How best to access images in Electronic Medical Records?

I have been working as an advisor to the Physician Information Technology Office (PITO) on a committee of Ophthalmologists to provide input on what we need to see as mandated minimum requirements in Electronic Medical Record systems. This past week, our discussion focused on how best to access images.

There are quite a variety of types of images that eye care providers need to access for their patients. Some of these are strictly 2-D photographs (fundus photos), others 3-D (HRT and OCT), and other have quantitative measurements that need to be analyzed (Visual Fields as well as HRT, OCT.) What should be the minimum standard for access to these different types of images for eye care providers?

The bare minimum should be the paper-record equivalent, that is, a digital printout. But shouldn't we require more if the technology exists? Shouldn't an EMR be an improvement over paper charts or else why would anyone bother the investment of time, energy, and money to switch to an EMR system. It would be foolish to have EMR vendors incorporate all the functionality of the viewing software for such test results as the HRT, OCT, GDx, Medmont VF or Humphrey VF. However, if the EMR can easily cause the appropriate viewing software to open to the current patient being examined then this would be very helpful. 

As for handling images in a way that they can be reviewed serially, what should the minimum standard be for an EMR? One option would be to have the EMR have a robust image viewer that easily allows images to be displayed for comparison. Better still if there is a way to have it highlight changes using something like the morphing special effect such that one image morphs into the next slowly enough to see what has changed. Does the EMR vendor need to have a robust image viewer built into their product or would it be appropriate to have them link to an external image viewer program so that the EMR vendor can concentrate on other areas of need?

My personal thought is that as long as we as health care professionals can access the information we need with an EMR then that should be the minimum standard. This would mean if the EMR vendor does not have a robust image viewer, then linking it to launch an external image viewer should be the minimum required standard. Similarly if other diagnostic tests such as the HRT that generate 3-D data and make complex calculations to look for progression can't be directly handled within the EMR itself, then as long as it launches the correct viewing software then we will have the functionality that we need. A primary goal in using an EMR is the ability to retrieve data quicker than sifting through pages in a chart; these solutions can work.

Does anyone have any additional opinions on this? Please add your comments below.