The elusive economics of enterprise imaging

How much must radiology spend to do its part— and what does the specialty get for it? 

From the average modern patient’s point of view, having all one’s doctors able to access all one’s medical images ought to be a given. That includes not only images captured by radiological “invisible light” machinery but also by “visible light imaging,” meaning the photos and videos that are now routinely getting snapped and filmed in exam rooms and procedure suites. Smartphones are, in many ways, the new stethoscopes. Add in endoscopy videos, point-of-care ultrasound loops and pathology slides—none of which completes the list—and you have a hint of the breadth of the gathering expectation. 

After all, this is the age of digitally connected everything and limitless, affordable cloud storage. Everyone under a certain age know this. Average modern patient: If I can go online to quickly store, retrieve and share all my music, photos and videos—and to find, order and receive almost any product made almost anywhere in the world—shouldn’t my doctors be able, as long as I’ve given my permission, to fetch just about any of my medical images from just about anywhere in the U.S.? 

That day, of course, is coming. Interoperability is still some years away from ensuring that level of anywhere/anytime access to health data, especially on a nationwide scale, but most observers agree that it’s a matter of when rather than if. (See “Interoperability in Radiology: A Game of Inches” in the December 2017 edition of this journal.) 

Meanwhile enterprise imaging (EI), inarguably one of the brightest stars in the imaging-informatics sky, isn’t waiting. It’s naturally drafting behind the rise of the image-enabled, viewer-embedded EMR. Growing numbers of providers are already using EI to—internally, at least—bring longitudinal, “every-ology” image sharing to every authorized clinician’s screen. And EI is further getting pushed along by IT leaders’ interest in improving their HIPAA security compliance by centralizing disparately secure siloes while also saving on storage costs. 

What’s more, saving money, or at least avoiding unnecessary future capital layouts, turns out to be one of the most attractive economic incentives for healthcare-provider systems to invest in EI. Not surprisingly, most systems look to their radiology departments or contracted practices to help lead the way forward with the available and in-the-works technologies that, together, can form the makings of a true enterprise-imaging service. A vendor-neutral archive (VNA) is a must for most, although entry-level EI can be achieved without one. Enterprise PACS to jointly serve radiology and cardiology is another option. Then there are tools to consider acquiring to manage imaging-related activities across the enterprise.

What should radiology be expending, in manpower as well as money, to do its part? And what can the specialty expect to get in return for going all in with enterprise imaging?


First things first. There’s not even a ballpark dollar figure to confidently attach to the question of how much money EI is going to cost any given radiology department or practice, much less the hospital or health system it serves. At some point a vendor may develop a workable all-in-one solution with negotiable price points, but the experts seem to agree that this scenario is unrealistic, given differences in providers’ size, community health status, EI-adaptable technologies already installed and so on. Meanwhile end users’ needs for the various possible components vary as widely as vendors’ wares containing or consisting of said components.   

And it’s not like there’s a one-size-fits-all formula for splitting the tab between the central IT divisions maintaining the EI architecture and the clinical departments producing and consuming the images. 

Thus the price of entry can vary from a few thousand dollars if you only need an enterprise-type app for capturing images all the way up to millions of dollars for a VNA, says Alex Towbin, MD, associate chief of clinical operations and radiology informatics at Cincinnati Children’s Hospital Medical Center. VNAs can range from $1 million to $2 million for a single-site hospital to the low tens of millions for the larger, multi-hospital systems, adds Towbin, who lead-authored a HIMSS-SIIM Enterprise Imaging Workgroup whitepaper on workflow challenges and co-authored others in the series. 

What’s more, EI adopters will have to get comfortable with “soft” returns on their EI investment. 

“If you’re focusing on what’s in it for a radiology practice, there may not be any direct monetary ROI from, for example, a VNA,” Towbin says. However, from the perspective of the enterprise, the ROI may be similarly fuzzy yet well worthwhile in a value-based healthcare economy. “I have easier access to images, and this allows me to make a better, more specific diagnosis,” Towbin says. “I can cut down on other imaging expenses or help the patient get to a diagnosis sooner so less money gets spent per episode of care.”

Just by getting all medical images into one spot and letting clinicians throughout the enterprise view those images, provider organizations take “a huge step forward” in the march toward value-based care, he adds. Then too, having a single entry point for image viewing across all specialties—optimally, the EMR synched and linked to a VNA—makes sense for those looking to more cost-effectively manage medical image data throughout the enterprise. And there are indeed times when multispecialty access offers distinct clinical advantage. 

“If I’m reading a knee MRI or a chest CT, a photo of a rash taken by a dermatologist or rheumatologist may help me change my diagnosis from a broad differential to something specific, like lupus,” says Towbin. Even if no such direct diagnostic aid emerges, the broad access can contribute to the cause of interspecialty collaboration. 

“The additional non-radiology imaging information can help me to better speak the language of my colleagues in other specialties and to understand what they’re doing,” he adds. “That’s a soft ROI, but it’s a real one.”


If radiology practices and departments are to engage in EI at the level suggested by the HIMSS-SIIM definition, they are going to need a VNA that can handle—by  whatever means of standards-based metadata indexing works for them—all non-DICOM as well as DICOM images. 

That’s according to radiologist Cheryl Petersilge MD, MBA, who serves as medical director of integrated content in the IT division of the Cleveland Clinic, which is widely recognized as one of the EI pioneers that other organizations do well to emulate. 

Petersilge says EI-aspirational radiology operations also need a universal viewer that can display all those images, along with workflow software that can support both orders-based and encounters-based workflows.  Meanwhile embedded communication and collaboration tools are nice-to-haves now but may become must-haves in the near future, especially as radiologists look to reclaim their identity as clinical consultants—aka the “doctors’ doctors”—from those who have come to see radiology as a commoditized interpretation service. 

If there’s one item every provider organization needs right now, it’s one that effectively incurs no cash outlay at all: an EI strategy. “As we move from volume to value, having a strategy in place is going to be critical,” Petersilge says. “In the volume world, we were incentivized to do more studies. In the value world, we are incentivized to use our resources most cost-effectively. We want to reduce duplicate imaging, and we want to make full use of all the information that is available to us.”

Enterprise imaging helps with both those aims, she says, adding that the sharpest EI strategies flow from EI governance committees, which needn’t be organized by radiology. At the Cleveland Clinic, for one, EI is led by the IT division. “We partner very closely with radiology, because they are the big gorilla when it comes to images,” Petersilge says. “But if you look across the United States, many of the high-performing imaging informatics operations reside not in radiology but in central IT.” 

At the same time, EI offers radiology a golden opportunity to shine in a co-leadership role, she adds. Somebody needs to oversee security, image exchange and other prime pieces of the EI puzzle that radiology is uniquely qualified to place. “This ongoing need provides an opportunity for radiology to show its value,” says Petersilge, whose peer-reviewed paper “The Evolution of Enterprise Imaging and the Role of the Radiologist in the New World,” published in the October 2017 edition of the American Journal of Roentgenology, shouldn’t be missed by any radiologist or imaging administrator interested in how EI can increase radiology’s value-add. 

“Some radiologists today are lamenting that they no longer have the pipeline to the C-suite they used to have,” Petersilge says. Stepping forward to co-lead on EI, she says, “is a way to reopen that pipeline.” The ROI on that business outcome, she suggests, could prove priceless. 


And so could ratcheting up one’s approach to healthcare delivery from patient-centric to person-centric. Enterprise imaging efforts can be applied to propel and sustain such a shift, says Rasu Shrestha, MD, MBA, chief innovation officer at the University of Pittsburgh Medical Center (UPMC). With almost 18,000 Twitter followers, he’s also one of the most influential radiologists in the U.S. 

Noting UPMC’s vantage point as an integrated delivery network, and one with especially tight payer-provider alignment at that, Shrestha says such alignment is key to evolving healthcare toward a more person-centric model. It also has helped UPMC to “almost immediately” realize meaningful ROI from its EI efforts.

“When you talk about enterprise imaging, you’re talking about taking a holistic approach to care and doing what is in the best interest of that person”—who is, at times but not constantly, a patient to healthcare providers and a claimant to healthcare insurers, Shrestha says. 

“We are incentivized not just to do what is in the best interest of that patient who may end up in the hospital and need lab tests, scans and other diagnostics but also to keep them healthy and at home rather than in the hospital,” he adds. “Incentivizing wellness and appropriateness becomes an economically sustainable model.”

Provider organizations with lower levels of payer-provider alignment than UPMC’s can still wring significant economic and clinical benefits out of their EI efforts, Shrestha says. 

To cite an example, he points to the cloud.

“If you are embracing the cloud as a core tenet of your enterprise imaging strategy, you are able to do things like manage downtimes and improve productivity and efficiency, all from an enterprise perspective,” Shrestha says. “Having the capabilities that cloud computing brings to your IT team almost immediately brings costs down and improves profits down the line. Whether or not you are part of an integrated delivery network, what I call ‘cloud-onomics’ in enterprise imaging makes a lot of sense for many different hospitals and health systems—especially those dealing with consolidation, as so many are.”


Towbin seconds Shrestha’s take on EI as equal parts care improver and cost reducer while adding that it goes far in helping the electronic medical record fulfill its promise. 

“What we’re really doing with enterprise imaging is building a complete electronic medical record,” says Towbin. “I liken it to a house that has two pillars. One pillar is the text- or numerical-based data, and that’s what we’ve focused on up till now with the EMR. The imaging pillar is still small, but it’s needed to hold the house up.”

With enterprise imaging, “we’re building a system where we can take a truly holistic view of the patient while continuing to care for patients in our own way,” he adds. “We are encouraging and celebrating our referrers in the role they play in patient care. And we’re getting to better outcomes for our patients.” 

Which nicely answers the question about what radiology can expect to get in return for embracing enterprise imaging, fuzzy economic ROIs and all.