1. Anand S. Patel MD*, Wyatt M. Tellis PhD, Mary Torosyan,
David E. Avrin MD PhD, and Ronald L. Arenson, MD
UCSF Department of Radiology and Biomedical Imaging
Laboratory for Radiological Informatics
*Correspondence: anand.patel@ucsf.edu

2. Introduction
 Medicare expenditure on imaging has nearly
doubled from $6.5B in the year 2000 to $11.7B in
2009.
 At least 10-20% of these costs are due to
duplicate exams, frequently due to inadequate
access to prior exams when transferring patients
between institutions.
 In response the RSNA, in partnership with the
NIBIB, launched the Image Share Network in
2009.

3. Introduction
 The Image Share Network is a secure cloud-
based electronic personal health record (ePHR)
where patients directly control, view, share, and
manage their imaging exams.
 The RSNA has partnered with 5 pilot sites in the
USA to evaluate the Image Share Network:
 University of California, San Francisco (UCSF)
 Mount Sinai Medical Center
 Mayo Clinic (Rochester, MN)
 University of Chicago Medical Center
 University of Maryland Medical Center

4. Introduction
 GOAL: to improve efficiency, safety, reduce
repeat exams, and empower patients with direct
control of their images and reports via a secure
HIPAA compliant internet cloud-based ePHR.
 As 1 of 5 national pilot sites, we present our
experience at UCSF with patient enrollment,
adoption, and patient/physician satisfaction.

5. Network Design Overview
 The Image Share network has a hub and spoke
design with a central ―clearinghouse‖ through
which all data are transferred.
 Clearinghouse is hosted in a HIPAA-compliant,
distributed data center with physical access
controls.
 Having a distributed data center provides
business continuity by allowing the clearinghouse
to continue operating in the event of a failure at
one or more of the data center sites.

6. Network Design Overview

7. Network Security
 Communication with the clearinghouse takes
place over the internet and is secured using TLS
1.0 encryption. All nodes are authenticated
through the exchange of TLS certificates.
 Additional security is provided by a firewall with
an access control list that permits only
authorized IP addresses to connect.
 Once data are at rest within the clearinghouse
they are encrypted and automatically deleted
after thirty days to minimize the chance of data
theft.

8. Network Technical Details
 To remain vendor agnostic, the network utilizes the IHE
XDS-I.b standard for data exchange.
 2 vendors currently provide PHR accounts to patients
participating in the network
 Dell (InsiteOne)
 lifeIMAGE
 Each site is interfaced to the clearinghouse via an
―edge server‖ which acts as an XDS ―document
source.‖
 HL7 and DICOM are used to retrieve reports and
images from the site‘s RIS and PACS respectively.

9. Network Technical Details
 Since the focus of XDS-I.b is the exchange of imaging
data across affiliated enterprises, modifications were
required for use in a consumer-oriented environment.
 A unique, single use security token is used to identify
submission sets within the network.
 To retrieve content from the network, an ePHR must
be able to reconstruct the token hash, the patient‘s
date of birth and a password known only to the
patient.
 By using this approach the network is able to abide
by the XDS-I.b standard while providing an increased
level of security by minimizing the exposure of PHI.

10. Methods
 With IRB approval, Network enrollment began in Aug
2011 with patients coming to the department‘s film
library to obtain a CD of their exams.
 During the first 10 months of the enrollment period
(Aug 2011 – May 2012), our site enrolled patients as
they contacted the film library for a copy of their
images on a CD, either in person or over the phone.
 Patients were educated about the system with a
standard informational script communicated by the
film library as well as formal brochures.

11. Methods
 Starting in Aug 2012, patients were also provided a
brief survey (2 pages for patient, 1 page for
physician) to be completed after use of the system.
 Incentive $20 gift cards are provided to those patients
who mail back the survey.
 Surveys gauge patients and physicians on:
 Perceived benefits/utility of patient-controlled ePHRs
 Importance of health record privacy
 Baseline computer, internet, and social media usage
 Satisfaction using the Image Share system (ease of
use, etc)
 Satisfaction with the Image Share system‘s security
 Whether difficulty with access to CD or Image Share
system led to repeat imaging

12. Methods
 Preliminary follow-up survey questions will be
grouped and scored with mean response values
based on the following scales:
 1 most satisfied, 2 satisfied, 3 neutral, 4 unsatisfied,
5 very unsatisfied
 A score of 1 (daily) – 4 (never) is used to assess
patient and physician baseline computer/internet
usage

13. Preliminary Results
 During this initial period (Aug 2011 – May 2012) a total of
only 90 patients (avg of 9 patients/mo), were enrolled.
 When asked about the low enrollment rates, film library
staff indicated that low enrollment patients were in a
hurry, and not willing to spend time to go through the
educational and consent process.
 Starting in June 2012, the patient recruitment process
was redesigned to enroll patients while they waited for
their scans.
 A recruitment coordinator was hired and dedicated to
the task.

14. Overview of Modified Patient
Recruitment Process
Patients checks in at
Radiology reception area
If patient is not interested
Research coordinator in the program, then
introduces the RSNA patient awaits his or her
Image Share Network scan
If patient wishes to enroll, research Patients access their
coordinator goes through the images/reports, and
educational process prior to consent request past and future
studies with the capability
to send the studies to any
Once reports have been finalized, research coordinator doctors, family, and
sends requested images to the clearinghouse, emailing friends, simply with a click
the patients with simple instructions for access of a button

15. Results
 After starting the new process with a study
coordinator, (3 months, Jun–Aug 2012), 357
patients were enrolled.
 Monthly average of 119 patients
 Increase of 1222% over the previous 10 month avg.
 4 of the 5 pilot sites are currently enrolling
patients
 Total of 1383 patients and 5807 exams.
 447 patients enrolled at UCSF for a total of 2288
exams.

16. Results – Enrollment Overview
 Significant enrollment rate increase in May
2012 after hiring of a study coordinator.

17. Results – Patient Survey
 N = 66 total surveys returned as of Nov 1, 2012
 Mean age 44 yrs (range 15 days to 87 years).
 Parents/legal guardians comprised 15% of enrollees
Frequency of general Frequency of internet use for social
computer use networking or online purchasing
5%
6% 12%
Daily
Weekly
Monthly 55%
27%
Never
95%

18. Results – Patient Survey
 Perceived benefits/utility of patient-controlled ePHRs.
 95% felt this was very important or important
 Average satisfaction score 1.5 +/- 0.7 (1 most – 5 least
satisfied)
4% 11% Very satisfied or satisfied
Neutral
Unsatisfied or very
85% unsatisfied
 2% stated they had repeat imaging because their
physician had difficulty accessing it

19. Results – Patient Survey Q‘s
Strongly agree
 ―In general I am particularly / agree
16%
concerned about
maintaining the privacy of Neutral
my health records.‖ (1 strongly 22%
agree – 5 strongly disagree) 62%
Strongly
disagree /
 Avg score 2.3 +/- 1.3 disagree
2%
 ―I was comfortable with the
Strongly agree
privacy and security of how 11% / agree
my medical images were Neutral
transferred to my doctor or
consultant.‖ (1 strongly agree – 5 Strongly
strongly disagree) disagree /
87%
disagree
 Avg score 1.6 +/- 0.8

20. Results – Patient Comments
 ―I love it!‖
 ―Easy…helpful‖
 ―The system works really well.‖
 ―…pleased by the speed and grateful not to have to
bring the image‖
 ―This is really neat. I‘ve always been curious about the
images of my own organs.‖
 ―I loved having the option to review my daughter‘s scan
with my husband who could not be at our appointment
in SF as we live a couple hours away…‖
 ―This was a great tool! I really appreciate the
opportunity to take all the time I wanted to read the
report and look at the images on my own.‖

21. Results – Patient Comments
 ―had difficulty registering…‖
 ―takes forever to download…‖
 ―Felt process to access images online was not well
defined. Need more detailed instructions on creating
account and URL to use. Also, no instructions on what
viewer to use for downloaded images. Took multiple
attempts to download file…
 ―A link would be easier rather than having to highlight
the address and open a new search‖
 ―It was easy for me to access the images however I
had a hard time accessing the report online.‖

22. Results –Physician Survey
 N = 34 total surveys returned
 Average satisfaction score 1.8 +/- 1.3 (1 most – 5
least satisfied)
21%
Very satisfied or satisfied
79% Neutral
 8% stated difficulty accessing CD exams led to
repeat imaging study
 12% stated difficulty accessing Image Share
Network led to repeat imaging study

23. Results –Physician Survey Q‘s
6%
 ―It was critically important that Strongly
I saw the medical image(s) in agree /
a short period of time.‖ (1 agree
strongly agree – 5 strongly disagree) Neutral
 N = 33, avg score 1.2 +/- 0.6 94%
11%
 ―I am comfortable with the Strongly
privacy and security of how agree /
this patient‘s images were sent agree
to me‖ (1 strongly agree – 5 strongly Neutral
disagree) 89%
 N = 27, avg score 1.4 +/- 0.7

24. Results – Physician Comments
 ―Dr. is at UCSF, so not applicable‖
 ―I think this is great‖

25. Discussion - Enrollment
 The lengthy conversation required by the
enrollment process proved to be an impediment for
enrolling patients when they contacted the film
library to request a CD copy of their images.
 The modification to include a study coordinator
helped increase numbers to their highest monthly
total to date.
 When patients were a ―captive‖ audience in the
waiting room they were far more willing to learn
about the network.
 Once they understood the process and its benefits,
the majority of patients were enthusiastic to enroll.

26. Discussion – Patient Survey
 85% of patients are satisfied or very satisfied with their
experience using the RSNA Image Share Network.
 11% nonetheless are unsatisfied or very unsatisfied,
perhaps due to online access/registration issues
 87% either agreed or strongly agreed that they felt
comfortable with the privacy/security of the system
 38% of patients either disagree, strongly disagree, or
are neutral that health record privacy is important
 This is perhaps higher than would be expected

27. Discussion – Physician Survey
 79% of referring physicians are satisfied or very
satisfied with their experience using the RSNA Image
Share Network.
 None reported dissatisfaction
 94% felt it was critically important to see medical
images in a short time
 ~10% reported the necessity for repeat imaging
regardless of using CD or the Image Share Network
 89% were comfortable with the privacy/security of
the system
 None reported dissatisfaction

28. Discussion - Comments
 Patients overall reported ease of use
 Certain patients voiced concerns that the online
registration process and system could be improved
 Physician use is often difficult to gauge since
most patients have a UCSF referring physician
 Already using the medical center‘s own online
medical record and image viewer, thus obviating
the need to use Image Share Network

29. Discussion - Survey
 Potential considerations that could confound results:
 Most patients could be considered ‗computer
literate‘ based on their computer/internet usage
 Most patients believe ahead of time that there would
be significant utility of patient-controlled ePHRs
 Physician cohort may have been mostly
homogenous working at UCSF
 Larger sample size needed to determine any
relationships between the above patient
characteristics
 Focus on identifying and surveying physicians outside
the UCSF network who do not already have access to
the images via the UCSF medical record
 These physicians may be able to elucidate if the
Image Share system could obviate repeat exams

30. Further Studies
 Further demographic and patient analysis will be
performed to assess factors that may relate to adoption
of the system, such as:
 Age
 Sex
 Distance patient resides from the medical center
 Type(s) of imaging exam patient underwent
 Chief diagnosis
 Radiology department cost-analysis
 Are there savings from reductions in CD distribution?
 Enrollment and surveying will continue through 2013
 Cumulative results from all 5 pilot sites will be tabulated

31. Conclusion
 A cloud-based image exchange network is
technically feasible
 Patients strongly feel that having a patient-controlled
ePHR would be of benefit
 Physicians strongly believe that viewing their patients
images in a timely manner is critical
 Patients and physicians are overall quite satisfied with
their experience and the security of the RSNA Image
Share Network
 Patient education is critical to the adoption of the
concept and the expansion of its use

32. References
1. Report to Congressional requesters: Medicare Part B imaging services—
rapid spending growth and shift to physician offices indicate need for
CMS to consider additional management practices. GAO-08-452.
Washington, DC: Government Accountability Office, June 2008
2. Brenner DJ, Hall EJ. Computed tomography: an increasing source of
radiation exposure. N Engl J Med 2007; 357:2277–2284
3. Brooks, L. (2009, November). RSNA Awarded Contract to Develop
Medical Image Sharing Network. RSNA Press Release. Retrieved August
24, 2012, from
http://www2.rsna.org/timssnet/media/pressreleases/pr_target.cfm?ID=46
0
4. ITI Planning and Technical committees. (2011, August 19). IT Infrastructure
Technical Framework. IHE International, Inc. Retrieved August 28, 2012,
from http://www.ihe.net/Technical_Framework/index.cfm#IT

33. Contact: anand.patel@ucsf.edu
https://www.rsna.org/Image_Share.aspx
http://www.radiology.ucsf.edu/