Article Date: 7/1/2008

Digital Imaging Soars to the Next Level

Digital Imaging Soars to the Next Level

Ophthalmic image management systems will enable you to store, evaluate and compare digital images from different modalities from any remote location.


Going digital sounds as familiar today as going for a walk, and now's the time to take the next step in digital imaging. The use of ophthalmic image management systems will give you the opportunity to store all of your digital images and data in one place and view all of it from any office location. Just as you use the Internet to view a Web site for your local weather forecast, you'll use a secure server to access a patient's optical coherence tomography (OCT) scans and other images from your remote offices — or anyplace with Internet access.

Software developers and device manufacturers are striving to develop standardized data and image formats to facilitate the communication of data electronically. But if you're ready to implement an integrated image network, you can profit from the advantages and convenience that ophthalmic image management systems have to offer.

Read on to find out how physicians are using these systems to improve diagnosis and disease management, and learn about the challenges that lie ahead.

Paper or Integrated Image Network?

Many practices have gone digital. That is, they use diagnostic devices that take digital images, although technicians often print the images and file them. There's no more photo-processing, but the hard-copy approach is the same.

Lon Dowell, director of marketing, Imaging Products, Topcon Medical Systems Inc., in Paramus, N.J., has spent several years working in ophthalmology and medical informatics, an emerging field that focuses on the analysis and dissemination of medical data through computer applications to various aspects of health care and medicine.

"Connectivity bridges gaps in medical devices to network instruments together. Informatics manages the data output from these machines in useful ways for enhanced diagnosis and treatment management, and provides easy access to images from various locations," he explains. "Ophthalmology uses all of the current high-end diagnostic devices, such as spectral domain OCT (SDOCT) and digital fundus cameras, and it takes streamlined medical informatics to bring together the large amounts of data created by these tools. The goal is to reduce the time the doctor must spend searching for images and enable him to simultaneously analyze images from various modalities. Right now, Topcon is focusing on connecting vision through its EyeRoute System."

Michele C. Lim, M.D., associate professor of ophthalmology, vice chair and medical director at the University of California, Davis, department of ophthalmology & vision science, in Sacramento, Calif., has been using the EyeRoute ophthalmic image management system (Anka Systems Inc./Topcon Medical Systems Inc., Paramus, N.J.) for almost 2 years at the university's main department site and at two remote locations.

The EyeRoute ophthalmic image management system (Anka Systems/Topcon) offers practitioners easy access to old and new images.

"[Using the EyeRoute] has made a huge difference for us," Dr. Lim explains. "Before, we had to print digital images, put them on a paper chart and then fax the chart to other locations. Now we can go to a computer and view the whole database from any location through a secure Internet browser. It helps organize my practice and helps me keep track of patient studies."

As a glaucoma specialist, Dr. Lim needs to analyze a series of images to detect glaucomatous changes over time. Not only is she pleased with the ability to view images side by side on her computer screen, but also with the reliability of locating the images.

"I'm not searching old charts and files for an image from 5 years ago," she says. "I know the historical data will be right there with the current data, so diagnosis is more efficient. In fact, when physicians realize they can look at images from 1 month to 5 years ago, I believe they'll order more images and analyze them more often."

IT director Patrick Beesley, at Sabates Eye Centers, a group of seven offices in the Kansas City area, built a digital platform from the ground up. He describes the practice's IT department as "small, but aggressive about integrating new technology and exploring new ideas." Ten years ago, one of those ideas involved a home-grown approach to digital fluorescein angiography that called for replacing an analog camera with a digital one. The practice progressed through several iterations of digital image management over the years, finally settling on the EyeRoute system.

"We interface the visual field, fluorescein angiography, topography, the Microperimeter MP-1 (Nidek), a GDx (Carl Zeiss Meditec), two OCTs and an UltraScan (Alcon)," Mr. Beesley says. "The doctors and techs don't have to be involved with how the system works — they just hit "print," and the image is transmitted to the EyeRoute system, which indexes the image and shows it in an Internet browser window."

Response to the EyeRoute has been positive. "It's an absolute necessity," Mr. Beesley says. "We use electronic medical records (EMR), so without EyeRoute, we'd have to scan all of our paper reports. The [EyeRoute] saves time and expense, and the doctors are enthusiastic about viewing all of their data side by side."

Matter of Compatibility

Because of the enthusiasm, practices feel the pressure to convert images, data and patient records to a digital format and reduce the potential for errors through EMR. Software developers feel the push to gather data together in ophthalmic image management and EMR systems. And the software and hardware industries feel the need to develop standardized data and image formats to effectively communicate medical information electronically.

All claims made by manufacturer

Until digital imaging becomes standardized, full integration remains a challenge. "Different devices have different proprietary software, so they don't necessarily communicate with each other," Dr. Lim says. "That's why third-party software has to tie these devices all together. Radiology is already there. Ophthalmology should be next in line."

Standards for medical information and image formats already exist. Digital Imaging and Communications in Medicine (DICOM) is a widely accepted industry standard for medical imaging. DICOM is endorsed by the Integrating the Healthcare Enterprise (IHE) Eye Care initiative. It defines how devices should format their images and how they should communicate data electronically. If all devices use these standards, they can exchange, combine, export and network data freely on the network.

Mr. Beesley offers an example: "Only a small number or our devices are DICOM compatible. The images are exported or extracted from the devices in a variety of formats, such as jpeg, TIFF, PDF and PCL," he says. "The DICOM standard will allow device manufacturers to provide a consistent format that's easily processed by the image management system." Mr. Beesley further explains that "a DICOM file consists of two parts, meta-data and the images or photos. The meta-data contains information, such as the patient's demographics and date of service, but it goes much further than that."

According to Mr. Beesley, a future with DICOM-compatible devices looks promising. He says that the modalities and the image management systems will be capable of seamless workflow made possible by DICOM HL7 standardization. The front desk staff will make an appointment for a new patient and type the patient's demographics into the system. Based on the appointment type, the system will recognize that the patient needs a visual field test, and it will transmit the demographics information to the DICOM-compatible visual field machine.

When the patient arrives, the machine will be ready for her at 1 p.m. The technician won't need to enter patient data into the device. Once the test is complete, the patient data and visual field image will continue to the next steps, such as prompting the provider for interpretation, assigning a procedures code for proper billing and/or sending a message to a referring physician. The opportunities for human error, such as typos, and the time it takes for staff and physicians to enter data and complete other documentation, will be drastically reduced.

Mr. Beesley predicts that DICOM will be slowly integrated into diagnostic equipment. Complying with new standards requires a lot of effort on the part of equipment manufacturers. Hopefully they'll recognize the benefits standardization provides to a digitial office.

"If you buy something new today, it may be DICOM compatible," Mr. Beesley says. "Our recent purchases have been DICOM compatible, but it's still something we need to ask for." He recommends that you look for this standardized format in your new purchases from this point forward. "Even if the purchase of an ophthalmic image management system is on the horizon, make sure the device you buy today allows for DICOM formatting, so you'll have a better interface experience."

All claims made by manufacturer

Shopping the Options

If you're exploring ophthalmic image management system options, consider how you want to view and integrate your images, as well as where you want to access them.

"The primary evaluation criteria for us are speed and image layout," Mr. Beesley says. "The initial success of an image management system is determined by the speed at which it indexes and makes the image available to the doctor." Diagnostic images can be large files, so the system must strike a balance between file size (speed) and maintaining the integrity of the image. A practice with remote locations should consider bandwidth requirements for the increased traffic on the network.

"Years ago, we had a system that required 15 to 30 minutes to download images from our remote locations," Mr. Beesley continues. "This delay caused a distressing bottleneck in our workflow. Now we use EyeRoute. It's much faster and integrates well into our EMR templates. Doctors want to look at images, such as fluorescein angiograms and OCT scans, side by side. We required a system that enables physicians to point, click and view full-size images on one screen."

Says Dr. Lim, "Obviously, this is the direction in which medicine is going. Image management systems, such as the EyeRoute, benefit the practice." She advises practitioners considering image management systems to be assertive about talking to vendors. "Companies often are willing to tailor their packages, so that smaller practices can afford them, too."

Right now, there are only three vendors of full ophthalmic image management systems: Medflow and RADinfo Systems partnership, Ophthalmic Imaging Systems Inc. (OIS) and Topcon Medical Systems Inc.

Medflow and RADinfo Systems offer an image system called oiPACS, which was created specifically for ophthalmology. The software is designed to "seamlessly integrate satellite offices across wide-area networks and provide remote access to your data," Mr. Beesley says. It integrates ophthalmic devices, practice management software, and EMRs, and it complies with the IHE Eye Care initiative. The modular system can be tailored to a practice's needs, and it can automate technical and professional billing.1

OIS offers IMPAX for Ophthalmology, a digital imaging system that allows doctors to view, store and distribute images from fundus cameras, slit lamps, ultrasonography devices and other imaging modalities from a single workstation. The company's OIS WebStation is a complete server, storage and remote-access system. From any Web browser, it enables physicians to retrieve patient tests, reports and images from fluorescein and indocyanine green angiography exams, OCTscans, visual fields and other diagnostic modalities.

All claims made by manufacturer

The EyeRoute from Topcon consists of a basic office ASP and web-based system, with capture stations, viewing stations, central patient records and central storage. Ophthalmology departments can capture images at multiple stations, automatically store them on a central network, view them from multiple locations and back up the studies to servers, videotape or DVDs for disaster recovery. EyeRoute can communicate with hospital information systems, and with additional modules, clinicians can review data and images on the Internet from any location.2

Converting to Digital

Some practices are fully electronic, others are just beginning the conversion and still others fall somewhere in between. The important thing is to make a start and be prepared for new developments.

"The earlier you digitize your images, the better, because when you implement an ophthalmicimage management system and EMR, you'll have a lot more history," says Mr. Beesley. "I think that using an image management system is a great first step toward EMR. It requires no extra effort from the tech and doctor, and you don't have to outfit the entire practice with hardware or additional bandwidth to start — just get something scalable so that you'll be prepared to take the next step. We're fully electronic, but we're still looking ahead to integrating to video, which will require some bandwidth optimization and server space."

Dr. Lim and her colleagues are looking ahead to expanded electronic records as well. "Now we're working on integrating the images into our EMR system, along with all of our patient documentation, prescriptions and so on," she explains.

As practices progress, software also will advance. "Today, doctors look at images onscreen and develop a diagnosis and treatment plan," says Mr. Dowell of Topcon Medical Systems Inc. "Soon they'll pull up the images from these different devices, and next-generation software will perform an advanced review and analysis of the data.

All claims made by manufacturer

Instead of doctors simply comparing, measuring and annotating images as they do now, they'll be able to also develop optimized treatment plans via software driven by compound analysis. The power of these review applications working together could give physicians greater ability to detect disease and progression. They'll get much more from their images than they ever expected they could." OM


1. Medflow and RADinfo Systems team up to launch Ophthalmology PACS. View the press release at Last accessed June 5, 2008.

2. Topcon Medical Systems Inc., Paramus, N.J. For product information, go to: Last accessed June 5, 2008.

Optometric Management, Issue: July 2008