Navigating Ongoing Issues of Image Ownership and Access in Radiology

Who owns the images in radiology?

There have been more than a few write-ups on the matter over the years. You can apply a high multiplier to whatever that number might be if you want to guess at how many times it has been discussed by radiologists, clinicians, policymakers, even patients.

I have never been too interested in such ownership and, for practical purposes, I think I am in the vast majority on this. I don’t need to own the images. I just want access to them. Let me conveniently eyeball the pix with an interface that allows me to extract the details I am seeking.

That is easier to arrange than it used to be. When I got into this field, if you wanted to review imaging, you needed to collect a jacket of films from someone’s radiological file room. If you wanted to actually keep some for yourself (or deliver them to a third party like a subspecialist), you would need the facility to make extra copies for you. Maybe you would pay a small fee.

Enter the film-less era, in which computer memory became ever cheaper, and other options emerged. You could have the study put on storage media to plug into whatever computer you liked. Someone could email you key images if those images were all you needed. They could put stuff on Google Drive or other “cloud” options, and grant you access. An increasing number of rad groups and hospitals have online portals that allow image review.

That sounds like an emerging golden age for image access, doesn’t it? Not so fast partner.

Not all “access” is created equal. Back in the day of films, copies were often of less-than quality. That continued into the age of portable media. CDs routinely spat disclaimers onto the users’ screens: “Not for diagnostic purposes,” a medicolegal necessity emphasizing that what was on the disk was less than what a rad would see by pulling up the original study on PACS.

As a rad (or other individual capable of interpreting imaging), one found that it wasn’t only the images that got dumbed down, but the interfaces for viewing them. Sometimes, you didn’t even get viewing software to go with the imaging files. If you didn’t have your own software for the purpose, you might as well use the CD for a coaster or a small Frisbee.

Some helpful individuals out there made “freeware” you could download to view studies. Of course, there was always an incentive to pay for the premium version. The incentives may have included better features, less interruption by ads, or the absence of a timer counting down to a day the software would stop working for you.

That freeware, or even the viewing software that got included on some of the CDs/DVDs, was never as good as a full-on PACS. Before interpreting any images at all, the user would first set about figuring what all the controls were and gradually discover which controls simply weren’t available. “Why don’t they have pre-set window/levels on this?” “How come I can’t measure anything?” “Is there no ‘refresh’ button? Do I really have to close and reopen everything to undo the changes I have made?”

If you have any experience with this stuff, you know that complaining about such things means you have already scored a minor victory by getting the software to run at all. Often, it won’t. The disk spins in futility as your drive fails to read it, or your PC crashes. Is it your machine’s fault, or did they not write the disk properly?

I have gotten software to run, only to find that no actual patient files made it to the disk. It makes me wonder just how frequently techs, after making a copy, take a moment to pop it into a computer to make sure it is, in fact, a usable copy.

The rise of rad group “portals” sidesteps these problems but introduces others. In addition to software errors and episodes of server dysfunction, they have built-in policies that can impede access. For example, I recently discovered that one portal doesn’t allow outsiders to view images until the reading radiologist has rendered his or her interpretation, or a certain amount of time has passed to allow the referrer to see things before the patients do.

That makes a certain sense. It drives rads and clinicians nuts when patients get ahold of their results, lickety-split, and start frantically ringing up their offices before the docs have had a chance to be ready. It seems that there can be too much access at times.

On the other hand, if the digital workflow fails to tumble properly, the “green light” never gets lit to allow patients (or their friend/relative radiologists) to view images and reports. A friend with an ankle MR, for instance, was hoping to get my two cents, and gave me his patient portal login info. The exam was over a week old, but the images were still nowhere to be found: “Study being processed.” It was just as well. I advised him that I was so rusty with ankles that he could probably have read it almost as well as I.

This past week, when my lady was getting a C-spine scan, I advised her to get a disk, just in case the facility’s portal misbehaved. They showed me though. The disk contained only one image from each sequence of the MR (lucky me, I got two pix from the localizer). I turned to the portal, which of course was down for the day being that it was a Friday afternoon, I knew there was no way things would be back up and running until the next week.

The consensus has been that the facilities that perform imaging and maintain the files “own” the files. I think that is probably the best take on things. If you told me I owned the imaging I had ordered, or which had been done on me, but your faulty disks or portal were keeping me from “my” digital property, I think I would find my lack of access to it exponentially more infuriating.