One of the most challenging aspects involved in building out the health information exchange (HIE) concept continues to be around the sharing of diagnostic images. For a variety of policy, process, and technical reasons, most HIEs around the U.S. continue to struggle with how and when to enable the relatively free-flowing sharing of diagnostic images among participating individuals and entities. For many HIE leaders, the “image question” continues to loom large, as they work to become more responsive to their participants, while at the same time putting into place the processes and procedures that can facilitate optimal image-sharing.
One organization that has been pushing ahead to fully empower image-sharing is Coordinated Care of Oklahoma (CCO), based in Norman. That HIE, led by chief administrative officer Brian Yeaman, M.D., a practicing family physician, has been focusing on data liquidity in the imaging realm as in the realm of documents. And the HIE has in the past two weeks gone live with image-sharing.
During the annual RSNA Conference, being held this week at the McCormick Place Convention Center in Chicago, executives at the Burlington, Mass.-based Nuance Communications announced that the leaders of CCO had been able to use its cloud-based PowerShare Network to enhance image-sharing. As a Nov. 28 press release noted, “This evolution in HIE interoperability provides full access to and the seamless exchange of digital medical images and reports through the cloud plus real time awareness of patient’s prior medical images at the point of care. Nuance PowerShare for HIE provides clinicians with intelligent access to consolidated patient imaging records across systems and facilities in a way that immediately becomes actionable. This delivers clinical and patient advantages, and adds sustainability and profitability where HIEs have struggled in the past.”
And the press release quoted Dr. Yeaman as stating that “We went looking for data and image liquidity across our HIE and took a real world, nuts and bolts approach that we know will work, will be familiar to users and drive immediate value. We looked to DICOM standards and the cloud as the most logical way forward. Since DICOM standards are the way all PACS systems currently handle images, it made sense to leverage it as a basis for this new evolution in HIE interoperability. To move images from one facility to the next, it's important to do more than just move pieces of the image, and Nuance PowerShare provided a solution that is awesome with full access to records through the cloud.”
Dr. Yeaman’s statement continued, “We are focused on delivering value to our clients, our providers and to our members in terms of reimbursement, and quality of services in a network. Nuance solved our problem because today we are able to exchange images across different PACS [picture archiving and communications systems] systems inside of one health system, as well as across multiple health systems, bringing that patient data including medical images and reports at the point of care.”
During the RSNA Conference, Dr. Yeaman sat down with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss Coordinated Care Oklahoma’s journey into optimizing image-sharing as an HIE. Below are excerpts from that interview.
Tell me a bit about Coordinated Care Oklahoma, and your journey as an HIE to date.
Back in the day, we were SmartNet. We evolved ourselves as an HIE in 2014 to Coordinated Care of Oklahoma. SmartNet was started in 2007. So we narrowed the organization down to make it a service organization, for sustainability. So we narrowed the organization down to make it a service organization, for sustainability. We’ve got over 65 hospitals and about 250-plus clinics, and another 100 or so post-acute care facilities. So we’ve got the care continuum piece; in fact, we cover 5 million patients across facilities in five states. So we’re doing high transaction volume: over 2 million inbound ADTs and CCDs a month. Our master patient index is very strong and mature, fewer than 5 percent duplicates. We’ve been talking with Nuance for about a year, where we use our MPI as the backbone for image-sharing through PowerShare. We bring the clinical data across the care continuum, and the images as well. So this use of the master patient index in an enterprise approach to the entire region is very different from how any of this was done in the health information exchange world. We were determined to make sure that this was not a centralized, point-to-point model. And that makes sense, given that 60 percent of our patients see two or more hospital systems, 28 percent three or more. It shows you the crossover involved with so many patients.
When did you go live with image-sharing?
About ten days ago. And we’re really able to improve our ability to ensure patient matching as well.
As a hospitalist who has worked in an ED, what is your perspective as a clinician, on diagnostic image-sharing via HIE?
Why we went with Nuance is the fact that it’s all about workflow for the provider. And if it’s a complex case… it’s all about being one click away as often as possible. We have one click for sign-on to the EHR [electronic health record]. And then we have the images layered. And we have the reports. You can click the report and view that. And now, to see the image, you can click an icon within the report now. So we have EHR integration, PACS integration, and an MPI to tie that all together. And the end-user satisfaction is very good. I want an overview of any new patient—chronic, acute, meds, allergies, and to see what the issue is. And oftentimes, that will require, even as a hospitalist, seeing an image. And for radiologists, the decreased cost of having to produce CDs is nice, but really, it’s about productivity. So if I need an image for comparison, rather than waiting eight hours from imaging, so turnaround times, higher-quality reports—that all supports satisfaction.
And the next step beyond that is obviously diagnostic imaging appropriateness. And to have those images for comparison, and then also be able to dictate—we can get smarter about it, in terms of things like body parts and total radiation dose, and how we make those images affordable for the patient. Everybody’s suffered that fate of having to carry a disk from doctor to doctor. And with PowerShare, you can view it in a lightweight viewer, but you can also download the high-resolution image directly into your PACS, with no loss of resolution.
You’re powering the image, correct?
From an HIE perspective, the PowerShare hub, in essence, very much mimics what we do with the data. We take centralized, federated connections. I think there’s a fork in the road for HIEs, if they want to continue to exist. There are those who are trying to monetize. And there are those that will drive a service. And the MPI allows us to drive the image-sharing piece. We also do advance directives. And we’re adding a point-of-care analytics piece. I think we have to do more than form bridges between organizations. We have to literally fill the gaps. We’re more than a bridge, we have to be the glue between disparate organizations. It’s part of a whole picture involving providing patient care between disparate organizations. This is extremely pro-provider, pro-health system, pro-patient. And we can work and facilitate the relationship with payers as well, because we have the information to feed prior authorization services. And so that’s a win-win for everybody. That saves about one FTE per provider organization [such as hospital]. You’ve typically got one person managing faxes, records going out, priori approvals, etc. The imaging procedures are by far the hardest to get approved, and require the most human interaction.
You’re talking about the interaction between referring physicians and radiologists, in this context?
One of the benefits for the referring doc is being able to see if there’s imaging out there, so we don’t have to duplicate imaging studies; and that affects reimbursement, too, obviously. But also, just as a referring physician—as an orthopod or cardiac surgeon, or even family doc, I want to see the studies. And we’re making it more immediate. And that piece that used to be heavy, this makes it practical at the point of care.
Where is HIE going, more broadly, right now?
I think you have to stand it up the time for academics has passed. This has to be an actionable service that produces an ROI just like any other type of solution that a provider or health system might otherwise purchase. And we have to mature as HIEs in order to focus on delivery, workflow, and the needs of our providers. We’ve got to take a step back around this idea that it would be a be all and end all to population health and analytics. It will be a tremendous benefit. But it will never have the richness of an EHR-based data set. And we have to fulfill a service. We can provide you the add-on services, and image-sharing will definitely be a part of that.
What should CIOs and CMIOs be thinking about right now, in the context of HIEs and image-sharing?
If you’re thinking about forming or joining an HIE or an image-sharing network, you’ve got to think with the end in mind, and make sure that it can adequately scale, because you’re always going to want to go further, and be inclusive of data contributors and image sharers, and you’ve got to adopt a solution that remains affordable and manageable, and scalable.
Things will have to become more atomized, in terms of the ability to share data and images, correct?
Yes, I think so. I had a very interesting conversation recently with a guy who does analytics. And there’s this misperception that you’ve got to have all the data all the time; and that’s not true. As a clinician, you need what’s relevant at the point of care and diagnosis. And when I started thinking about data like a patchwork quilt, across different organizations. You don’t need all the squares all the time. And the infrastructure becomes too heavy and too cumbersome to try to have all the data all the time. You don’t need that.
