Postcards From the Imaging Informatics Road [Healthcare Informatics]

DESPITE POLICY COMPLEXITIES, DIAGNOSTIC IMAGING INFORMATICS MAKES PROGRESS ON MULTIPLE FRONTS

EXECUTIVE SUMMARY:

The current strategic landscape/or imaging informatics is one filed with great contrasts and paradoxes. On the one hand, because imaging informatics was not explicitly addressed in Stage 1 of the meaningful use requirements under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health Act (ARRA-HlTECH) legislation, it instantly lost some of the environment of turbo-charged energy characterized by areas that were directly addressed by the HITECH Act, such as quality data reporting, care management, and of course, core electronic health record (EHR) development.

On the other hand, an interesting combination of factors - rapidly advancing technology, the expansion of the image archiving concept across different medicai specialties, and the inclusion of diagnostic image-sharing as one element in the development of health information exchange (HIE) arrangements nationwide-is nonetheless pushing imaging informatics forward towards new innovations.

The five articles below provide readers with different glimpses of the path ahead for imaging informatics. The first presents a look at the current policy and reimbursement landscape. Each of the four subsequent articles delve into different aspects of innovation, from a process developed at a public hospital to improve and speed up the diagnostic process for trauma patients, to a radiology-specific financial analytics solution in the group practice setting, to an advance in cardiology information systems, to a seif-developedfederated image viewing platform at one of the nation's largest integrated health systems.

Each of those initiatives is very different; yet it is clear that a great deal of innovation is taking piace across the U.S. healthcare system when it comes to imaging informatics. With a landscape filled with uncertainties and potential policy, reimbursement, and industry shifts in the offing, CIOs, CMIOs, and other healthcare IT leaders will need to think very strategically where this critical area fits into their organizations' overaU clinical /T strategies goitigforward.

LOOKING ACROSS THE INDUSTRY AND POUCY LANDSCAPE

THE ACR'S KEITH DREYER, M .D., IS MAKING THE BIG PICTURE AROUND IMAGING INFORMATICS

Keith Dreyer, M.D., is as involved as any practicing radiologist with the policy and strategic IT issues facing radiologists as any radiology professional in the country these days. Not only is Dreyer vice chairman of radiology at Massachusetts General Hospital (one of the member hospitals within the Bostonbased Partners HealthCare), and assistant professor of radiology at Harvard University; he is also co-chair of the Informatics Committee at the Reston, Va.-based American College of Radiology (ACR), and chairman of the ACR's Government Relations Informatics Committee.

Dreyer sees three important trends advancing within the imaging informatics world. The first is the shift towards vendor-neutral archiving; the second is forward progress around meaningful use, as well as interest in accountable care organization (ACO) development under Healthcare reform. And the third is technological and tactical changes in approaching image capture and acquisition in hospitals and other patient care organizations. In addition, Dreyer is carefully tracking current reimbursement and policy trends, and representing the ACR and his fellow radiologists on policy issues in Washington, D.C.

The first industry trend, towards vendor -neutral archiving, is evolving forward in the context of enterprisewide clinical image management, Dreyer notes. "For example," he says, "at Partners HealthCare, we installed PACS [picture archiving and communication systems] in the mid-1990s. And at that time, our then-CIO, John Glaser, Ph.D., said to me, 'This isn't really my thing, it's a radiology thing.'" That view was nearly universal among ClOs at the time, Dreyer says; the first PACS were seen as department-level systems meant to help radiologists with what were seen as uniquely specialized needs.

Fast-forward to the present day, however, and it's become increasingly clear to CIOs and other healthcare IT leaders that, "Now that radiologists have had their needs met, the cardiologists, pathologists, gastroenterologists, and other specialists are increasingly seeing the need for image archiving systems for their specialties." And while the industry initially responded to cardiologists' needs with "cardiology PACS," it's becoming clear that the only workable solution is to create an enterprise-wide image archiving system that meets the needs of all specialties (and of their referring physicians) for such tools.

SHARING IMAGES ACROSS ENTERPRISES

At the next level, of course, there is image-sharing that takes place among providers in different organizations. "It's very easy now to take an image from an MR or CT and store it in a PACS system; and nearly everybody can also store images now in the EMR," Dreyer says. "But what nearly no one can do is send that image across to another enterprise." Fortunately, he notes, vendors are beginning to create secure private or public clouds (or mixed private-public clouds) that can securely and in a timely way get images from one clinician to another, as appropriate, so that, "without building VPNs or dedicated lines or anything, they can create that connectivity and sharing."</p>

In addition, Dreyer and his colleagues at Mass General and Partners HealthCare have implemented and have been enhancing "technology that loads a CD from another organization and transmits the images into our PACS and then into our EMR. We call that cross-enterprise image import," he says, and notes that his organization is already able to exchange diagnostic images through that technology without the use of CDs. As that technology improves over time, he emphasizes, patient care organizations will finally move out of the current situation, in which imaging departments find themselves drowning in CDs, some of them in non-compatible formats, from other organizations, and sending out many thousands a year themselves. (Mass General alone produces 200,000 CDs a year for other organizations, Dreyer notes.)

REIMBURSEMENT ISSUES COMPLICATE EVERYTHING

On the policy and reimbursement front, numerous diverse trends are affecting radiologists in different ways. On the one hand, the Office of the National Coordinator for Health IT (ONC) confirmed last year that radiologists are considered eligible providers under both the Medicare and Medicaid HITECH programs; under the Medicare stimulus program, a physician cannot provide more than 90 percent of their Medicare-covered services in the inpatient or emergency room settings. But there are still some complications around achieving the meaningful use requirements, and it is not entirely certain thai the Stage 2 requirements will clarify things for radiologists. Still, the ACH has been urging radiologists to participate in MU/HITECH.

More broadly, however. Medicare physician reimbursement overall may pose more serious issues for radiologists, particularly if the "super-committee" created in the U.S. Congress to work out remaining unresolved issues from the bipartisan agreement this summer over lifting the federal debt ceiling cannot resolve certain questions. Some federal policy analysts are predicting major provider payment cuts under Medicare, with specialists the most vulnerable. In addition, the ongoing lack of resolution around the continuing delay in implementing the sustainable growth rate (SGR) formula for Medicare physician payments (with an average 29.5-percent pay cut looming next year), is adding uncertainty to the mix.

"I don't disagree with you that radiology may get hit," Dreyer says of the cluster of physician reimbursement issues; "and there are a lot of advocacy efforts involved around that, because you could end up decreasing imaging, but increasing costs elsewhere- But regardless of what happens from a reimbursement standpoint, the challenge for radiologists around MU is very simple, because the 25 main requirements don't really apply to what we do, and don't really speak to the necessary technology necessary for improving patient care within our specialty," he adds.

Given all this uncertainty around reimbursement, which likely will strongly influence how radiologists respond to the meaningful use imperative, Dreyer urges CIOs to "get educated. 1 would bet that no more than 25 percent of CIOs realize that radiologists are going to be eligible providers, so CIOs need to get radiologists involved in the conversation," he says. They need to start looking at enterprise visualization tools [formerly referred to as "enterprise image distribution tools"] and crossenterprise image-sharing," as tools that can appeal to radiologists as they begin to transition to the emerging world of image management. And on the other side of the ledge, CIOs should look into clinical decision support for image-ordering, for ordering/ referring physicians.

And then there is the work towards creating health information exchanges (HIEs), which will most certainly involve radiologists at some point, in every organization.

In the end, Dreyer says, CIOs and other healthcare IT leaders need to iook at the imaging informatics world as one key piece of the overall clinical informatics puzzle. With technological, policy, and industry changes all creating shifts in the landscape, radiologists and imaging informatics will, he concludes, become more and more a part of the broader conversation going forward.

DENVERHEALTH:

Co-Development at a Safety-Net Hospital

Denver Health, the 500-bed safety-net hospital for the Denver area, faces unique opportunities and challenges. On the one hand, part of the operational lifeblood of the hospital is referrals and transfers of trauma patients to its facility from outlying hospitals in the region. On the other hand, operating within a publichospital context, Denver Health's 150member IT staff has always had to make do with less-than-unlimited financial resources. So it's not surprising that the organization should pioneer imaging-sharing advances through collaborative development work with its vendor, says Jeffrey Pelot, Denver Healths chief technology officer.

"To be clear," Pelot says, "trauma care is a money-making opportunity; and to be good at trauma, you have to do a lot of it. There are four other level 1 trauma hospitals in the Denver area. So this was a business development effort, and the intent was to provide a very quick and reliable method for level 2 and level 3 hospitals to contact us and to send images to help determine whether a patient should be transferred."

But the historical method for handling such situations involved 11 steps, he notes, including bringing a patient into Denver Health, facilitating physician-to-physician phone consults, burning a CD, - "and we might end up doing duplicate exams" because various time-lag elements.

Pelot says, "My PACS administrator came up with an idea for a solution. We approached what was Arnicas at the time, and said, we'd really like to be able to receive images with great rapidity, as opposed to going through a typical CD-burning process. So they built a CDCOM router for us." Ultimately, the solution, which first went live at Denver Health three years ago, was enhanced and commercialized as iConnect, one of a suite of solutions from the Chicagobased Merge Healthcare.

Nowadays, when a remote hospital facility produces a diagnostic imaging study, that study can be communicated to Denver Health with the push of a button. The study is immediately put into a pending status, so once the associated patient arrives at Denver Health, the study is assigned to that patient, with a medical record number immediately attached to it. As a result, more than an hours worth of time is usually saved, which, in the context of trauma care, is an enormous time savings.

What's more, 27 care sites are linked to Denver Health through the solution, across three states, Colorado, Wyoming, and Nebraska. And the volume involved is significant, with more than 500 diagnostic imaging studies per quarter are involved. In addition, Denver Health has created a cardiology gateway, with cardiac image-sharing capability; and the organization also participates in a Web-facilitated tumor review board process with other hospitals in the region.

Asked what the lessons learned so far in Denver Health's venture have been, Pelot says, "We continue to learn stuff all the time. The biggest thing we've learned so far is that we're providing much better patient care, because we can decide far more rapidly whether a patient should be transported or not; and when we do transport, the chances of the patient surviving are very, very high."

Andrew Steele, M. D., director of medical informatics at Denver Health, uses the iConnect imaging solution that was co-developed by Denver Health and Merge Healthcare. Photo: Merge Healthcare; photographer: Stephen Higham

KOOTENAIIMAGING:

Better Financial Management in Idaho

Like radiology groups around the country, the 12-radiologist Kootenai Imaging in Coeur d'Alene, Idaho has been typical in its growing need for optimized billing management. With only two non-physicians on staff- the organization's practice administrator, Scott Venera, and one nurse practitioner, Kootenai Imaging is a lean medical organization, and until earlier this year, the practice had its billing and collections work done by a small, locally owned firm. "But we've essentially outgrown that model," Venera says. "So we put the whole thing out to bid, and at the end of the day, we settled with McKesson"- the McKesson Revenue Management Services solution from the Alpharetta, Ga.-based McKesson Corp.

Todays reality for medical groups, Venera says, is that "You can't just send out a bill any longer and call it good." Instead, he says, he and his colleagues came to realize that "We needed a better pulse on our financial practices, and the ability to data-mine, so that we would be better prepared for changes we're currently facing, and are about to face, including competitive pressures, reimbursement, the transition to ICD10, and the PQRS pressures," referring to the quality measures required under the Medicare programs Physician Quality Reporting System, which currently provides bonuses for meeting certain quality standards, but which will also involve reimbursement cuts in the next couple of years.

The solution went live on July 1, and at press time, Venera and his colleagues at Kootenai Imaging were just beginning to plumb the first metrics around improvements in efficiency and effectiveness of their billing system. But what is already clear, Venera says, is that the future in this area lies in the ability to apply data analytics to all aspects of billing and collections in the medical group setting. "Data is so important to analyze moving forward," he emphasizes. "You really need to anticipate where you need to be; and if you don't have the ability to take the data that you generate and be able to show measurements of various types, you're not going to succeed."

COOPER HEALTH SYSTEM:

Cardiology Considered

At Cooper Health System in Camden, N.J., which encompasses a 500-bed urban university hospital and over 80 physician office locations, Phil Curran, CIO, and Rose Alapatt, applications analyst, have been helping to lead innovation in a number of areas, one of which has to do with cardiology. As in other hospital organizations nationwide, the cardiologists at Cooper Health System found themselves struggling to manage the ever-expanding welter of images and data they need to work with in order to best serve their patients. So beginning in late 2008, Curran, Alapatt, and their colleagues began looking into vendor solutions in the cardiology area. What Curran and Alapatt knew from the outset was that cardiology image management is very different from radiology image management, for a variety of reasons.

Asked whether they believed initially that implementing a cardiology image management system would be similar to implementing a radiology PACS, Curran says, "We never made that assumption. And we work very closely with the cardiology folks, and they flat-out told us, we need more information, we need to manipulate the images differently; so it's not a cardiology PACS system."

For one thing, as Alapatt notes, "Cardiology images are moving images, whereas the radiology images are still," meaning that any kind of image management system in cardiology must be very robust from the get-go. Indeed, she reports, "Four of our five outside offices do images, and we did have to increase the bandwidth from those offices to our cardiology information system at our data center. We figured out the average number of bytes per image, figured out how many images would be taken during a day. added that to the amount of bandwidth that they already had, and added that much more bandwidth to those four offices" in preparation for the go-live, she says.

After vetting severa) products, the folks at Cooper ended up going with the Horizon Cardiology cardiovascular information system (CVlS) from McKesson, going live with the CVIS in the spring of 2010, and interfacingit with the hospital's core EHR, from the Verona, Wis.~based Epic Systems Corp. As of press time, the CVIS, which is web-enabled» is fully implemented for echocardiology and vascular medicine, across about 12 modalities, and across the hospitals main campus and four satellite locations. Any clinician with appropriate access to the CVIS can now view an image or interact with the system from any PC across the health system. What's more, virtually 100 percent of the cardiologie images are going into the Epic EHR (which spans inpatient and outpatient care delivery), Curran notes.

"This was a very big team effort between cardiology and ?G testifies Curran. He and Alapatt agree that having the cardiologists on board from the very outset has been essential to the success of their CVlS implementation. Another critical success factor, Alapatt says, is doing what the Cooper IT team always does, which is establish the goals and objectives before anything moves forward.

What would he advise other CIOs? Tellingly, Curran says thai "If they don't have any type of PACS system in place yet, they need to think about getting all their OIogies' into place in a coordinated way: radiology, cardiology, pathology, and so on. If they do have a radiology PACS system in place, they need to make sure the front end of the radiology PACS system works well with cardiology. And the third thing is to significantly reduce the physical footprint. They do need to consider virtualization; you can call it an internal cloud, if you'd like."

UPMC:

In Pittsburgh, a Federated View of Diagnostic Images

If anyone might be said to have a big-picture view of the future of imaging informatics, it would be Rasu Shrestha, M.D., vice president for medical information technology and medical director for interoperability and imaging informatics, at the University of Pittsburgh Medical Center (UPMC) health system.

Shrestha, who practiced as a radiologist for a number of years before gradually moving towards full-time imaging informatics management and strategy, is helping to lead a revolution in informatics across this vast integrated healthcare system, which encompasses 20 hospitals, 400 outpatient sites, nearly 50,000 employees (including 2,700 employed physicians), and, when it comes to imaging, has a staggering 400 terabytes worth of radiologie images stored in its servers (out of 1.9 petabytes of data and images system-wide), and whose clinicians are performing 2 million diagnostic imaging exams a year across UPMCs 20 hospitals and 30 imaging centers.

Given such a huge volume of images and studies, as well as diverse PACS systems across its hospitals and imaging centers, it should come as no surprise that Shrestha and his colleagues would have "developed a number of things around addressing the pain points" hi terms of physician access and management of information, as Shrestha puts it. Indeed, one of the signal informatics achievements of the past few years at UPMC has been the development of a platform called SingleView.

SingleView is not a vendor-neutral archive, Shrestha emphasizes. Instead, it is a federated platform. "It's like an umbrella," be explains, "deployed across 20,000 desktops across UPMC. And both attending radiologists and referring physicians rely heavily on SingleView, because it provides a federated view of the patient across systems." Rather than acting as an archive, SingleView works in the background, he explains, "bringing up different radiological reports from other hospital's within the enterprise, and from other PACS systems that previously did not talk to each other."

Work began on developing SingleView after a conversation Shrestha had had with a UPMC radiologist who is considered one of the top MRI neuroradiologists in the U.S. That doctor had fortuitously guessed at the existence of a study for a patient who had been treated in two different UPMC hospitals during different periods of time. The logic of creating a federated view, Shrestha says, was unassailable. So he and his team set to work, architecting the federated platform within about six months.

SingleView has proven to be a great success among physicians across UPMC, Shrestha reports. What's more, the platform's capabilities will only become more broadly applied, as the integrated health system moves forward in multiple informatics areas, including, notably, its breakthrough digital pathology initiative, announced late last year as a partnership with GE Healthcare, through the longstanding UPMC-GE joint venture, Omnyx.

As digital pathology comes online, and as other specialties move forward with digital informatics initiatives, it will be through such architected solutions as SingleView that UPMC clinicians will be able to make the most of the vast, if highly diffuse, resources, of their integrated health system, Shrestha says. He adds that the benefits will be improved patient safety, care quality, clinician workflow, efficiency, and cost-effectiveness. In other words, getting the big picture will continue to be an essential part of the journey forward in clinical informatics.

IT'S VERY EASY NOW TO TAKE AN IMAGE FROM AN MR OR CTAND STORE IT IN A PACS SYSTEM: AND NEARLY EVERYBODY CAN ALSO STORE IMAGES NOW IN THE EMR. BUT WHAT NEARLY NO ONE CAN DO IS SEND THAT IMAGE ACROSS TO ANOTHER ENTERPRISE. -KEITH DREYEK, M.D.

I WOULD BET THAT NO MORE THAN 25 PERCENT OF CIOs REAUZE THAT RADIOLOGISTS ARE GOING TO BE PROVIDERS, SO CIOs NEED TO GET RADIOLOGISTS INVOLVED IN THE CONVERSATION. -KEITH DREYER, MLO.