Bridget M. Kuehn

A physician at The Cleveland Clinic can now view  photos of a patient’s hand and an X-ray of the same hand side-by-side within the electronic medical record to determine the best treatment plan, according to Louis Lannum, the director of enterprise imaging at the nine hospital health system, during a session at the HIMSS 2015 annual meeting.

This advance was made possible by the organization’s adoption of an enterprise VNA to facilitate access to images and other unstructured patient data throughout the system. The organization is one of a growing number that have adopted an enterprise-wide imaging strategy. It’s the latest step in the evolution of imaging, explained Richard “Skip” Kennedy, MSC, a radiologist and regional technical director of imaging information at Kaiser Permanente Medical Group.

“We adapted to the idea that the EMR is the fundamental [hub] for all imaging, “ Kennedy said.

Lannum said the Cleveland Clinic was motivated to make the switch to an enterprise-wide image solution when they realized that more than 60% of the data physicians need at the point of care-unstructured data such as images-were missing from the medical record. These data were trapped in silos throughout the organization.

To remedy this, the organization opted to pursue an organization-wide strategy for cataloging and storing images, regardless of which department created them.[[{"type":"media","view_mode":"media_crop","fid":"34497","attributes":{"alt":"Louis Lannum","class":"media-image media-image-right","id":"media_crop_8233973144881","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3671","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 169px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Louis Lannum","typeof":"foaf:Image"}}]]

“It’s more than just storage,” Lannum said. He explained that VNAs initially emerged to extend storage capabilities of radiology departments, however, these systems have evolved to include workflows, central image management, and a single access point.

Previous imaging strategies have been “radiology-centric,” Lannum said, but as more specialties utilize images, it is becoming more important to look at imaging management at the enterprise level. At many organizations, this process has included no longer referring to other specialties using the VNA as  “the ologies.”

“It is time to stop talking about ologies,” Kennedy said. “Now, we have to learn to collaborate (within the enterprise model).”[[{"type":"media","view_mode":"media_crop","fid":"34498","attributes":{"alt":"Richard “Skip” Kennedy, MSC","class":"media-image media-image-right","id":"media_crop_3702769266793","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3672","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 213px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Richard “Skip” Kennedy, MSC","typeof":"foaf:Image"}}]]

So far, 35 of the 45–50 departments that produce images at the Cleveland Clinic have been integrated into the enterprise-wide system.

In addition to solving some of the storage and access problems associated with siloed image management, Lannum said the new system is giving physicians the opportunity to utilize a wider array of image capture devices and provide more efficient care. For example, if a patient sees a dermatologist for a rash, the dermatologist could ask the patient to take “medical selfies” of the rash during treatment and the physician can incorporate these images into the record to assess treatment results.

One of the keys to a successful enterprise image strategy, according to Lannum, is having strong governance. He explained that the Cleveland Clinic has created a governance body, including the chief information officer and representatives from the departments using imaging, that meets regularly. This body helps set image storage policies and helps to ensure that new systems purchased by various departments are compatible with the enterprise system.

Another key to a successful enterprise imaging strategy is to ensure that communication among specialties doesn’t suffer, said Kennedy. He explained that despite the inefficiencies associated with earlier generations of imaging technologies, these older technologies also required one-on-one discussions among clinicians or even physical handoffs of data. It is critical, he said, for enterprise strategies to include good cross-department communication and collaboration.

“For all the inefficiencies, we had a communication and collaboration process build into that,” he said. “We need to maintain that.”

Articles

Experts that have developed enterprise imaging strategies talked about their process at HIMSS 2015.

Successful Execution of Enterprise Imaging

Health system purchases of VNAs are outstripping PACS purchases by 5 times, according to presenters at HIMSS 2015 in Chicago.Presenters Trent Conwell, technical manager at Sentara Healthcare, and Eric Rice, Chief Technology Officer of Mach7 Technologies, a company that sells VNAs, highlighted the factors driving this trend.

Slideshows

7 reasons why it might be time to switch from PACS to VNA.

The Case for Unpacking PACS

Reports that a quarter of New York patients who undergo cardiac catheterization likely received this invasive test 

 have raised concerns for both patients and payers across the country. But when those questions arise, Creagh Milford, DO, MPH, associate medical director at Partners Health Care, and his colleagues are prepared to allay them with data that show that about 90% of catheterizations at Massachusetts General Hospital and its sister hospital Brigham and Women’s Hospital meet criteria for appropriateness.

That data and the confidence it inspires is a product of the hospital’s Queriable Patient Inference Dossier (QPID), which Milford described during a session at the HIMSS 2015 annual meeting. The QPID system is a software program that extracts data from patient records, medical literature, and relevant guidelines to help guide physicians and patients through the process of assessing the treatment options for a particular condition.

The physician still leads the process and makes the final decision, said Michael Zalis, MD, a radiologist and chief medical officer of QPID Health, a company created to commercialize the QPID platform. But the software cuts out some of the labor associated with culling relevant data from the patient’s medical record and highlights for the physician which patient data may be relevant to the decision. With these data in hand, the physician is guided through a decision tree based on the relevant clinical guidelines and professional consensus. At the end of the process, the physician and patient discuss a list of possible options graded based on their appropriateness.[[{"type":"media","view_mode":"media_crop","fid":"34247","attributes":{"alt":"Creagh Milford, DO, MPH","class":"media-image media-image-right","id":"media_crop_5822654009154","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3642","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 190px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Creagh Milford, DO, MPH","typeof":"foaf:Image"}}]]

“We are trying to move us to a system where patient and provider are making decisions based on quantitative evidence,” said Milford.

Once a decision has been made, the system guides the patient through a personalized consent process that includes calculation of the risks of the procedure given their medical background and pictures and descriptions of the procedure, explained Zalis.

“It completely changes the game in terms of the patient’s understanding of what they are getting involved in,” Zalis said.

So far, a pilot of the QPID system for lumbar spine care involved 95 cases; the care selected for 83 of them (87%) was deemed appropriate. Seven cases were deemed rarely appropriate and are currently under review. By the end of the year, the health system plans to have QPID up and running for 9 costly procedures.[[{"type":"media","view_mode":"media_crop","fid":"34248","attributes":{"alt":"Michael Zalis, MD","class":"media-image media-image-right","id":"media_crop_8202817250507","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3643","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 190px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Michael Zalis, MD","typeof":"foaf:Image"}}]]

The hospitals have reaped other benefits as well. The system has helped lower the costs of unnecessary care, Milford said. It can also be used as a selling point to patients and referring physicians who want evidence that the organization’s care is cost-effective. It has also cut the administrative work associated with prior authorizations for both the hospitals and the insurers they work with. Milford explained that some insurers have been willing to forgo preauthorization now that the QPID system is in place. Additionally, the system helps provide data for state and federal registries on appropriate use.

Ultimately, Milford said the system may not reduce the number of procedures, but it helps to improve relationships between patients, payers, and clinicians.

“The goal is not to reduce the number of procedures, but to attest to their appropriateness,” he said.

A program presented at HIMSS 2015 highlights the value of decision support for appropriateness in imaging.

Maximizing Appropriate Use With Smart Decision Support

CHICAGO - Declining reimbursements, commoditization, and preparing radiologists to adapt to health care reform are some of the key issues leaders from the American College of Radiology (ACR) are grappling with, according to ACR leaders who spoke at the Radiological Society of North America’s “Critical Issues Facing the Practice of Radiology” round table discussion.

Bibb Allen Jr., MD, chair of the ACR board of directors, noted that many radiologists are practicing hyper-efficient radiology in which they sit at a work station and try to minimize interruptions from referring physicians and patients, a phenomenon documented in 

. But Allen noted that the model isn’t sustainable and contributes to commoditization.

“If all we have to offer is interpretation, anybody can do it,” he said. “It can be traded on the market based on price.”

To help radiologists stay relevant, ACR has launched the 

 initiative. Allen said the initiative aims to help drive culture change in the specialty by providing radiologists and referring physicians with tools that will help them integrate high-value care into their workflows. The initiative, he said, also aims to better align pay incentives, so that physicians are rewarded for making these changes.

He noted that the organization has created a clinical decision support tool called 

) that makes it easier for referring physicians to integrate the ACR Appropriateness Criteria into their image ordering. The program has a web-based version and can be integrated into an electronic medical record system. Bibb noted that the Appropriateness Criteria have long been widely available in books, guidelines clearing houses, and other formats, but referring physicians haven’t used them. Electronic decision support tools integrate the criteria into the imaging order workflow of an electronic record and automatically set up a radiologist consult if a physician orders a low value test.

The college is also working on developing electronic tools that will help improve radiologists’ performance. For example, the organization is working to help develop programs that will ensure fail-safe reporting of critical patient results. Bibb noted that electronic systems can ensure that critical results are reported in minutes, hours, or days depending on the urgency.

The organization is also developing decision aids for radiologists to help them make more consistent and evidence-based decisions about the tests they order.

“Our goal is to deliver all the imaging care that is beneficial and necessary and none that is not,” said Geraldine B. McGinty, MD, MBA, chair of the ACR Commission on Economics.[[{"type":"media","view_mode":"media_crop","fid":"30615","attributes":{"alt":"ACR","class":"media-image media-image-right","id":"media_crop_1763377234780","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3214","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 104px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

James A. Brink, MD, vice chair of the ACR board, said the ACR is developing dashboards to help radiologists track quality measures. These dashboards, he noted, can help practices demonstrate their value and meet the requirements of accrediting organizations.

While the ACR works to help adapt to health care reform, the organization is continuing to shore up the current fee-for-service reimbursement system most practices operate under, McGinty said.

“We are fighting hard to prevent further cuts,” she said.

She noted that the ACR has had success working with diverse stakeholders to address reimbursement issues. For example, ACR worked with patient groups, physician organizations, and others to support Medicare payments for lung cancer screening of long-time smokers and the Centers for Medicare and Medicaid Services agreed to coverage beginning in 2015.

All of these initiatives create greater opportunities for radiologists and other physicians to track the value of the care they provide. Brink said it is essential to embrace these quality improvement tools going forward. He noted that at Massachusetts General Hospital, where he is radiologist-in-chief, physicians have been able to identify areas where they may not be performing as well as their peers and improve the care they provide while reducing unnecessary imaging.

“If we don’t become our own watchdogs, others will do it for us,” Brink said.

ACR leaders debate reimbursement, commoditization, and health care reform at RSNA 2014.

Bridget M. Kuehn

Articles

Successful Execution of Enterprise Imaging

The Case for Unpacking PACS

Maximizing Appropriate Use With Smart Decision Support

ACR Leaders Focus on Moving Radiology Forward