ARRA/MU Stage 2’s Fuzzy Image

June 24, 2013
In February the CMS published the proposed rules for Stage 2 of the ARRA/Meaningful Use act. The proposed rules include the possible inclusion of imaging, specifically image sharing as a criterion. The comments period closed in May, and now it will now be up to the government to see if imaging survives as part of Stage 2. I have heard some rumblings that advocate the removal of imaging, as “the technology is not mature enough.” I, for one, cannot support this viewpoint.

In February the CMS published the proposed rules for Stage 2 of the ARRA/Meaningful Use act.  The proposed rules include the possible inclusion of imaging, specifically image sharing as a criterion.  The comments period closed in May, and now it will now be up to the government to see if imaging survives as part of Stage 2.  I have heard some rumblings that advocate the removal of imaging, as “the technology is not mature enough.”  I, for one, cannot support this viewpoint.  From my perspective it is less about the technology and more about the application, and the willingness and ability to use it.

In reviewing material on ARRA/MU Stage 2, I came across the following blog ( by David Clunie ( that does a very thorough job of evaluating the imaging references in the proposed criterion.  From David’s blog and other material, I surmise the following issues with respect to the ARRA/MU State 2 criterion with respect to imaging:

  1. Intended Audience

The proposed criterions discuss the potential for image integration with an EHR with the objective of sharing information, but it is not really clear who the intended audience is.  In some respects the proposal seems to be addressing clinician to clinician sharing, but in other respects it seems to address the need to share information with the patient.

Regarding my premise, the ability to share information between clinicians is today routine, and I seem to recall that when considered for Stage 1, part of the argument for not including imaging was exactly that such capability is generally available and routine.  There are a multitude of vendors today that are offering alternative approaches to image sharing, such as replacements for CD’s and the use of edge appliances and the cloud.  Clearly, there is incentive on the part of clinicians to use this capability. 

On the other hand, the capability for electronically sharing image information with the patient is not as robust, and clearly, despite technology advances, there is not yet much incentive for the patient to demand access to their images and to manage them (unless you happen to be someone within the industry such as myself that experiments with the technology, such as storing images on Microsoft’s HealthVault).

  1. The intended use seems to be more about EHR integration and the repository than about the rationale for sharing

Much of the specific discussion relative to imaging is around the EHR integration, and the mechanism for image access, namely a repository in the EHR or a link to the EHR.  I suppose if the intent was to make the EHR the repository for images, integration would be a factor.  In reality, I suspect that more than likely, EHR vendors are looking to imaging and imaging IT companies to do the heavy lifting in terms of the repository, and to rely on a link to the EHR for image display. 

Related to the repository question is the viewer technology.  If EHR vendors are responsible, they will have to be responsible for the viewer technology as well.  Alternatively, if the link approach is employed, the viewer can be from any number of vendors, and can address any number of requirements.  For example, for clinician access it may be essential to have a viewer that can present the native image format, such as DICOM, whereas for a patient view, it does not have to be diagnostic and it could be a simple image viewer.  Similarly, there are emerging “zero footprint” viewers that will enable linking ever more sophisticated image viewing and processing applications to the EHR. 

It does not appear that the basis for sharing is as well defined.  The key sharing implication is that information will need to be shared in native format so that diagnostic quality is preserved.  More on this in the next issue.

  1. There seems to be a preoccupation/perpetuation of the use of DICOM

I have nothing against DICOM, but it seems that perhaps it is a consequence of the state of the industry that the drafters of the proposed criterion dwell on the use of DICOM as the format for sharing data.  Granted the most advanced imaging services such as radiology and cardiology rely on the DICOM format for most of their requirements.  However, this ignores the prospect for imaging areas that are not yet nor may they ever be part of the DICOM standard!  Take for example the case of Dermatology, where the majority of images may be generated from cameras and which are already in an industry standard format such as JPEG or BMP.  In these cases no diagnostic information is lost to deal with them in this format as opposed to DICOM. 

A far better approach may be to consider a protocol proposed by the IHE (Integrating the Healthcare Enterprise), a joint governance of HIMSS and the RSNA (Radiological Society of North America).  The so-called XDS (Cross Document Sharing) profile, specifically the XDS-i profile is meant to handle all imaging objects whether they be DICOM or not.  ARRA/MU Stage 2 repositories may be better to follow the XDS profile than to simply rely on DICOM, as there may be opportunities to exploit non-DICOM imaging areas for ARRA/MU Stage 2 that are just as high a priority to the provider.

Related to the storage format is the viewing format.  If image resolution is to be preserved, viewers will need to support the DICOM format if that’s how the images are stored.  On the other hand, if the intended viewer is viewing for non-diagnostic reasons, a simple image viewer may be all that is necessary.  Again, one type does not fit all circumstances, and it may be a further rationale for allowing for multiple options through the EHR, but not burdening the EHR with managing multiple viewers.

  1. The picture is still far from clear in terms of who has control of patient images

Again the emphasis seems to be on EHR managed sharing of information, including to the patient.  One aspect discussed extensively is the mechanism for two clinicians to share image information, such as in the case when a primary care physician transfers a case to another physician.  The implication is that this is the responsibility of the care provider, not the patient. 

Again, I take issue with total reliance on the care provider for this, as opposed to the patient having ownership for their information.  There are all sorts of implications for both options, such as the rule sets for retention.  A care provider is only responsible for maintaining the images for whatever the state’s legal retention period is (usually five or seven years, but longer for mammography, juvenile, and environmental cases).  How would a patient handle this if they were in charge of their own records?  Would they be dependent on the storage provider (such as Microsoft HealthVault) for such retention rules?  Or, would they be expected to make up their own minds as to how long to store the data?

Clearly, the state of sharing images with the patient is not as advanced as between clinicians, but ultimately, I can foresee reasons why the patient should have some say in this.  For example, what if a patient seeks a second opinion from a source the primary physician does not concur with, or is not directly in the physician’s network?  Shouldn’t the patient have the right to share such information?  And if so, shouldn’t it be the patient’s responsibility for sharing?  Today I can readily go to the medical records department and walk out with a CD or film folder and transmit it to anyone.  Shouldn’t I be able to do this electronically as well? 

Granted there are a lot of issues to be resolved.  The question is, should providers wait for all this to be sorted out, or are there opportunities to leverage the technology today?  One interesting example of a progressive organization already pursuing imaging integration is HealthInfoNet, the Health Information Exchange of the state of Maine.  According to Todd Rogow, Director of Information Technology at HealthInfoNet, they will be piloting an image storage and integration capability to image-enable their HIE.  They expect to have the results of the pilot by the end of 2012 and to roll out across Maine with board approval.  (

What is encouraging about HealthInfoNet’s approach is that they are not trying to “swallow the whale whole,” but take one bite at a time.  By partnering with Dell, they intend to provide a cloud-based image storage capability to their membership that encompasses the capabilities of their HIE to enable a common patient identity (IBM’s Initiate application), as well as Dell’s image viewing technology from Merge Technology. 

At present, HealthInfoNet does not have plans to address non-DICOM images, but Dell’s technology does embrace XDS/XDS-i, so it should be able to address non-DICOM objects in the future.  Their approach is to provide a mechanism/enabler to link images to the EHR, not an integration. 

What is encouraging about HealthInfoNet’s effort is that it is positioning itself to address potential early compliance with ARRA/MU Stage 2, should it indeed end up including imaging

What can be learned from HealthInfoNet’s initiative?  To use another colloquial, “the early bird catches the worm!”  Providers would be wise to follow HealthInfoNet’s lead by considering:

  1. The need to begin to develop strategies for image enablement of the EHR, whether they be data silos, an enterprise application, or an HIE participation
  2. The potential advantages to being an early adopter
  3. That an HIE participation may hedge the bet in terms of how best to achieve EHR interoperability

This week’s Supreme Court ruling may end up resulting in the potential for significant changes to healthcare reform, but one thing is certain – the horse is out of the barn and ARRA/MU is here to stay!  So, the sooner providers embrace the technology, the better off they will be!

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