Radiology, Meaningful Use, and Consumer-Driven Healthcare: How Do All the Puzzle Pieces Fit Together?

April 9, 2013
At the “Merge Live” client conference in downtown Chicago, well-known imaging informatics expert Eliot Siegel, M.D., offers his perspectives on the future of imaging informatics, and the large gap between EHR reality and medical specialist usability

On Aug. 27, Eliot Siegel, M.D., a professor of diagnostic radiology and nuclear medicine at the University of Maryland School of Medicine, and director at the Baltimore Veterans Affairs Medical Center, in Baltimore, Md., delivered the opening key note address at the “Merge Live” client conference sponsored by the Chicago-based Merge Healthcare. The conference, held at the Swissotel in downtown Chicago, brought together several hundred leaders from Merge Healthcare customer organizations. Dr. Siegel shared with attendees an update on the work he’s currently involved in with the IBM Watson project, working to translate some of the Watson concepts into the medical environment. He also shared with his audience his perspectives on where electronic health records (EHRs), picture archiving and communications (PACS) systems are in terms of meeting the needs of practicing radiologists and other medical specialists, and what the journey ahead might look like.

Following Dr. Siegel’s keynote address, Merge Healthcare chairman Michael W. Ferro, Jr. presented to attendees his vision of Merge’s direction going forward, which he said would be strongly driven by the combination of the increasing demands on the part of patients and healthcare consumers for more convenient scheduling and other satisfaction-related factors, and of steadily improving technological capabilities, the leveraging of which, he predicted, would make all the difference between successful providers and their less-successful competitors.

For example, Ferro noted, the suite of capabilities that Merge is completing development on, known as “MergeClear,” will soon allow a physician to press a button on her or his smartphone, using a new Merge app, and will instantly be able to facilitate a patient’s making a diagnostic imaging appointment. Combined with kiosk technology at the front desk of an imaging center, he said, radiologists and their staffs will soon be able to greatly ease the challenge patients face in arranging imaging appointments and going through the check-in process. The suite of technologies involved, he announced, would be available by the first quarter of 2013, under an allied site called

“It is us against them,” Ferro said of Merge Healthcare’s vendor competitors. “All I care about is Merge customers. If you’re a hospital, you’re my customer. If you’re an imaging center or physician practice, you’re my customers. I want to make sure you get more customers and win. Because there are going to be a lot of losers in this space.”

Looking at diagnostic images more broadly

After the morning’s presentations, Dr. Siegel sat down with HCI Editor-in-Chief Mark Hagland to discuss his perspectives on the future of imaging informatics and the large gap between EHR reality and the need for greater usability on behalf of medical specialists. Below are excerpts from that interview.

When you look at EHRs, PACS, and other clinical information systems, what is your perspective on where the various clinical information systems are right now in their evolution, and how they need to evolve to meet the needs of medical specialists, including radiologists and referring physicians?

On the one hand, we are in an era where the technology is incredibly advanced and sophisticated; and on the other hand, the imaging informatics and EMR systems we have are incredibly dumb. I brought up the example that when I try to sign into the PACS system at my own hospital, I’m required to type my full name in capital letters. If I type my name in, in any other way, it won’t sign on, but won’t explain why. Or the system will give me a message or notice to the effect of, are you sure you want to do that? And I’ve been spending the entire day working on that issue, but it still asks the same question over and over. And, while I’m dictating my notes for transcription, I can say a measure of 4.8 centimeters on an aneurysm, and the transcription system will type out, “foreplay.” It should have a mechanism to tell me that its level of confidence for that is significantly lower than normal. So, we talk about our pets and kids training us instead of us training them; and [in clinical informatics], we put up with so many things that are so counter-intuitive and dumb.

Eliot Siegel, M.D.

And, as a result, we end up with clinicians being resistant to using those systems, correct?

Yes. I helped achieve the first filmless radiology department in a hospital, at the Baltimore VA. We were the first hospital in the world, in 1993, to go filmless. And what we were really trying to do is to have a way to not lose the images, and to make the images available to everyone. Back then, that was incredibly revolutionary; and we weren’t sure whether it would take the radiologists longer to read the images. We weren’t even sure whether it was legal, because the state at the time had mandated that you keep film for seven years. And the resolution on screen wasn’t equivalent to the resolution on film.

But now, it’s 19 years later, and being able to have images digitally is really pretty much taken for granted. And, at my hospital, we’re in the process of replacing that original system. And in 2012, how can we transform what seems to be an incredibly dumb system that really doesn’t talk very well to other systems, and prepare for the next generation?

Paging Mrs. McGilliguddy

You have an interesting story to tell regarding a visit you made to the Mayo Clinic in Rochester, Minnesota, years ago.

Yes. As a visiting professor, in 1997, I visited the Mayo Clinic; and I was amazed at how efficient and effective the [radiology] department was. What I found was that they had this mini-army of blue-haired ladies assisting the physicians. So, sitting next to the radiologist was not some dictation system, but a sweet lady I’ll call ‘Mrs. McGillicuddy,’ who was typing the case in real time at Dr. Smith’s side. And if he would say “left hip” in his report, while intending to say “right hip”—and that happens—she would, in a very kind, gentle way, say, “Hey, Doctor, didn’t you mean ‘left hip’?” And she would never make that “foreplay” mistake.

And that assistant would communicate unusual findings, like an unusual nodule—she literally would go and find the doctor and tell him there was an unexpected finding. And she would go and check later to see whether the doctor had communicated that finding. And the whole question is, why can’t I take my dumb systems that are primitive by today’s technology standards, and do more with them? I’d like to know why I can’t search through reports, I can’t search the EMR, all sorts of things. So give me the kinds of things that Mrs. McGillicuddy did at Mayo, to make me at least that effective.

Meanwhile, back at our hospital, we’re now in a situation nearly two decades later, where we can’t take advantage of our old software. If I weren’t tied and shackled to this single vendor, I could migrate my own images to the new storage forms. We’re looking at a variety of vendors [for a replacement PACS]. But the bottom line is that I want the flexibility to run multiple different imaging systems for different types of diagnostic imaging. And it may be that the software I use may not be tied to a single vendor. So if I can have control of my own images and archive, and have the archive be able to display images on multiple different workstations across multiple modalities, I have maximum flexibility. And if I ultimately have to separate from my vendor, I can do that in a way without being essentially entangled, that was one of the biggest lessons we ended up learning.

What should CIOs and CMIOs be doing right now?

John Glaser [John Glaser, Ph.D., CEO of the Health Services Business Unit at the Malvern, Pa.-based Siemens Healthcare] was recently quoted in an article talking about how he sees the electronic medical record becoming more intelligent. Rather than just a digital mirror of the paper record, it will become searchable, it will become smarter; it will be able to provide guidelines and alerts in a much more intelligent way. And I’d like CIOs to see the significant disconnect between diagnostic imaging and the electronic medical record as it now exists. I’m literally sending a report digitally. There are so many ways we could approach this more intelligently. When I have an unexpected finding, I want that to trigger something in the EMR.

When I do a new PET scan, right now, I have to rely on the information that a physician or her assistant typed in; and you might be a patient with a really complex history, but the only thing I see in my PACS interface is literally the indications for the imaging study. So if I want to learn more, I have to go into the EMR and search it and take 10, 20 minutes. But what if I want pertinent lab data, or I want to know that the patient is HIV-positive and has recurrent Kaposi’s sarcoma, and that a large mass was found in the abdomen in the last imaging study? And we have patients who will come into the department and they’ll call for Mr. Smith, but it’s the wrong Mr. Smith. There are dozens of ways I’d like to make sure, now that meaningful use stage 2 is including imaging, there are so many ways to make imaging so much more intelligent, not just by modifying PACS and speech recognition systems, but also by making systems more intelligent.

So being able to automate this “Mrs. McGillicuddy” from the Mayo Clinic, and being able to automate resident notes’ reports, and being able to create all sorts of touchpoints with the EMR, is exactly what I’d like to have the CIOs do. And I’d love to have the CIOs have us come in, whether at CHIME or wherever, come in and talk with them. And when people talk about meaningful use, I love the fact that people are mentioning that images are part of the electronic record.

Do you have any thoughts on the Stage 2 final rule?

I think what’s going to be really important is to help define more precisely what the interpretation is under Stage 2 around images, and whether they’re referring to reports or images; and whether the EMR can just point to images or whether there needs to be some storage of the images themselves, and whether or not reports can point to images. So I think that imaging in meaningful use is really just the start of where we need to go. And I think now they’re purposely being vague and non-prescriptive, to allow as many sites to be invited to the party. But in a short time we’ll see references to being able to communicate images to patients, to tracking doses, and to referencing quality. And what is the equipment, and is it certified? So I’m really happy to see this relatively broad and general reference to images being a part of the electronic medical record. But what’s exciting is being able to partner into the future; that’s going to be a great opportunity.

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