Sarah Jersild

Your patients want to view their medical images, and the federal government - through the meaningful use program - suggests they're going to get them.

So the big question becomes how should they get those images? Vendors are making a push for a next generation of patient portals, saying they can reduce costs, increase patient satisfaction and eliminate wasteful duplicate imaging.

"We started looking at patient portals about two years ago," said Cristine Kao, worldwide marketing manager for Carestream Health. "This is the right time."

That's in part due to how technology has advanced - and how comfortable the general public has gotten with that technology. With Carestream's portal, Kao said, "There's no dedicated training required. You know where to log on, you know where to navigate right away. It's like iTunes: You kind of open it up and you intuitively know how to organize and do what you need to do."

Sound like a bold claim? Carestream just completed a case study with Houston Medical Imaging. In all, 1,500 patients activated their image portal account and used it to view and share images. During the three-month case study, Kao said, they received only 47 calls for technical support.

Portals use zero-download clients so nothing has to be installed on a patient's computer. They just log in to a website, click on a folder and get the images they want. When they log out, the images are gone. Nothing is stored on their computer.

But that ease of use makes some physicians nervous. What if patients see the images before the doctor does? Don't panic: Vendors have taken that fear into account.

"One of the things we talked about with a lot of customers was setting up business rules so that either a certain amount of time would elapse or we would get some kind of notification from the referring physician to release the image," said Erica Agran, senior director of solutions management at Merge Healthcare, which has two portal solutions and another concept in the works. "We're not suggesting that we make the rules on delivering the image. We’re just suggesting that we can deliver the image and enable patients to share images."

That sharing is key. The easier it is to see an image, the less likely you are to have to repeat a study. "I have had the personal experience of getting a CD of an image and going for a follow-up right away," Agran said. "They told me they couldn't read the CD and they did the ultrasound again. ... You don't have that problem if you have an electronic copy."

Portals don't just make life easier for patients. They can also cut down on work in your practice. "If you think about how PACS have changed the film-based workflow for the clinician, this is sort of equivalent by taking film or manual media like CDs or DVDs away from the front desk staff and the administrators of the facility," Kao said.

You do have to adjust the workflow in your practice to allow time to educate patients about how to register and use the portals. But at Houston Medical Imaging, the time and costs saved from dealing with CDs outweighed the time spent on education. The case study estimated a cost savings of $7.69 per exam using the portal versus distributing CDs.

But Agran cautions that simply giving patients access to their images isn't enough. "It's not just as easy as giving someone a password," she said. "You still have to explain to patients what they're going to see, what information they're going to get. The technology is there, but there's still that translation that needs to occur."

And as compelling as a patient image portal is to radiology practices, they're just as appealing to other medical facilities, Agran said. "I think the real challenge here is there are too many things you're supposed to sign up for and sign into. For the majority of customers going into a radiology center, they're only going to go once in a while. If you're just going once a year or every other year, it's a challenge for the radiology's portal to mean anything to you."

That's why an ideal solution would aggregate all patent records, Agran said. Merge debuted the merge.com concept at RSNA: "You can do your scheduling, you can get your images, you can come back later and look for things - it doesn't matter if it was a test with your orthopedic surgeon or your mammogram," Agran said.

Both Merge and Carestream plan to roll out their image portals more widely in the coming months. Carestream's solution will be widely available in March, while Merge plans to beta-test the merge.com concept in a small market later this year.

Articles

Vendors are debuting a next generation of patient portals that may reduce costs, increase patient satisfaction and eliminate duplicate imaging.

Imaging Sharing Patient Portals Gaining Ground

The government wants to give you money - but you're probably leaving it on the table. And you're not alone.

Less than a quarter of radiologists qualified for the bonus money CMS hands out for meeting Medicare's Physician Quality Reporting System (PQRS) requirements. That's according to a study from the Harvey L. Neiman Health Policy Institute published in the 

Journal of the American College of Radiology

. Researchers found that only 23.7 percent of eligible radiologists qualified for PQRS incentives in 2010, the most recent year for which data is available.

Why? Three big reasons are cost, confusion or outright contempt. Some physicians crunched the numbers and figured out the 0.5 percent bonus on Medicare billings didn't cover the cost of complying with PQRS.

Others tried to comply, but got contradictory instructions. And some threw up their hands and decided the whole process was meaningless - which is a shame, because the intentions behind PQRS are pure.

"Ostensibly, this was established as a first step in moving our payment system from one that's a fee-for-volume system to one that's a fee-for-value system," said Richard Duszak, MD, chief executive officer and senior research fellow of the 

Unfortunately, PQRS became "a multi-paradoxical type of system that winds up emphasizing a lot of regulatory processes over what was the core intent, which is quality," Duszak said. But he doesn't advocate ignoring PQRS. Instead, he urges radiologists to participate: "I think we all have to look at this as a step in the right direction rather than be cynical about the process."

How? Here’s our guide to overcoming common PQRS objections.

Objection No. 1: The bonus isn't big enough to bother

A bonus payment of 0.5 percent doesn't sound like much - but it won't stay a bonus for long. In 2015, CMS will move to assessing penalties on physicians who don't participate in PQSR, and those penalties could rise to 2 percent or higher on all Medicare billings. What’s more, those penalties will be based on what happens this year, meaning what you don’t do now will come back to bite you in two years.

“It’s still early in 2013,” said Duszak. “There’s still 11 and a half months for folks who aren’t in the process to potentially achieve their metrics this year. Your performance in 2013 will dictate penalties for 2015.”

What's more, your compliance with the system will be a matter of record - a record your patients can see online on Medicare's Physician Compare website. "To some patients who aren't sophisticated enough to understand that this is a reporting metric and not a true quality metric, there may be some implications back to that practice," Duzsak said. "They may say 'Oh, Dr. Jones or Dr. Smith didn't meet his quality metric, he must not be a good doctor.'" You know that's not how the program works, but do you think you'll be able to explain that to potential patients?

Objection No. 2: It costs too much to comply.

Some billing companies are incorporating PQRS reporting into their services at no extra cost. But if you do your billing in-house, the costs may outweigh the bonus. If that's the case, Duzsak said, you might want to consider using a registry service instead.

"The registry gets composite data and reports them as a group," he said. "The key ones have been approved by CMS for reporting, so that information is accepted by CMS as a valid indicator that that physician had fulfilled his or her reporting responsibilities over the course of the year."

And besides, Medicare may not be the only entity paying for participation in the future, Larson said. "Other [payers] are going to start doing this, and you're going to set up a system that's going to get more money from more places in the future."

Objection No. 3: It takes too much effort.

Physicians actually have it easy, Larson said. "With a lot of people using voice recognition and templates for the reports these days, it's pretty easy to put in a line that says, for example, fluoroscopy time, which then reminds you to fill that in," Larson said. "More of this falls on whoever does your billing, whether you do that within your own practice or whether you use an outside billing firm. They're the ones that really are turning that information into a code that the CMS is looking at and using to track whether you're participating and whether you're submitting codes on enough of the patients."

Objection No. 4: The whole system is confusing and contradictory.

Well, yeah, this is government we're talking about. But things have improved since the start of the program, when practices and providers were getting contradictory advice on what we required.

That doesn't mean it's all smooth sailing, however. "You can get tripped up a little bit if Medicare decides some patients were eligible to be reported and you didn't report them. That's a way that people potentially fail," Larson said. "But as far as we can tell, there's no penalty if you submit the code on a patient and they say it's irrelevant. They don't say, 'And by the way, we're going to pay you less because you submitted a bad code.' You should probably err on the side of submitting anyone you think it might be relevant for."

Objection No. 5: The system doesn't measure actual quality, so why bother?

This is a tough one, because there's some truth to that. You get your bonus for reporting, not for reporting good things. "I think some people miss the point that reporting you didn't do the thing counts just as well as reporting that you did do the thing," Larson said. So, if you report that you didn't record your fluoroscopy time 75 percent of the time, that still counts, and you still get paid.

And that particular measurement can be maddening, Duzsak admits. The metric PQRS is looking for is did you report the fluoroscopy time, not whether that fluoroscopy time was appropriate. "To bring that to its illogical extreme, I could report I used six hours of fluoroscopy to perform a barium enema, a dose that no one would consider remotely appropriate, but still the coders would be able to apply it. And I would potentially get a bonus based on that," Duzsak said.

Metrics like that may be the crux of the PQRS image problem. "Folks feel like they're dotting these artificial i's and crossing these artificial t's, which really don't have substantial consequences for patient care," Duzsak said.

But Larson has an answer for these objections: "Get over it. Someone's offering you money for this. Just do it."

Most radiologists aren’t meeting CMS’ Physician Quality Reporting System requirements. But bonuses will soon turn to penalties. Overcome your objections with this guide.

PQRS: Why Radiologists Should Care

Expect 2013 to be a big year for informatics... like every other year for the past decade or so.

But this time, analysts say, it's informatics with a difference. These IT tools could bridge the gap between radiologists and referring physicians, opening up the possibility of real consultation without disrupting workflow.

And the new developments are coming just in time, because the informatics tools that helped radiology thrive over the past several years may also be contributing to its precarious position now.

"The first phase of IT deployment in radiology has made radiologists more productive, more independent, more mobile, and it has allowed them to provide a service without the need for all the surrounded added value," said Nadim Michel Daher, principal analyst for medical imaging at Frost and Sullivan. "This next generation of its deployment has to keep in mind the role of the radiologist, because they feel the future is at stake."

One of the biggest breakthroughs in informatics this year isn't coming from the radiology side. It's coming from the client side.

"Mobile devices - with tablets, and their battery life, resolution, internet connectivity - mean the human-computer interface has gotten to the point where we can now bring back consultation and bring back our relationship with our referring physicians," said Paul Nagy, PhD, SIIM, director of quality at the Russell H. Morgan Department of Radiology at Johns Hopkins University.

About 70 percent of physicians use tablets in their practices, Nagy said, and that gives radiologists a tool to communicate with them in real time but in virtual space.

"Basically what we're talking about is like Skype for PACS,” Nagy said, referring to an Internet phone and chat service. “You're both logged in to the same session, you're both shared into the same video chat and you're actually sharing the images, looking at the same slice and the same nodules. You're both looking at the images together and having a conversation about them. You're guiding them in the image interpretation process and helping them interpret the results."

That's a huge improvement over the reports radiologists could send out via their PACS, Nagy said.

"Before PACS was really an asynchronous technology: The radiologist reads the image and the referring physician reads the report. There's not much collaboration going on as part of that, nor is there much feedback."

The rise of tablets, and the demand for greater collaboration, is both fueled by and is promoting the growth of zero-footprint clients. This technology uses standard, ubiquitous web technology to deliver images and communication.

"It's only HTML, CSS and JavaScript, so nothing else has to be loaded on your computer," said Jim Philbin, PhD, co-director of the Center for Biomedical and Imaging Informatics at Johns Hopkins University. "The application is downloaded automatically by the browser without storing anything on the [device]."

That's a huge plus to a referring physician - and for that physician's IT department. Before zero-footprint clients, Philbin said getting software updates pushed out to all the different departments at Johns Hopkins could take up to a year. Now? Any updates and necessary maintenance can take place instantly at the source. The referring physicians aren't disrupted at all.

This seamless delivery should only help the relationship between radiologists and their customers, Philbin said. "Zero clients are all pushing hard on the collaboration front so that you can do electronic consultation and the equivalent of an electronic curbside consult," he said.

All that collaboration means the push toward an easy way to share data is heating up. So this may be the year when the data breaks free of competing standards.

"Most of the industry is now using digital PACS - certainly more than 90 percent of radiologists' sites are now digital," Philbin said. "I expect this year will be a large leap in Vendor Neutral Archives (VNAs), and I expect that trend to continue in the future."

When that data can be easily shared between different platforms, the ideal of a truly comprehensive patient record could become a reality. "[There's a] whole movement toward having search within radiology," Nagy said. "The radiologist can do a Google-like search within the medical records... and be able to do search of different disease characteristics, to look at the relevant priors quickly, to be able to understand where this patient is and where this patient is going, to be able to put that in context to be able to make their diagnosis."

But the real potential benefit may be in giving patients the keys to all of their medical data.

"The biggest problem we have in the industry is the lack of an aggregated medical record, and the fact that it’s very difficult to share information across enterprises," Philbin said. "The best things we can do for patients is create an aggregated patient record ... so patients can start controlling who has access to their images, and also so they would get ready access to their medical imaging or other medical information through a website without having to do the aggregation themselves. It's all stored anyway, we're managing the cost of that. Just providing the patient access in a secure and controlled way is not a significant expense and would improve patient care significantly."

All that data can also help improve the way radiologists run their businesses. "Radiology has been at the forefront of technology adoption in healthcare, and because of that, we're now sitting on mountains of data: about our referring physician utilization, about how we utilize our scanners and about how we provide services to our customers," Nagy said. "People are beginning to really mine their databases from the RIS and from the PACS, and are building graphical dashboards as a support tool to help them improve service. That's going to be a big deal for building a competitive practice that can reduce costs and improve service at the same time."

But it takes more than one system's data to get the biggest bang for your informational buck, and that amplifies the need for VNAs and other common standards. "The challenge is you need to know more information than just what's in your PACS," Nagy said. "You need to know more about the RIS and maybe the order entry system to have a holistic view of your department. The trick is to be able to aggregate that data in a way that's constant so you can build models around how your patents are experiencing service within your organization. That requires a data warehousing strategy where you're able to extract the data into a common area, translate the format and the able to put a graphical dashboard tool on top of it."

Radiologists and referring physicians are leading the charge for this - but vendors are taking notice. "A real differentiator between the different vendors is how interoperable they are," Nagy said. "Are they trying to hoard the information, or are they trying to provide an open architecture where [physicians] can reuse that data for other purposes?"
 

2013 will be a big year for informatics, helping radiologists collaborate and consult with referring physicians and increase productivity.

The New Informatics: Productivity Meets Collaboration

CHICAGO - Referring physicians have simple needs. All they really want is for you to read their minds, deliver exactly what they desire, and pinpoint what's wrong with the patient every time. Oh, and if you can stop the MRI from making so much noise and freaking out the patients, that would be awesome.

Don't panic. Your referring docs know that's impossible. But there are things you can do to keep them happy - and other things you can avoid to keep them from going nuts. The referring docs shared their dos and don'ts at RSNA 2012 this week.

Do give them all the relevant information.

You're the imaging expert, and the physicians wants your input. "A description of the findings with a differential diagnosis does help me," said Sally Reynolds, MD, medical director of the emergency department at the Ann and Robert Lurie Children’s Hospital of Chicago.

Incidental findings are also important, said Stephan Wyers, MD, assistant professor of surgery at the University of Chicago. "If there are incidental findings, which are increasingly picked up as imaging gets better and better, and those incidental findings require action, that needs to be in the summary at the very bottom of the report."

"The busy internist has 12 minutes to see a patient," said Mary Mahoney, MD, director of breast imaging at the University of Cincinnati Medical Center. "They can't spend 20 minutes to read the radiology reports. And don't be pixel catalogers. We don't need to prove that we've looked at every single corner and speck on the image and cataloged every pixel that's there."

Reynolds agreed. She likes differential diagnoses, but "a differential that's 72 things long isn't going to help me."

"It would be helpful to get some sense in a layman's term: How much radiation is that really?" Reynolds said. "A radiologist a long time ago told me a chest X-ray is the same amount of radiation that you get flying from Chicago to Denver round trip." More of that, please.

"This issue of 'do we need contrast or not' is a one for primary care doctors," said Jeffrey Kopin, MD, medical director of the Northwestern Memorial Physicians Group. "Anything you can do to help your docs know whether to do that or not would be very, very helpful."

Don’t share your expertise on things you don't actually know about.

"I don't have a problem with people telling patients what they see on an X-ray," Reynolds said. "The trick to this is don't tell them what's going to happen next. Sometimes you don't know what's going to happen next. We've had radiologists say 'The orthopedic surgeon will come see you.'
We have a list of things that I do and a list of things that the orthopedic surgeon does. The list of things I do is pretty long, and they don't come see everybody with a fracture."

Do use structured reports and standardized language.

"I like reports to be structured. It gives me the sense that the radiologist has a checklist and they've looked at everything," Wyers said. "That makes it easy to go back and find specifics."

"What does peribronchial cuffing mean?" Reynolds asked. "I don't know. I always look at that and say 'Jeez, I shouldn't have ordered that chest X-ray; I'll never be able to explain this to the patients.'"

"I think it's the best thing that's ever happened to medicine," Kopin said. "We need to leverage the technology that we have. It's happened so fact that we haven't had a change to properly digest it, and we haven't had a way to properly acculturate all this technology into our patient care that truly benefits our patients while making our lives as the physicians that much easier and that much more fulfilling."

Don’t let things fall through the cracks.

"There's nothing like a physical inbox to remind you to check that final report, so significant pathology that really wasn't integral to the acute problem is addressed later," Wyers said. "We need to find a way to push important information in a timely fashion. ... There is an inbox on our EMR but I don't think the radiologists use it, and not even all the clinicians have adopted it."

Do remember that everyone loves a phone call.

"If you page a primary care doctor and you say 'I need to talk to you about Mrs. Jones' CT scan', I'll have to pull myself off the floor because I'll be so surprised and delights that somebody wants to actually talk to me directly from radiology," Kopin said. "That's a game changer to do that."

Don’t make it difficult to get in touch with you.

"If you're part of a big radiology group and people rotate through various parts of the group, publish telephone numbers for referring physicians," Kopin said. 'And if you can publish your schedule ... if you share it with your referring physicians, you're going to be amazed at how efficient it's going to make you and how happy you're going to make your referring doctors. If you make it easy, you're going to be the radiology group that everyone is going to want to send their patients to."

"If I could do one thing, I would make all the imaging be the same so I can actually open all those crazy discs," Reynolds said. "If I have an intubated trauma kid, and I have a disc with a head CT on it, I really need to look at that right now."

Don’t ever use this one phrase in your reports.

"Please banish this sentence from every report: Clinical correlation recommended," Wyers said. "It would be as if I came to you and said 'Please look at the images before you prepare your report.'"

CHICAGO - Referring physicians share their list of dos and don’ts for their colleagues in radiology.

Sarah Jersild

Articles

Imaging Sharing Patient Portals Gaining Ground

PQRS: Why Radiologists Should Care

The New Informatics: Productivity Meets Collaboration

The Dos and Don'ts of Dealing with Referring Physicians