Journal of Digital RIGINAL PAPERAn Interview with the Carequality Imaging Use Case ImplementersBlanca “Didi” Davis1,2,3· David S. Mendelson2,4,5 · Alan Swenson1,6Received: 19 August 2021 / Revised: 19 August 2021 / Accepted: 9 November 2021 The Author(s) under exclusive licence to Society for Imaging Informatics in Medicine 2021AbstractImagine you had a cell phone plan that only allowed you to call other customers within the same carrier network. That is thesituation most healthcare providers experience when joining a data sharing network. Carequality is a network-to-networktrust framework that brings together the entire healthcare industry to overcome this challenge by providing a national-level,consensus built, common interoperability framework to enable health information exchange between and among health datasharing networks. The RSNA partnered with Carequality in 2019 to develop an implementation guide to enable the ImagingExchange Use Case. The implementation guide was published in December 2019 for early adopters to sign up as implementers to the Carequality framework. Exchange standards must be clearly laid out so that all implementers can easily follow andbe held accountable to enable interoperability of medical imaging. The guide was reviewed and tested by implementers andapproved for production use in March 2021. Since the launch of the implementation guide, five Carequality Implementershave participated in Carequality’s Image Exchange Use Case: Ambra Health, Hyland, Life Image, Nuance, and Philips. Theseimplementers recognized a gap in image interoperability and the need for change and collaboration. Carequality has askedeach of the implementers to share their thoughts on issues pertinent to becoming an implementer and imaging interoperabilitywith the hope that the reader will gain insight as to the evolution of network-based image exchange.Keywords Interoperability · Imaging · RSNA · Standards · IHE · DICOMOn Dec. 2, 2019, Carequality presented the revised Carequality Image Exchange Implementation Guide Supplement,jointly developed by Carequality and the Radiological Society of North America (RSNA). Imaging data poses differentchallenges and is managed using different tools and differentstandards than clinical document data. But imaging’s placeas one of the highest value pieces of clinical informationunderlines the importance of image data exchange. Caregivers and patients are impacted by the lack of access to medical imaging in the USA today. Expanded standards-based* Blanca “Didi” [email protected] Sequoia Project, Knoxville, TN, USA2Integrating the Healthcare Enterprise (IHE) - International,Illinois, Oak Brook, USA3Global Consortium for eHealth Interoperability, Chicago, IL,USA4Mount Sinai Health System, New York, NY, USA5Icahn School of Medicine at Mount Sinai, New York, NY,USA6Carequality, Vienna, VA, USAexchange of medical imaging will enable innovation andimprovements that benefit clinicians and patients.Since the launch of the implementation guide, five Carequality implementers have participated in Carequality’sImage Exchange Use Case: Ambra Health, Hyland, LifeImage, Nuance, and Philips. These implementers recognizeda gap in image interoperability and the need for change andcollaboration. Below, Carequality has asked each of theimplementers to share their thoughts on issues pertinent tobecoming an implementer and imaging interoperability withthe hope that the reader will gain insight as to the evolutionof network-based image exchange.Tell Us a Little Bit About Your Company, ItsHealthcare Business, and Its Involvementin Image ExchangeAmbra HealthFounded in 2006 by a group of physicians, Ambra Health isa pioneer in the cloud digital health business. Today, Ambrastores, processes, and shares over 10 billion diagnostic13Vol.:(0123456789)

Journal of Digital Imagingimages, enabling improved patient care and research. Thereare more than 600,000 users in the Ambra Health networkacross 50 countries, improving care for millions of patientsaround the world.“Simply put, Ambra Health takes medical imaging likex-ray, CT, ultrasound and moves it to the cloud so hospitals, health systems and research institutions can getto it anytime, anywhere and doctors can focus on whatmatters most: patient care,” said Morris Panner, chiefexecutive officer of Ambra Health. “In the past, thistype of information was shared via CD or a dedicatedVPN line, a cumbersome and time-consuming processthat led to increased financial costs and delays in care.”What started as Image Exchange is now Enterprise Imaging with more than a focus on just getting a study from pointA to point B; it is about enabling telestroke, embedding AIinto imaging workflows, and it is about facilitating globalresearch and clinical trials through de-identification andadvanced research capabilities. It is about leveraging imaging to improve patient care in a clinical setting and patientcare globally through next-generation research.HylandHyland delivers Enterprise Content Management and Services globally to the healthcare marketplace. Hyland’s Enterprise Imaging solutions enable our customers to capture,manage, view, and share all imaging-related content acrossthe enterprise, regardless of specialty. Hyland’s commitmentto security and interoperability ensures that imaging content is available securely to support application integrations,research initiatives, and clinical access to content wheneverand wherever it is required.“Hyland has always been adopting standard and interoperability specifications as the architectural foundation of their Healthcare platforms,” said Razvan Atanasiu, chief technology officer healthcare at Hyland.“The Enterprise Imaging organization has supportedIHE XDS and XDS-I for a decade, and we continueto prioritize interoperability across all aspects of theorganization.”Life ImageLife Image is a large global medical evidence and imageexchange network facilitating access to medical information to a wide ecosystem of healthcare organizations andconnecting more than 13,000 facilities, 160,000 providers,58,000 global clinics, and tens of thousands of patients,orchestrating more than 4 million clinical encounters in13the USA each week. Life Image provides an essential service for patients and clinicians that enable diagnosis andtreatment. Accelerating access to medical informationsaves lives in addition to improving patient care, patientexperiences, and reducing cost in addition to saving lives.“Life Image was formed in 2008 to solve the toughest challenge in healthcare interoperability — theexchange of complex imaging data,” said MatthewMichela, chief executive officer and president of LifeImage. “We were born inside complex academicmedical centers struggling to improve patient carebecause of the lack of interoperability support byimaging manufacturers.”The first interoperability facilitated by Life Image provided access to imaging inside the firewall of a hospitalor system, allowing clinicians, regardless of location orclinical service, digital access to this vital clinical information. At that time, one department or clinical specialtywas unable to share clinical imaging with another unlessthey provided the films or images on CD via interdepartmental mail or courier. Life Image was the first organization to support imaging access enterprise-wide, regardlessof modality or manufacturer.The second phase of interoperability for Life Imagewas facilitating image exchange outside the firewall ofthe system, connecting the majority of major US medicalcenters to their community referral partners for imagingexchange. This started as a unidirectional point-to-pointexchange and evolved to a truly bidirectional exchange ofimaging and reports among a broad connected network,using the first and still most robust exchange application,called LILA (Life Image Local Application).The third phase of interoperability connected patientsand other healthcare organizations, such as life sciencescompanies, researchers, imaging centers, and artificialintelligence companies, and federal medical facilities toproviders, and each other globally.NuanceNuance is a leader in transforming patient care with AIpowered solutions for providers and patients. Used by 77%of hospitals and 10,000 healthcare organizations worldwide, Nuance unburdens healthcare teams by providingefficient ways to capture clinical information.Nuance PowerShare helps health information exchanges(HIEs) to become image enabled. Related, but not alwaysprovided via an HIE, is leveraging available MPI services tofacilitate further automation of the processes to access andexchange medical imaging data.

Journal of Digital Imaging“As an industry leader in the radiology IT space,Nuance noticed the challenges that existed with providing access to patient images,” said Nassib Khanafer,senior product manager at Nuance. “Nuance decidedto address this challenge with an electronic imageexchange solution.”PhilipsAt Philips, our purpose is to improve people’s health andwell-being through meaningful innovation. We aim toimprove 2.5 billion lives per year by 2030, including 400million in underserved communities. As a technology company, we — and our brand licensees — innovate for peoplewith one consistent belief: There is always a way to makelife better.Philips sees healthcare as a connected whole helping people to live healthily and prevent disease. We provide clinicians the tools they need to make a precision diagnosis, todeliver personalized treatment, and to aid the patient’s recovery at home in the community. All supported by a seamlessflow of data.As a leader in the complete imaging value chain, fromcreation to long-term retention, Philips knows the importance of seamless image exchange plays in improving quality of care, enhancing processes, and reducing cost. PhilipsInteroperability Solutions is a leading global supplier ofIntegrated Health Enterprise networks, and we support allrelevant IHE profiles which can be used by healthcare professionals to easily share patient information, enjoy collaborative workflows, and connect healthcare networks.Why Participate in the Carequality ImageExchange Use Case?Ambra HealthAmbra has always pursued interoperability, both via standards-based solutions such as those historically championedby RSNA, and through ad hoc DICOM connections betweengateways of different image exchange solution providers.Clearly, there is new momentum driven by TEFCA, bothin EHR data and in imaging data. As the industry pursuesstandards-based solutions today, and we see those standardsevolve in the future, Ambra will participate to ensure thatproprietary technology does not limit patient care or keyresearch.Furthermore, many hospitals and health systems still relyon CDs and outdated, on-premise technology for storing andtransferring medical imaging. The COVID-19 pandemicushered in a new sense of urgency. Ambra enabled facilitiesto move to the cloud to establish teleradiology for field hospitals, enable cloud viewing for specialists, provide imageexams directly to patients, ensure remote surgical secondopinions, and even anonymize COVID imaging exams forresearch studies.External forces like TEFCA and COVID-19 are accelerating the need for interoperability. “We (Ambra Health) viewCarequality as an extension of the work begun with RSNAfor interoperability. However, with Carequality there is alarger context of interoperability beyond imaging. Althoughthe challenges of exchanging imaging are far different thanthe challenges in exchanging other types of patient data,viewing all patient data under the same umbrella makessense for the patient, and makes sense for the healthcareproviders,” said Panner.HylandA customer pushes as well as other vendors who now implement the Carequality Image Exchange. At the same time, wehave always been an evangelist for basing Image Exchangeon the IHE profiles, like IHE XDS and XDS-I. Hyland hasembraced and will continue supporting major Healthcareexchange initiatives in North America (Seqouia’s RSNAImage Sharing Validation program) and the rest of the world(Dutch TWiiN, NHS Image Exchange foundations).“4’s commitment to standards-based interoperability inhealthcare aligns with the Carequality Image ExchangeUse Case,” said Atanasiu. “The adoption of and adherence to clear, well-defined standards is absolutelycrucial to health data interoperability. If vendors don’tconform to agreed-upon industry standards, then theclinical information these systems manage may remaintrapped in proprietary siloes.”Life ImageInteroperability in Imaging is one of Life Images core aims.“Life Image has a 10-year history of participating in interoperability innovation with the Radiological Society of North America (RSNA) and Sequoia. In 2011, Life Image was selected asthe clearinghouse for the RSNA’s National Medical Image Sharing Project,” said Michela. “As part of its initiative to promote astandards-based workflow for populating personal health record(PHR) platforms with patients’ medical image data, the RSNAselected Life Image to serve as a digital clearinghouse for a twoyear image-sharing project funded by a federal contract from theNational Institutes of Health/National Institute of BiomedicalImaging and Bioengineering. Life Image was among the firstvendors that the RSNA, in collaboration with The Sequoia Project, announced as successfully completing the RSNA ImageShare Validation program in 2016.”13

Journal of Digital ImagingFrom the start, Life Image has focused on interoperability and managing the technical complexity of imaging — alltypes, forms, and modalities — with some of the largest andmost complex medical centers in the USA. We recognize thevalue in supporting 1000 s of unique workflows, multiplestandards, and providing a platform that allows connectivity toother data types and networks. Life Image continues to supporta number of well-established data-exchange standards whichapply to complex imaging data and associated clinical information across our solution set such as FHIR, SMART, XDS,and DICOM or DICOMweb restful services.NuanceAs a long-time supporter of ACR and RSNA standards initiatives, Nuance believes it is important to contribute our inputand expertise to the ongoing development of the CarequalityImage Exchange.“We (Nuance) consider consensus-building approaches andparticipation by all stakeholders an essential step for standardization to address today’s challenges while enabling theradiology community to take full advantage of the opportunities enabled by interoperability and information-sharing,”said Khanafer.PhilipsAs a leading global supplier of IHE networks, Philips isencouraged that Carequality broadened the scope of information exchange to include imaging at a national level. “Fortoo long our customers have been limited by private imageexchange networks leaving collaboration gaps and challenges”said Mike Sharland, Product Manager for Philips Interoperability Solutions. Philips will continue to invest in industrywide standardization and interoperability programs to assistour customers in achieving the highest maturity stages on theHIMSS Analytics Digital Imaging Adoption Model and theirquadruple aim goals.What Have Been the Challengesof the Carequality Use CaseImplementation?Ambra“Ambra is still early on the path towards full implementationof the Carequality Use Case, and we are the first vendorsto pursue this implementation, so there are a few structuralissues that need to be worked through, but those roadblockshave been minimal. I think it will be even easier for vendorsthat come to the party now as some of those initial bumpshave been identified and removed. The IHE protocols are13complex, but the specification is generally complete thoughoften distributed across many different documents. Thematurity of the test tools has been a small challenge, butwe are working through that with the Sequoia Project,” saidPanner.Hyland“Hyland supports all the Carequality IHE transactions, butwe are just beginning to test the Carequality Use Case withother vendors. The XCPD transactions are so far Hyland’sbiggest challenge. Hyland has passed XCPD at numerousIHE North American and European Connectathons, howeverXCPD updates were required after reviewing the CarequalityUse Cases which are more complex than the IHE Connectathon XCPD test cases,” said Atanasiu.Life Image“Life Image continuously evaluates which interoperability standards and transactions to support as we innovate. Life Image is still in the early stages of implementing the Carequality Use Case. Working with thetop Academic Medical Centers in the country, werecognize it’s not deployment of the standards themselves that pose a challenge but rather the business andclinical processes surrounding those transactions thatcontinue to present a challenge. Privacy and patientsafety are of the utmost concern.”“Until healthcare providers and their Privacy, Compliance, Legal, Health Information Management and Securityofficials have confidence in automated patient-matching andthat the data being released is being consumed by an authorized healthcare entity, providers will remain highly reluctantto release clinical imaging based on endpoint transactionswithout manual review and authorization for release,” saidCristin Gardner, Vice President of Product at Life Image.“We must also consider the performance strain on technical systems or archives that require high availability,such as PACS. Information Technology support teamsare rightfully protective of these systems which cannotbe queried constantly, at random, and at high volumewhile simultaneously performing at the level neededfor Radiologists to detect cancer or Trauma Surgeonsto view the vital images they need in an emergent situation. Many hospital systems expect a level of controlor gating which allows them to load balance and ensurethese critical systems are not compromised. Any interoperability solution focused on imaging specificallymust address this unique requirement.”

Journal of Digital ImagingNuanceHyland“XDS and XCA show both the promise of enabling interoperability as well as the challenges of achieving it as technologies change and advance. The SOAP technology underlyingXD* itself illustrates the opportunities as well as limitations,” said Khanafer.With a vast product portfolio at their disposal, our customers have built image exchange solutions leveraging eitherthe Acuo VNA functionality and/or the NilRead advancedvisualization platform, which both support a large numberof IHE profiles used for interoperability and document sharing. Hyland’s support of FHIR and the IHE FHIR profiles:MHD, PIXm, PDQm, and PMIR delivers modern interoperable web services for cloud deployments. These solutionscan be deployed on prem or in a public or private cloud.Hyland also offers a patient portal (Hyland NilReadPatient Portal). Many customers are looking for integrationwith Epic Care Everywhere, which we endorse due to ourextensive support for IHE profiles embedded in our Healthcare platforms.Philips“As one of the first vendors to test and implement the Carequality Use Case, we are solving initial challenges interpreting and implementing comprehensive IHE profiles that canlead to testing tools and make broader adoption easier forvendors that follow,” said Shaland. Philips InteroperabilitySolutions platform is based on open, established standards,such as XDS, XDW, XCPD, XCA, HL7, FHIR, and DICOM,making our solution multi-vendor positive, and we welcomeand support vendors at every level.This Program Promotes Network‑BasedExchange and Exchange Between DisparateNetworks. What Other Exchange Services DoYou Offer (i.e., Image Enabled PHR) or SeeEmerging? What Are Your Customers Askingfor?AmbraThough we started as an exchange vendor, Ambra is a full CloudPACS offering. We see exchange as the foundation for numerousother enterprise imaging workflows — imaging archive, patientportals, referring physician portals, AI algorithm facilitation,de-identification for research, and/or algorithm development.Replacing the CD in getting imaging from point A to point Bis a necessary first step, but the secondary workflows that comeafter exchange unlock much larger value for our customers.These are still early days for interoperability. Most of theIDNs are interested in securing the imaging for optimal patientcare and are less concerned about the standards that are used.The healthcare providers want the imaging they need, butthey also want to avoid the imaging that might be extraneous (for example, filtering by body part or modality in prefetching). They are tied to their existing PACS and EMRinfrastructures, so it is not enough just to bring imaging totheir doorstep. Exchange providers need to allow imagingto work through the IDN in the way that works best for theIDN, and that can vary greatly from IDN to IDN.The standards we are using today will work quite well, butwe all know they will evolve, and we as trusted imaging partners need to commit to interoperability in whatever form it takestoday and in the future.Life ImagePatient access and ownership of clinical data will continueto be a focus for Life Image, and we expect to see a shift inindustry focus around this over the next 24 months. Mostpatient portals, including EHRs, cannot assemble, store,and share complicated diagnostic images that are criticalto treating chronic and complex conditions. For patientswith conditions such as oncological, neurological, COVID19-related conditions, as well as musculoskeletal illnesses,diagnostic images are especially important. With these conditions, imaging exams taken over time must be compared tobe clinically useful for diagnosis, treatment, therapy evaluation, and post-acute patient monitoring. “Unfortunately,most patients in the United States must wait to obtain theirown imaging data via CD, which is often unusable, and aburden to obtain,” says Gardner. “This data should be patientowned, and mobile in order to meet the demands of patientstoday. Under HIPAA, providers are required to give patients,upon request, access to their protected health information inthe form and format of the individual’s choosing, includingan electronic format and via a third-party application. Toaddress ongoing industry resistance and barriers to interoperability, new regulations released in March 2020 from TheOffice of the National Coordinator for Health InformationTechnology of the 21st Century Cures Act are mandatingthat patients be allowed greater control and access to theirhealth data and are targeting technologies that block information access.”Clinical support teams working with complex imagingdata will continue to push for integration with legacy workflows, systems, and portals. The industry is getting portalfatigue; HIEs and hospitals are no exception. Imaging datais not as straightforward as EHR data or clinical documentsin terms of workflow enablement and clinical usability.Complex clinical workflows and the usability of the data13

Journal of Digital Imagingmust be considered when planning for the future of imaginginteroperability. Simply exchanging the data from one provider to another does not make the data usable for clinical oradministrative teams as part of their existing workflows anddownstream system integrations. Data delivery that resultsin large-scale process change or inefficient manual workarounds for clinicians or clinical support staff will yield lowto no adoption.How the information is received, processed, accessed,viewed, tagged, normalized, and integrated all play a rolein clinical usability.NuanceNuance PowerShare helps health information exchanges(HIEs) to become image enabled. Related, but not alwaysprovided via an HIE, is leveraging available MPI services tofacilitate further automation of the processes to access andexchange medical imaging data.We are seeing requests from HIEs, IDNs, and other thirdparties to image-enable their applications via APIs, typicallybased on simple REST services.expect to be able to analyze the flow of data across theirenvironment to drive operational improvements and performance,” said Sharland.“In the era of precision diagnosis, healthcare professionals need a comprehensive patient medical record thatincludes the patient’s imaging studies. This complete patientrecord is critical to improve quality of care, to enhance processes and reduce cost,” said Frank Laarakker, Product Management Lead for Interoperability Solutions at Philips.Availability of Data and Material Not applicable.Code availability Not applicable.DeclarationsEthics approval Not applicable.Consent to participate Not applicable.Consent for publications Not applicable.Competing Interests The authors declare no competing interests.PhilipsPhilips Interoperability Solutions is a leading global supplierof IHE XDS networks, and we facilitate patient documents andimaging data exchange at local, regional, and national levels.“Our partners look to Philips to help them remain currentwith legislative requirements, standards, and technology;however, more importantly they are asking to provide theirusers with relevant patient information to make the best clinical decisions at the point of care. Additionally, customers13References1. Carequality, https:// careq uality. org2. Carequality Image Exchange Implementation Guide Supplement,https:// careq uality. org/ wp- conte nt/ uploa ds/ 2019/ 11/ Imagi ng Data- Excha nge- Imple menta tion- Guide- v02. pdf3. RSNA, https:// www. rsna. org/Publisher's Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.

Nuance Nuance is a leader in transforming patient care with AI-powered solutions for providers and patients. Used by 77% of hospitals and 10,000 healthcare organizations world-wide, Nuance unburdens healthcare teams by providing ecient ways to capture clinical information. Nuan