDs into both the local EHR and PACS, although survey findings suggest that even this system is not being fully leveraged. Given the observations, future effective image sharing solutions should seek to eliminate the role of image transfer through use of a CD or other physical means altogether.

To our knowledge, a paucity of data exists regarding radiologists’ and EM providers’ perceptions of the quality, value, and challenges associated with the use of outside imaging in the ED setting. A national survey of the membership of the American Society of Emergency Radiology reported that the most common reason for repeating outside imaging studies, even when outside examinations were available was that the outside examinations were nondiagnostic, missing sequences, or had improper scan technique, aligning with our survey’s finding regarding concerns about outside image quality [14]. A qualitative interview-based study of 29 EM providers regarding their thoughts about HIE in general found that outside records could serve to change clinical decision making, increase confidence in the existing plan even if unchanged, and decrease additional imaging requests [15]; these themes align with the observations in our study. We are unaware of previously published data directly comparing radiologists’ and EM providers’ perceptions of outside image sharing. In addition, our investigation is unique in that it highlights a particular concern regarding the confidence of radiologists and EM providers alike in the quality of an outside radiologist’s interpretations of examinations performed at outside community facilities. Given these concerns, some health care systems have implemented formal processes for second-opinion interpretation and reporting of outside imaging studies in the ED setting [16, 17].

The present study supports the need for wider adoption of integrated, seamless image sharing solutions that mimic existing workflows and satisfy basic human factors engineering design principles [18, 19]. Such solutions must provide access to both outside reports and images and should minimize the need for providers to engage separate portals, systems, or sign-ins or even to search separate sections and fields within existing systems. The solutions would ideally fully integrate the outside examinations into the EHR for EM providers and into the PACS for radiologists, such that the examination would be seamlessly accessed and viewed using the same workflows as for imaging examinations performed at the local institution. For maximal impact, the outside imaging examinations would be automatically retrieved and available within the local EHR and PACS for EM providers and radiologists, even for patients not undergoing imaging at the local institution. Although cloud-based image-sharing solutions have become available in recent years [10], so far these have had limited penetrance throughout the medical community and have not yet achieved the degree of complete and seamless automated integration of images and reports into the local EHR and PACS, without any additional workflow steps for radiologists or other providers, that we have discussed. Providing patients the ability to directly download and share their images and reports and reports through the patient portal represents another potential solution for improving the availability of outside reports and images.

The present study has a number of limitations. First, we recorded the perspectives of radiologists and EM providers from a single institution. Second, the response rate was limited, although this is typical of physician surveys. Finally, our data provide information solely regarding perceptions about image sharing and do not objectively show actual challenges in access or benefits for patient care.

In conclusion, radiologists and EM providers perceive outside image sharing to have high value for patient care in terms of quality and safety, helping to reduce rates of repeat imaging, reduce rates of recommendation for additional imaging, improve diagnostic confidence, and influence management plans. However, considerable challenges exist in accessing both outside images and reports, and providers are unlikely to access separate systems to attempt to do so. Adoption of information technology solutions for fully automated integration of outside images and reports into existing systems and workflows would help maximize the clinical impact of the outside examinations. Nonetheless, even if seamless integration is achieved, potential issues remain regarding providers’ confidence in outside studies, particularly those performed at community facilities.

APPENDIX 1:

Survey on Perceptions Regarding Outside Imaging

Radiologist Survey

Role: resident/attending

Years since medical school graduation:

Ia. For imaging examinations performed at outside academic facilities, I am confident in (strongly agree, agree, neutral, disagree, strongly disagree): the quality of the images themselves the quality of the outside radiologist’s interpretation my ability to successfully and efficiently access the reports my ability to successfully and efficiently access the images Ib. For imaging examinations performed at outside community facilities, I am confident in (strongly agree, agree, neutral, disagree, strongly disagree): the quality of the images themselves the quality of the outside radiologist’s interpretation my ability to successfully and efficiently access the reports my ability to successfully and efficiently access the images II. When I have access to reports for outside imaging studies, it (always, frequently, sometimes, rarely, never): helps to reduce rates of recommendations for additional imaging for incidental findings changes my diagnostic interpretation of the current imaging examination increases my confidence in my diagnostic interpretation of the current imaging examination provides unexpected useful information for the patient’s care III. When I have access to images for outside imaging studies, it (always, frequently, sometimes, rarely, never): helps to reduce rates of recommendations for additional imaging for incidental findings changes my diagnostic interpretation of the current imaging examination increases my confidence in my diagnostic interpretation of the current imaging examination provides unexpected useful information for the patient’s care IV. I have accessed any patient’s prior imaging report by reviewing it (Y/N): in Epic in Epic Care Everywhere in Healthix through Epic in Healthix through separate portal V.Please record any additional comments about report or image sharing here:

ED Provider Survey

Role: resident/attending/physician assistant

Years since medical school or PA school graduation:

Ia. For imaging examinations performed at outside academic facilities, I am confident in (strongly agree, agree, neutral, disagree, strongly disagree): the quality of the images themselves the quality of the outside radiologist’s interpretation my ability to successfully and efficiently access the reports my ability to successfully and efficiently access the images Ib. For imaging examinations performed at outside community facilities, I am confident in (strongly agree, agree, neutral, disagree, strongly disagree): the quality of the images themselves the quality of the outside radiologist’s interpretation my ability to successfully and efficiently access the reports my ability to successfully and efficiently access the images II. When I have access to reports for outside imaging studies, it (always, frequently, sometimes, rarely, never): helps to reduce rates of repeat imaging in the emergency department changes the diagnostic or management plan for the patient increases my confidence in the diagnostic or management plan for the patient provides unexpected useful information for the patient’s care influences the patient’s final disposition III. When I have access to images for outside imaging studies, it (always, frequently, sometimes, rarely, never): helps to reduce rates of repeat imaging in the emergency department changes the diagnostic or management plan for the patient increases my confidence in the diagnostic or management plan for the patient provides unexpected useful information for the patient’s care influences the patient’s final disposition IV. I have accessed any patient’s prior imaging report by reviewing it (Y/N): in Epic in Epic Care Everywhere in Healthix through Epic in Healthix through separate portal V.Please record any additional comments about report or image sharing here: