Why can’t image sharing work like Netflix?

The average American family moves every five years and 16 times during an average lifetime. My last move occurred in 1995 when I left my sleepy hometown in southeastern North Carolina to attend college. Over the next 15 years I remained firmly planted in my adopted hometown of Chapel Hill, NC, as I attended undergraduate, graduate, and medical school and completed my residency.

When time to apply for fellowships rolled around, my family and I decided to venture beyond the comfort of the Chapel Hill town limits. Statistically, we were due for a move, but little did we know we would make up the stagger (and then some) on this statistic.

In fact, we have moved five times over the past four months. I dragged my wife, newborn son, and all of our possessions across the state of North Carolina before finally landing in New England. Two broken lamps, one damaged shelf, and three pairs of lost jeans later we are starting to settle into our latest (and hopefully last) apartment in Cambridge.

While we have experienced a good deal of upheaval in our lives over the past few months, the one constant throughout this time has been the little red envelope from Netflix that has faithfully followed us to each new address. After each move I logged into my Netflix account, updated my address, and voila! The little red envelope would be waiting for us two days later (unlike the rest of our mail, which would arrive weeks later plastered with up to four forwarding stickers on each piece). Unfortunately, the ease with which we access outside imaging studies favors the route of my forwarded mail and not that of the Netflix system.

Last Thursday, as my colleagues and I reviewed the case of Mr. Jones, I realized radiology could learn a few things from Netflix. Mr. Jones was sent to one of our outpatient facilities to have an ultrasound of his thyroid gland. The requisition stated, “evaluate for mass.” The technologist did not discover a mass or detect any worrisome lesions and sent Mr. Jones on his way. On further review, my attending noted what she believed to be a mass lesion extending off the inferior margin of the left lobe of the thyroid, but she was not sure. As a result, Mr. Jones was called back to the clinic two days later to follow up on this questionable mass.

When Mr. Jones arrived, the attending performed the exam and, in talking with the patient, discovered that a chest CT had been performed at another hospital and demonstrated a large exophytic mass lesion extending off the lower pole of the left lobe of the thyroid. Further sonographic scanning revealed that there was indeed a mass extending from the left lobe. My attending was correct in her original suspicion, and we were more confident in our findings because of the results of the chest CT.

However, as my colleagues discussed how best to biopsy the mass, we were unable to access the chest CT. Why? Because the study had been performed at a sister institution down the road, and those images were not available on our PACS. Fortunately, the patient was able to provide us with a CD of the images. But alas, it would not load onto our PACS viewer. We now grappled with the question of whether we should reradiate the patient by ordering a new CT, since information gleaned from the study would affect our approach for biopsy. Without it, we could not determine which modality would allow for visualization of the safest window for accessing the lesion. Fortunately, one of our tech-savvy fellows was able to load the CD on his personal laptop and, after review, a CT- rather than ultrasound-guided biopsy was planned.

I find it unfortunate and frustrating that I am able to access the latest Hollywood blockbuster more easily than Mr. Jones’ chest CT. Why couldn’t Mr. Jones just log into a website, change his location, and allow his images to instantly stream to our network? Redundant exams not only generate up to a staggering $8 billion in wasteful medical expenditures each year, but also cause unnecessary radiation exposure to the patient, the adverse affects of which are still not fully understood.

Patients are seeking more consults from specialists at a variety of institutions due to more access to medical information on the web. Imaging has become a critical tool in the diagnosis, therapy, and management of patients. Without access to prior imaging, unnecessary energy and resources are expended. Private companies, such as lifeIMAGE, are developing cloud-based solutions that allow for timely and efficient image sharing, but government funding to support such initiatives on a national scale is generally lacking. Having Avatar waiting in my mailbox at the end of the day regardless of how many times I may move is nice, but having access to Mr. Jones’ chest CT is much more important.


Dr. Krishnaraj is a clinical fellow in the abdominal imaging and intervention division, department of imaging, at Massachusetts General Hospital/Harvard Medical School. He can be reached at akrishnaraj@partners.org. References
1. Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484.
2. lifeIMAGE