Getting the whole picture

Rachel Kroeger

Staff

October 19, 2026

WISCONSIN – The digital exchange of health records has been common practice for many years – however, Epic Software Development Team Lead Adam Nygard said diagnostic image transfers have long been the exception to the modernization of care communication.

“These aren’t the kind of images you might have on your smartphone,” he said. “These are medical images taken by X-rays, CTs, MRIs [or] what have you. So, they’re oftentimes a lot higher quality as individual images, [and] there’s often a large set of images that need to be transferred together [as well].”

Epic’s August update of Care Everywhere – “our platform that allows Epic customers to connect to each other, as well as other organizations and national frameworks” – Nygard said, helps solve that problem with a new large-image transfer functionality.

An industry-wide issue, Nygard said there were a couple of large hurdles he and Epic’s Care Everywhere development team overcame to push the update – the first being a historic disconnect between electronic health record (EHR) systems and medical image vendors.

“What’s happened is you have the EHRs, which have been really involved in the forefront of interoperability, and then you have these imaging vendors that are storing the images, but they haven’t necessarily been brought into the picture,” he said. “You have this siloed data within the healthcare system, and you have a lot of vendors that have tried to solve the problem.”

The second hurdle, Nygard said, is that files were being received and stored using image vendors’ (often) proprietary platforms, so hospital systems couldn’t transfer files to one another unless they happened to be using the same one.

“A lot of these networks and image exchange vendors that exist have built their functionality on proprietary technology,” he said. “That means if you have image-sharing vendor A at your hospital, and you go down the street to a different hospital, but they just so happen to use a different vendor, those images can’t flow electronically over that network.”

Even further, Nygard said the image transfer problem can impact the efficacy of patient care because it leads the industry to “fall back on CDs.”

“That’s still such a prevalent workflow for sharing images today, and that’s either snail mail or you’re going to send that CD directly with the patient,” he said. “If they forget it, then that leads to delays in treatments, rescans, things like that.”

However, with the recent rollout of Epic Care Everywhere’s latest instance, Nygard said hospital systems using the EHR will be able to transfer large image files between one another with relative ease, as compared to previous workflow strategies.

“Our customers came to us with that problem, and they said, ‘Epic, can you do something here?’” he said. “Now, Epic’s an EHR. We don’t have ownership over that imaging data, but we knew there was some place that we probably could. So, what we created was a diagnostic image exchange built on top of this Care Everywhere functionality.”

Ease of interoperability

Though the large-file exchange functionality is new, Nygard said Care Everywhere has been assisting in hospitals’ image transfer interoperability since 2008.

“We’ve been able to share reference quality versions of these images for quite a long time,” he said. “What that means is, instead of the original quality [of that] entire study, comprising potentially thousands of images, we’re able to take a small cut of that – either the middle image or a small set of those images – and then compress them down so they’re easier to manage.”

However, regardless of being easier to manage, Nygard said the compressed images often did not do the originals justice, leaving providers to wonder if they were, literally, getting the whole picture.

“There’s often a large set of images that need to be transferred together,” he said. “If you think about a case like an MRI, if you have a mass you want to scan, oftentimes you’re going to have multiple images taken as slices over the span of that mass so you can not only get the cross-sectional area in each image, but you can also get that depth.”

The complexity of this data, Nygard said, played a role in why, over time, the responsibility of taking and storing the images was “bifurcated.”

“We’ve done a great job along with the rest of the industry at connecting all the EHRs together on national networks like TEFCA [on which] we’ve been able to really expand the amount of data that is shared between organizations, regardless of the vendors we’re on, and that’s what we really love,” he said. “These images are just [so] large and complicated that they have been stored in these special systems called PACS (picture archiving and communication system) or VNAs (vendor neutral archives).”

So, while EHRs have been working on contextual care interoperability, Nygard said medical image archiving has taken on an industry of its own.

“The other problem that exists with a lot of these networks today is these are push-based networks – so if I want to receive the imaging from an outside organization because a patient shows up at my facility, I need to call or fax the other organization to say, ‘Hey, can you send me those images?’” he said. 

Placing that call, Nygard said, often requires the receiving physician to relay the request to their respective hospital’s “imaging management department,” which then must call the original hospital’s department, “load up the images and send them over.”

“That takes clinicians out of their workflow, and it also isn’t a very patient-friendly workflow to get their data,” he said. “Patients obviously can message their provider, call their institution [and] get their images through other ways, [but] you have the patients bringing in their own media…, [making them] the mule of interoperability, which is not good for patients. We want to make sure their data just shows up in an expedient way.”

Especially compared to other functionalities Epic has implemented within “other interoperability networks” and its MyChart application, Nygard said large image exchange was still “a very heavy-handed workflow.”

“The other thing is [it can] delay treatment if we can’t get that imaging,” he said. “Sometimes you’re just going to have to rescan the patient, which is going to add extra cost to the health system, extra cost to the patient, additional radiation exposure, [etc.] So, this was a pretty universally agreed-upon problem that we needed to solve.”

Open standards, cross-industry application

Though exciting, Nygard said the addition of a new “single-click” workflow for providers to share large medical files is not intended to replace Epic’s compressed image functionality.

“[Compressed images are] great for patients as well who don’t need that full diagnostic quality to read their own studies, but there are still physicians – your radiologists, neurologists, cardiologists – who really need that full fidelity, original quality and the entire set of images,” he said. “So, we wanted to build a workflow for them that was streamlined [in which] they could self-service their own transactions and pull the data they need.”

Using the new exchange tool, Nygard said physicians will be able to “pull the patient’s imaging directly into the chart” and store them in a “downstream imaging archive.”

“Epic’s just the postman in the middle, so we’re facilitating the exchange [which we’ve] done for nearly two decades at this point – this is just another type of mail we’re sending,” he said. “We’re really excited to work with industry partners to get consensus around these standards and build workflows and use some of these national networks like TEFCA (Trusted Exchange Framework and Common Agreement) to really accelerate what we’re able to do.”

And, not only did Epic build a tool to solve the problem, but Nygard said they did so in service of all healthcare systems.

“We wanted to build it upon open standards so we could really get everybody involved in this and solve the problem across the entire healthcare ecosystem,” he said.

Building the functionality on open standards, Nygard said, was an intentional decision by Epic in hopes of further standardizing an important and necessary step in the continuation of quality patient care.

“It’s great that Epic organizations can share this, but we really want to bring it to more than just the Epic community,” he said. “We’re ready for it, we’re excited for it and talking to our customers, I know they’re excited as well.”

Despite being involved on the more (if not the most) technical side of health care, Nygard said he and his development team are dedicated to understanding the providers they serve.

“One of the superpowers, [as] we call it here at Epic, is our relationship with our customers and our continued dedication to go on site, see workflows and understand the problems that people are having,” he said. “So, we have a really good blend here at Epic of understanding what our customers actually need, along with some really, really smart people on the back end who know this technology in and out, and it’s because of that relationship that we’re able to push boundaries and do some amazing things.”

Outside of the company’s standard industry, Nygard said Epic’s new technology is gaining attention.

“[We have] government partners that are interested in image exchange; there’ve been a couple of requests for information that have been pushed [and] a lot of industry partners that are excited to go to upcoming industry events,” he said. “The Centers for Medicare & Medicaid Services’ Ditch the Disk [Imaging Exchange] Work Group, for instance, is a group of EHRs, image sharing vendors, some of our customers and other health systems that are really excited to tackle this problem.”

As Epic users and industry partners across the state and country begin to adopt the new system, Nygard said he and the development team are simply excited to be producing tools that make a genuine, positive impact on millions of patients.

“Things take a little bit for customers to upgrade and do the other background work that comes with an Epic upgrade,” he said, “but we’re really excited to see who our first adopters are, how they use the feature and build some case studies we can take to some of our other industry partners and say, ‘Look, this works; these aren’t just standards on paper. This is impact that we’re having in people’s lives.’”