Postcards from the Imaging Informatics Road

EXECUTIVE SUMMARY

The current strategic landscape for imaging informatics is one filled with great contrasts and paradoxes. On the one hand, because imaging informatics was not explicitly addressed in Stage 1 of the meaningful use requirements under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health Act (ARRA-HITECH) legislation, it instantly lost some of the environment of turbo-charged energy characterized by areas that were directly addressed by the HITECH Act, such as quality data reporting, care management, and of course, core electronic health record (EHR) development.

On the other hand, an interesting combination of factors-rapidly advancing technology, the expansion of the image archiving concept across different medical specialties, and the inclusion of diagnostic image-sharing as one element in the development of health information exchange (HIE) arrangements nationwide-is nonetheless pushing imaging informatics forward towards new innovations.

The five articles below provide readers with different glimpses of the path ahead for imaging informatics. The first presents a look at the current policy and reimbursement landscape. Each of the four subsequent articles delve into different aspects of innovation, from a process developed at a public hospital to improve and speed up the diagnostic process for trauma patients, to a radiology-specific financial analytics solution in the group practice setting, to an advance in cardiology information systems, to a self-developed federated image viewing platform at one of the nation's largest integrated health systems.

Each of those initiatives is very different; yet it is clear that a great deal of innovation is taking place across the U.S. healthcare system when it comes to imaging informatics. With a landscape filled with uncertainties and potential policy, reimbursement, and industry shifts in the offing, CIOs, CMIOs, and other healthcare IT leaders will need to think very strategically where this critical area fits into their organizations' overall clinical IT strategies going forward.

LOOKING ACROSS THE INDUSTRY AND POLICY LANDSCAPE

THE ACR'S KEITH DREYER, M.D., IS MAKING THE BIG PICTURE AROUND IMAGING INFORMATICS

Keith Dreyer, M.D., is as involved as any practicing radiologist with the policy and strategic IT issues facing radiologists as any radiology professional in the country these days. Not only is Dreyer vice chairman of radiology at Massachusetts General Hospital (one of the member hospitals within the Boston-based Partners HealthCare), and assistant professor of radiology at Harvard University; he is also co-chair of the Informatics Committee at the Reston, Va.-based American College of Radiology (ACR), and chairman of the ACR's Government Relations Informatics Committee.

Dreyer sees three important trends advancing within the imaging informatics world. The first is the shift towards vendor-neutral archiving; the second is forward progress around meaningful use, as well as interest in accountable care organization (ACO) development under healthcare reform. And the third is technological and tactical changes in approaching image capture and acquisition in hospitals and other patient care organizations. In addition, Dreyer is carefully tracking current reimbursement and policy trends, and representing the ACR and his fellow radiologists on policy issues in Washington, D.C.

The first industry trend, towards vendor-neutral archiving, is evolving forward in the context of enterprise-wide clinical image management, Dreyer notes. “For example,” he says, “at Partners HealthCare, we installed PACS [picture archiving and communication systems] in the mid-1990s. And at that time, our then-CIO, John Glaser, Ph.D., said to me, ‘This isn't really my thing, it's a radiology thing.’” That view was nearly universal among CIOs at the time, Dreyer says; the first PACS were seen as department-level systems meant to help radiologists with what were seen as uniquely specialized needs.

Fast-forward to the present day, however, and it's become increasingly clear to CIOs and other healthcare IT leaders that, “Now that radiologists have had their needs met, the cardiologists, pathologists, gastroenterologists, and other specialists are increasingly seeing the need for image archiving systems for their specialties.” And while the industry initially responded to cardiologists' needs with “cardiology PACS,” it's becoming clear that the only workable solution is to create an enterprise-wide image archiving system that meets the needs of all specialties (and of their referring physicians) for such tools.

SHARING IMAGES ACROSS ENTERPRISES

At the next level, of course, there is image-sharing that takes place among providers in different organizations. “It's very easy now to take an image from an MR or CT and store it in a PACS system; and nearly everybody can also store images now in the EMR,” Dreyer says. “But what nearly no one can do is send that image across to another enterprise.” Fortunately, he notes, vendors are beginning to create secure private or public clouds (or mixed private-public clouds) that can securely and in a timely way get images from one clinician to another, as appropriate, so that, “without building VPNs or dedicated lines or anything, they can create that connectivity and sharing.”

IT'S VERY EASY NOW TO TAKE AN IMAGE FROM AN MR OR CT AND STORE IT IN A PACS SYSTEM; AND NEARLY EVERYBODY CAN ALSO STORE IMAGES NOW IN THE EMR. BUT WHAT NEARLY NO ONE CAN DO IS SEND THAT IMAGE ACROSS TO ANOTHER ENTERPRISE. -KEITH DREYER, M.D.

In addition, Dreyer and his colleagues at Mass General and Partners HealthCare have implemented and have been enhancing “technology that loads a CD from another organization and transmits the images into our PACS and then into our EMR. We call that cross-enterprise image import,” he says, and notes that his organization is already able to exchange diagnostic images through that technology without the use of CDs. As that technology improves over time, he emphasizes, patient care organizations will finally move out of the current situation, in which imaging departments find themselves drowning in CDs, some of them in non-compatible formats, from other organizations, and sending out many thousands a year themselves. (Mass General alone produces 200,000 CDs a year for other organizations, Dreyer notes.)

REIMBURSEMENT ISSUES COMPLICATE EVERYTHING

On the policy and reimbursement front, numerous diverse trends are affecting radiologists in different ways. On the one hand, the Office of the National Coordinator for Health IT (ONC) confirmed last year that radiologists are considered eligible providers under both the Medicare and Medicaid HITECH programs; under the Medicare stimulus program, a physician cannot provide more than 90 percent of their Medicare-covered services in the inpatient or emergency room settings. But there are still some complications around achieving the meaningful use requirements, and it is not entirely certain that the Stage 2 requirements will clarify things for radiologists. Still, the ACR has been urging radiologists to participate in MU/HITECH.

More broadly, however, Medicare physician reimbursement overall may pose more serious issues for radiologists, particularly if the “super-committee” created in the U.S. Congress to work out remaining unresolved issues from the bipartisan agreement this summer over lifting the federal debt ceiling cannot resolve certain questions. Some federal policy analysts are predicting major provider payment cuts under Medicare, with specialists the most vulnerable. In addition, the ongoing lack of resolution around the continuing delay in implementing the sustainable growth rate (SGR) formula for Medicare physician payments (with an average 29.5-percent pay cut looming next year), is adding uncertainty to the mix.

I WOULD BET THAT NO MORE THAN 25 PERCENT OF CIOs REALIZE THAT RADIOLOGISTS ARE GOING TO BE ELIGIBLE PROVIDERS, SO CIOs NEED TO GET RADIOLOGISTS INVOLVED IN THE CONVERSATION. -KEITH DREYER, M.D.

“I don't disagree with you that radiology may get hit,” Dreyer says of the cluster of physician reimbursement issues; “and there are a lot of advocacy efforts involved around that, because you could end up decreasing imaging, but increasing costs elsewhere. But regardless of what happens from a reimbursement standpoint, the challenge for radiologists around MU is very simple, because the 25 main requirements don't really apply to what we do, and don't really speak to the necessary technology necessary for improving patient care within our specialty,” he adds.

Given all this uncertainty around reimbursement, which likely will strongly influence how radiologists respond to the meaningful use imperative, Dreyer urges CIOs to “get educated. I would bet that no more than 25 percent of CIOs realize that radiologists are going to be eligible providers, so CIOs need to get radiologists involved in the conversation,” he says. They need to start looking at enterprise visualization tools [formerly referred to as “enterprise image distribution tools”] and cross-enterprise image-sharing,” as tools that can appeal to radiologists as they begin to transition to the emerging world of image management. And on the other side of the ledge, CIOs should look into clinical decision support for image-ordering, for ordering/referring physicians.

And then there is the work towards creating health information exchanges (HIEs), which will most certainly involve radiologists at some point, in every organization.

In the end, Dreyer says, CIOs and other healthcare IT leaders need to look at the imaging informatics world as one key piece of the overall clinical informatics puzzle. With technological, policy, and industry changes all creating shifts in the landscape, radiologists and imaging informatics will, he concludes, become more and more a part of the broader conversation going forward.

For more information about imaging informatics, check out these case studies:

Healthcare Informatics 2011 November;28(11):08-17