There are counities and regions for which the health information exchange concept is ideal. One example is the largely rural state of Maine, where a small number of HIE organizations have begun to go live with the sharing of diagnostic images to improve care quality and efficiency.

One interesting aspect of this evolution, according to Barry Blumenfeld, M.D., vice president and CIO of the 600-bed Maine Medical Center (Portland), is the development of HIEs and PACS systems that have spurred the increasing mobility of diagnostic images. Maine Medical Center is the flagship facility for a seven-hospital system across the southern region of the state (Blumenfeld is CIO of the entire system), and all those hospitals have referral relationships with physicians from across the region. So it was a natural progression, he says, for his organization to develop an HIE. One Maine Health Collaborative, an initiative that brings together Maine Medical Center, Eastern Maine Medical Center in Bangor, and Maine General Hospital in Augusta, has been sharing images for about a year-and-a-half.

Blumenfeld credits the work that Bob Coleman - Maine Medical Center's director of radiology informatics - and his team have done to establish and evolve diagnostic image-sharing as part of the HIE. Coleman estimates that about 10 diagnostic imaging studies, and their related images, are shared every day. “This has really helped solve the old ‘CD problem,’” he says, referring to the challenges of sharing diagnostic images among clinicians and patients on CD-ROMs. While for some the issue might seem minor, Coleman says resolving the problem has made the staff's lives easier, speeding up decision-making and unburdening physicians considerably.

Another organization moving forward in this area is Lakeside Health System, a 61-bed community hospital in Brockport, N.Y. Lakeside participates in the Rochester RHIO, which connects 15 hospitals in the Rochester region, says CIO John Schrenker. At press time, members of the RHIO were sharing laboratory and radiology results and reports. And although the organization doesn't technically “share” diagnostic images, its processes allow for rapid accessing of images by clinicians across the RHIO.

“When we see a patient and the radiologist signs off on the transcribed report, that report gets sent to the RHIO,” Schrenker explains. A notification is sent to eHealth Global Technologies (the Rochester-based vendor firm that is facilitating the image exchange), whose devices “sit on our network and are connected to our PACS.” The eHealth solution, he says, “triggers an image pull, so that the completion of a report automatically pulls the images up to the RHIO.”

One advantage of this strategy, Schrenker says, is that it removes him from the process and lets community physicians access images through the regional health information organization. “It brings traffic to the RHIO, and takes burdens off our shoulders. And if there are images from two or more different hospitals - and as additional facilities participate over time - it makes it easier to access all the images,” he says.

The volume of data involved is considerable, says Ted Kremer, executive director of the Rochester RHIO. “We exchange about 1.4 million clinical results a month among 1,500 users, including 500 physicians,” he says. Included in this exchange are 60,000 radiology reports per month, along with their associated images.

Kremer says the sharing of diagnostic images and radiology reports provides clear value to participating physicians. “As soon as you start making that kind of cross-institutional data available, physicians see a lot of value and want a lot more information. And even where tightly integrated delivery networks often didn't think patients were moving across their delivery network into another system, they are, and physicians struggle with providing information to them.” What's more, Kremer says, “Providing access to images has actually brought more radiologists and radiology providers to the table, and people started looking at creating more value propositions around images.” Kremer and his colleagues are utilizing HIE technologies from San Jose, Calif.-based Axolotl Corporation.

Can Medicaid Provide a National Information Network?

“There's now a tremendous effort going on to generate statewide e-health initiatives” under the Medicaid banner, says Washington-based Saunders. He and his colleagues are working to create statewide HIEs for Alabama, Kentucky, Wyoming, and Missouri. “There have only been six to eight states that have done something so far in this regard,” Saunders says. However, based on planning being directed at the federal level by the Obama administration and the U.S. Congress, he believes, “all will eventually be required to do so.”

Saunders sees two great advantages to the projects being developed in the public sphere. First, he says, Medicaid programs are seen as “neutral players” by hospitals and physicians, in contrast to how providers see private health insurers. As a result, he says, Medicaid programs have a far better shot at getting providers' cooperation and participation in Medicaid-driven HIEs. Second, “The vendors used by Medicaid will learn from the experience.” Ultimately, the HIEs being created by Medicaid programs could help to establish the national health information network that federal policymakers and industry experts envision, he says. That day is still a long way off, but, Saunders says, healthcare CIOs should keep abreast of developments in Medicaid, as well as on the private side of healthcare.

Meanwhile, hospital CIOs who are collaborating in HIE/RHIO development are already seeing the benefit of moving towards active sharing of diagnostic images. Robert Buchanan, CIO of the 123-bed Anna Jaques Hospital (Newburyport, Mass.), says his hospital is involved in the Massachusetts E-Health Collaborative, whose numerous initiatives have been connecting Bay State hospitals for the past few years.

“Right now, our community health information exchange is really still in its infancy,” Buchanan says. “We've been exchanging laboratory results for three years and radiology results for two years now.” And though physicians can't yet directly exchange diagnostic images with one another through the HIE, he says they can get images via a separate Web browser, which accesses a server that publishes the images. Since image-sharing is indirectly already a part of the overall initiative, Buchanan says he and his colleagues at Anna Jaques are working with Cambridge, Mass.-based Wellogic to address connectivity.

Lessons learned so far? “Start slowly, but with enough functionality that it will provide value to the physicians, so they'll want to use the exchange,” says Buchanan. “Because if you try to make it too complex, I don't believe you'll have much success.”

Meanwhile, says Maine Medical Center's Blumenfeld, “The CIO has to be a facilitative leader in this - and at times, even an activist leader. Wherever possible, you want to have clinical and business partners, but this is one area where IS does need to lead,” he adds. “And unless the CIO is a visionary and is able to corral people together to some extent, this won't happen.”