Article Date: 5/1/2010

Getting the Picture
image management

Getting the Picture

Integrating images and diagnostic equipment into electronic health record software.

Salem, Ohio
Plano, Texas

With the American Recovery and Reinvestment Act (ARRA) signed in to law February 17, 2009, there has never been a better time for deploying an electronic health record (EHR) system in your practice. After all, you're now eligible to receive up to $44,000 from Medicare through the Health Information Technology for Economic and Clinical Health (HITECH) Act by using these systems. (See “Image Management System Vendors,” below.)

Image Management System Vendors

Carl Zeiss Meditec (Forum)

Chace & Associates (iViews)

Kowa (DigiVersal)

OIS (Symphony Web)

Topcon (EyeRoute)

As a brief aside, EHR is defined as the aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one healthcare organization and is managed and consulted by licensed clinicians and staff involved in the individual's health and care.

An electronic medical record (EMR), on the other hand, is the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual's health and care.

Therefore, by these definitions, an EHR is an EMR with interoperability (i.e. integration to other providers' systems).


EHR deployment presents our image dependent profession with a new set of challenges that impact workflow, staff education, image management and equipment interfaces. Perhaps the biggest challenge lies in retrieving “the picture” (diagnostic images and other evidence documents) in an exam room where we don't have direct access to diagnostic equipment, but where we may have access to a computer.

In this article, we address the methods for employing diagnostic testing interfaces, software for viewing images and documents in your EHR and the need to plan for interoperability, as the scope of electronic communications continues to evolve. It's what we like to call “getting the picture while going and getting green.”

Methods for interfacing

The two basic methods for equipment interfaces are direct interfaces and indirect interfaces. A direct interface allows data from your diagnostic equipment to auto populate directly into the appropriate data fields in your EHR. (See figure 1, below.) An indirect interface enables you to access the data from your diagnostic equipment by selecting the appropriate “link” icon from your desktop or EHR system, which then either deploys the native software for the diagnostic equipment or allows you to view an evidence document from a diagnostic device. (See figure 2, below.)

Figure 1: This is an example of a direct interface. Selecting the Marco TRS-5100 item from the drop down menu auto populates the refractive data, Keratometry readings, pupillary distance, binocular data and acuities directly from the equipment into your EHR.

Figure 2: This is an example of an indirect interface. The Optomap icon deploys the patient's images in its own review software. The Zeiss icon deploys Visual Fields in PDF or another format. Medical Correspondence and Biometry icons deploy items scanned into your EHR.

Digital refraction systems are an example of a direct interface, as they allow refractive data to auto populate EHR systems in the appropriate data fields. This eliminates errors associated with legibility and transcription, significantly reduces recording time and ultimately results in improved workflow. Further, the refractive data can auto-transfer to your practice management software and populate the lab order, again reducing the risk of errors.

Direct and indirect equipment interfaces require EHR and equipment vendors' interoperability for software development. Therefore, prior to choosing a diagnostic equipment solution, you must understand not only how the interface will work, but also who is responsible for the interface. Is it the equipment company or the software company? Who will actually be responsible for the deployment? These are questions you must ask.

Viewing software

Two types of viewing software are available: remote viewing software and workstation review software. This software is independent of the EHR but technically becomes part of it. Remote viewing software allows you to access any Microsoft Windows-based machine on your network, including diagnostic equipment. You can control, view and operate machines remotely from any other workstation in your office, even through the Internet.

For instance, while in an exam room, you can view ocular coherence tomography (OCT) findings from the OCT instrument, which is located in your diagnostic testing room. You can operate the OCT device annotating, printing or saving images as if you were standing right in front of it. The drawback to this option: You can't review data while someone else is using the device. In other words, a staff member cannot operate the OCT while you're viewing a separate OCT result. As a result, this viewing software option is best for low-volume diagnostic instruments.

Perhaps the most attractive feature of this option is it's free. You can download the free VNC Viewer at (VNC is an abbreviation for virtual network computing.) In addition, you can view your instruments remotely from outside your practice via Internet remote viewing software, such as

Combining these two technologies really packs a punch. You can access your desktop from the Internet, and use the VNC viewer to access any machine in your office. (See figure 3, below.)

Figure 3: You can put VNC viewer, image management and review software on the Start Menu of your computer for quick access during exams.

Workstation review software is available for many diagnostic instruments that you can load onto exam room computers to access diagnostic data. Its advantage: You can review data from the diagnostic instrument while a staff member or colleague is using the instrument on a different patient.

You can utilize the diagnostic tools the equipment supplier includes in the review software. Annotation, measurement, print, print to pdf and save tools make this a very attractive option for some instruments.

Before acquiring new diagnostic instruments, check review software price and compatibility with your EHR system.

Image management software

Accessing diagnostic tests and images in the exam room is becoming one of the biggest challenges in the technology-integrated practice. Be wary of EHR vendors who sell an easy “plug and play” solution, as true image management requires a carefully thought out plan.

Many EHR programs allow you to view one image at a time from the equipment interface, but what happens when you want to view multiple images from multiple instruments at the same time? How can you view multiple images from multiple instruments in one place? How can you access these images remotely in the exam room and from the EHR? Can you review images in the instrument's native software, or can you simply view saved images? The image management interface with EHR is important because it allows communication between the technologies that eliminate redundancies associated with multiple demographic data entry into your diagnostic equipment. Also, it's critical for the accurate diagnosis of many conditions.

For example, you must review OCT Cirrus cube data in the native instrument review software for a complete analysis. If you simply review “evidence documents” from the technician, you may miss critical images and as a result make an improper diagnosis. The management of many diseases, such as glaucoma, requires information from multiple sources.

The bottom line is that your decision-making is greatly enhanced when you can view a visual field, OCT and stereo disc image at the same time. You can achieve these capabilities by implementing and deploying an image management software solution with your EHR.

In summary, your EHR should be able to easily deploy imaging software, should allow for both capture and review capabilities, eliminate redundant patient demographic information and enable you to review an image in the instrument's native software. Further, your imaging software should allow for preferences.

For example, the review software should enable you to view all anterior segment images at once, or by date, or date range. You should be able to review images side by side and view multiple images at once. And, this should occur quickly, without delays in image download, which negates the efficiencies of the system.

It's very important to consider your own workflow and patient management processes when making the decision as to what image management software to choose in conjunction with your EHR. (See“Interoperability: Getting The Picture to Colleagues and Patients,” below.)

The future is wide open. With the emergence of SaaS (software as a service, or web-based) EHR systems, new and different instrument interfacing and image management methods will emerge. The important “take away” for you, the 2010 O.D., is be sure to understand the significance of diagnostic instrument interfacing, recognize this significance when buying new equipment, learn how to ask vendors the appropriate questions, and choose software that is evolving with the “real” times. OM

Interoperability: Getting The Picture to Colleagues and Patients

The electronic transfer of images has become a vital component for the future of the healthcare delivery system. Soon, you'll be able to access testing results and images through patient portals, which will reduce or eliminate the need for you or your staff to directly communicate with the patient for testing results, in many cases. Security, ease of image transfer, ease of image storage once received and ease of image review are all important components of interoperability.

Here are the three ways we currently send images to our colleagues:

1. Snail Mail

Time-tested, slow but sure. This is the most expensive option in terms of resources and the environment. Hard costs include you and your staff's time and the use of printers, printer ink and postage — all of which most doctors underestimate the costs. The recipient must save or scan the paper-based evidence documents. Scanning documents into the EHR just to shred the costly documents doesn't seem right even if it is the most common solution.

2. E-mail

This has become an efficient means of communication between healthcare providers. Some considerations of e-mail communication include:

Security. You or your staff should confirm the accuracy of e-mail addresses and utilize secure encrypted e-mail options.
Receipt acknowledgement. You or your staff should activate your e-mail's delivery and receipt options. Also, make sure the file size isn't too large for the e-mail servers. Compressed or zipped image files are smaller and faster, especially for multiple images. can be valuable in sending large files.
Documentation of communications sent and received. Make a note in the referral letter and save it in the EHR for outgoing communications. For incoming correspondence, cut and paste the e-mail message to a patient, and save the evidence documents to the EHR. You and your colleague's planet and pocketbooks smile on e-mail interoperability.

3. Online health records

Online health records are the least common but perhaps the best interoperability solution available. Confusion, apprehension and lack of interoperability standards and EHR integration are holding online solutions back, but their advantages are obvious. Your patients and/or colleagues have access to secure data 24/7. We simply put the web link, the user name and password in the patient's EHR for the data sent or received. Then, we send the link and login information to a patient or colleague via e-mail or snail mail. The recipient can also post the link and login data in the EHR, avoiding printing and saving or scanning evidence documents. Trees and plants are spared with this green option. A few online health record options:

Personal health records (PHRs). Personal health records from Microsoft and Google have been available for a few years. Microsoft's HealthVault ( offers options for providers and patients. Google's GoogleHealth ( offers options for patients. While we have yet to see how PHRs will impact the healthcare market, we think it's only a matter of time before EHR systems start connecting to PHRs.
Health information exchanges (HIEs). These are national, local and regional health information organizations that provide Internet portals to providers for health information exchange. “HIE,” and “RHIO” (regional health information organization) are often used interchangeably. (Soon, these organizations will help make up the National Health Information Net work [NHIN]). U.S. Health records ( is one of the first health information exchanges formed for portability of health information among providers. Once enrolled, you simply upload images and information, and send a link and login information to other providers who need patient information.

Dr. Lippiatt is CEO of Salem Eyecare Center, Inc., in Salem, Ohio. She is a technology consultant to the eyecare industry and a pioneer in EHR and healthcare information technology. E-mail her at
Dr. Castleberry is CEO of Plano Eye Associates, a group single-location private practice in Plano, Texas. He is a technology consultant to the eyecare industry and a pioneer in EHR. E-mail him at

Optometric Management, Issue: May 2010