The U.S. healthcare system is designed to facilitate freedom of choice by letting patients seek care from multiple providers.
The U.S. healthcare system is designed to facilitate freedom of choice by letting patients seek care from multiple providers. While the benefits are far-reaching, electronic data sharing between providers and unified views of patient health records still leaves much to be desired. A patient's medical history, including diagnostic imaging data, is often scattered across multiple unconnected organizations. What's more, these data, and therefore the problem, continue to grow.
By 2012, diagnostic imaging volumes in the U.S. are expected to exceed one billion exams per year. Of exams conducted today, estimates put the percentage exported to physical media (CD/DVD) for the purpose of cross-provider sharing at 10% to 20%. A visit to any modern healthcare facility will reveal that these data volumes have already surpassed the effective limits of physical media. And, as volumes continue to increase and government regulations are imposed, the need for advanced solutions that simplify and improve information sharing between providers, radiologists, clinicians, and patients has become essential.
Today, the digital distribution of medical images between providers and their radiologists has surpassed 90%. Despite this high level of digital adoption, all other image access involving patients and their clinicians and cross-providers has been limited to physical media.
When patients visit a physician, they typically present their diagnostic images on CD/DVD. A number of potential issues may arise with this form of physical data sharing. The CD/DVD:
• may contain a wide variety of image viewers with varying capabilities;
• may not contain the radiology report;
• may contain image data from different or multiple patients;
• image data may not be DICOM formatted; or
• image data may not load.
Even if these issues are overcome, there is no process for data archiving, which may become necessary for liability reasons and future clinical review.
Right now, image-centric subspecialties, such as oncology, cardiology, orthopedics, trauma, and surgery, are most affected. But as imaging becomes a common diagnostic tool, these problems will continue to expand and affect generalists and a wider range of specialists alike.
Let's use the neurosciences to illustrate some of these challenges. Interviews conducted at Massachusetts General Hospital reveal that during a patient consult, much of a neurosurgeon's time is spent loading, viewing, and interpreting multiple CD/DVDs with various image viewers. Up to 50% of that time can be wasted simply trying to display the patient's image data; the amount of time these subspecialists have for the patient consult is considerably reduced.
With the vast array of problems associated with this CD/DVD workflow process, it has become apparent that physical media must be replaced with electronic files, and the physical media eventually eliminated. Many providers have attempted to import digital patient data directly into their PACS. However, this creates more challenging questions that your organization must answer:
• What if the patient has no medical record number (MRN) at your organization?
• If available, do you import the associated report?
• Do you create an accession number in the RIS?
• Is the report recorded as the date entered or the date performed?
• How do you denote these images within your PACS as not having been performed at your facility?
• Do you render an official interpretation? If so, how does a physician request it?
• How do you import the CD data: in a centralized or distributed manner?
• If distributed, how do you prevent nonradiology data from importing?
• What if only a few key images are desired by the physician?
• What do you do with any nonradiology image data? and
• How do you predict and plan for the volume of CD/DVD media to be imported?
MGH estimates that our facility receives between 50,000 and 100,000 CD/DVDs annually in hundreds of physicians' offices. With the diverse nature of our organization, it was quickly determined that a distributed solution for physical media import was necessary. Aside from appropriately distributing the workload, the physicians' office is the last “point of truth” for patient data validation.
Through interviewing a subset of our physicians, we determined that incoming CD/DVD media can be attributed to one of three major categories:
Category A: Radiology exams on patients with an existing MRN;
Category B: Nonradiology exams on patients with an existing MRN; and
Category C: Any imaging exams on patients without an existing MRN.
Each of these categories has its own unique set of requirements. While a solution for category A may be attempted with an existing PACS, it would not be possible for category B or C. However, a distributed solution for category A is not possible with today's PACS applications. To best deal with these categories, a new software application must be introduced. This new technology must serve as an adjunct to PACS and be able to read, display, store, and transmit imaging data with a central-server, thin-client architecture that utilizes industry standards.
Over the next three years, and with National Institutes of Health funding, the RSNA will develop a reference model for image sharing using IHE standards including cross document sharing (XDS), patient information exchange (PIX), and evolving electronic medical record (EMR) standards. This new model will serve as a framework for industry-developed solutions. MGH has chosen to implement lifeIMAGE (lifeIMAGE, Newton, MA), a flexible cloud-based image sharing solution that conforms to these evolving industry standards.
Let's revisit data flow from the physician's perspective with this new technology in place. The process begins when the patient arrives at the physician's office with physical media.
The physician, or office staff, loads the patient's CD/DVD into a web-based computer. The lifeIMAGE application automatically detects the disc, prompts the user to log in, and provides an opportunity to validate, view, and store the patient's image data.
If the patient has no MRN (category C), the physician can immediately view and centrally store the patient's data into the lifeIMAGE system. If the patient has an existing MRN but the CD/DVD contains nonradiology image data (category B), the physician selects the patient's MRN and the data are again stored in the lifeIMAGE system, with a reference to the patient's MRN. With the appropriate EMR interface, this data can be retrieved by anyone with authorization to view patient data within the organization's EMR.
Finally, if the patient has an existing MRN and the CD/DVD contains radiology data (category A), the physician selects the patient's MRN and can request to have their images uploaded to the PACS. Furthermore, at MGH, if the exam was performed within the past six months, the physician can also request an overread by radiology.
Additional features this solution provides, and that MGH has opted to implement in a phased approach, include:
• PACS nomination: If a patient with no existing MRN is subsequently admitted, his or her data in the lifeIMAGE system can be nominated to PACS;
• Patient access: Patients will be able to securely upload and download their own imaging data; and
• Cross-provider image sharing: Organizations with a referring relationship will be able to share patient image data (with appropriate patient authorization) electronically with no physical media.
Freedom of choice will not be removed from U.S. culture any time soon. However, the challenges that this imposes on our healthcare system must be addressed. Through the American Recovery and Reinvestment Act, the federal government has begun to redefine healthcare IT and promote cross-provider data exchange.
The Centers for Medicare and Medicaid Services proposed rulemaking of December 2009 suggests that providers will be required to demonstrate cross-provider patient medical data sharing by 2011. Furthermore, at least 80% of patient requests for electronic medical data must be able to be delivered within 48 hours. It is expected that medical imaging will be an important component of these requirements. As the federal government begins to require even more communication among all healthcare providers, the need for standards-based technology will undoubtedly become an integral part of the medical imaging IT infrastructure.
By taking a proactive approach and deploying technology such as image sharing applications, your department-and organization-will be better prepared for the impending future.