As ACOs and Population Health Move Forward, No “Big Boxes” of Diagnostic Images Needed

Nov. 18, 2014
Multiple revolutions are taking place simultaneously, with accountable care and population health, HIE development, data-sharing and storage technologies, and policy and reimbursement changes, all impacting imaging informatics now

Industry executives and thought leaders agree: the bottom line, when it comes to the intersectionality of accountable care and population health with imaging informatics and health information exchange (HIE) and data-sharing and data-storage technology advances, is this: the future is not about gigantic warehouses of diagnostic images and radiologic reports in the sky. Rather, it’s about intelligently connecting clinicians and other appropriate healthcare professionals in order to share and access diagnostic images and rad reports at the right moment and in the right way.

Perhaps, for some, that concept might seem self-evident. And yet it really isn’t, as the path of health information exchange has been a wandering one over the past decade, with all sorts of concepts and objectives involved. But as health information exchange matures, as the technology and processes around HIE mature, the focus is becoming clearer.

Phil Beckett, Ph.D. chief technology officer of Greater Houston Health Connect, is a good person to talk to in this context. Greater Houston Health Connect (GHHC), which became operational in October 2011, encompasses 10 hospitals across a broad region of Texas. Beckett says it’s clear that the direction of HIE is moving away from any notions of trying to replicate and store countless diagnostic images and reports in the cloud. “You don’t need one gigantic image repository,” he says. “And some are arguing for centralized repositories, but honestly, I think, leave the images where they are, get the meta-data, get the studies if you need them. There are some advantages in a centralized repository model with regard to workflow, per the cloud,” he concedes, “but more and more, even those are going away. In fact,” he says, “the workflow advantages of centralized models will go away.” Most importantly, he says, increasingly, “you’ll be able to access things remotely without having to move images from PACS [picture archiving and communications systems] systems to centralized repositories.”

Rasu Shrestha, M.D. absolutely agrees with Beckett that accountable care and population health advancement will shift the discussion around imaging informatics to one of availability and agility. “In fact,” says, Shrestha, the vice president of medical information technology at the vast 20-plus-hospital University of Pittsburgh Medical Center (UPMC) health system in western Pennsylvania, “the approach should not be one of boiling the ocean, but one of focus—especially with regard to the concepts of population health and accountable care, two distinct yet overlapping ideas. So yes, focus will be mot important.”

What’s more, Shrestha, a practicing radiologist, says, “If you look at what accountable care means for imaging groups, referring physician groups, hospitals, etc., it means different things to different people. And just moving everything into central repositories doesn’t make sense. So what we’ve already started to do is to embrace the power of the cloud, of collaborative care, and also of value-based healthcare across the continuum. And for imaging, the care continuum starts at the point of a patient searching for a physician; or of an order being placed for a certain type of imaging procedure. And the care continuum goes all the way through the imaging procedure, the study report, and archiving.”

Indeed, Shrestha says, “I call it the value-based imaging continuum—and we need to look at things from an end-to-end perspective. It starts from how you get scheduled and have imaging procedures ordered; and it goes into smarter reports that are more meaningful today, and managing archives, and  radiologists facilitating collaboration with the ED physician and the vascular surgeon and the neurologist, making sure follow-up happens. Looking at the care continuum is most important and what drives my thinking.”

Moving towards “semi-universal registries”

Rethinking patient care organizations’ enmeshment in proprietary systems of image storage will be an important step forward, says Joe Marion, founder and principal at the Waukesha, Wis.-based Healthcare Integration Strategies consulting firm, says a recent consulting experience really underscores for him one of the challenges to making images available for population health and accountable care purposes. “I’ve been working with a group in a western province of Canada,” he reports, “And in the Canadian healthcare system, hospitals are government-owned, while physicians contract with the government to do imaging procedures in the hospitals. In this case, a government study had recommended that the healthcare administrators of that provincial health authority should consolidate and store everything in the provincial PACS, for easy accessibility. The problem,” he says, “is that everything has now been stored in a proprietary system, and that there would be costs for the independent physicians of sending their studies in to be stored in that system. And that makes no sense. It would cost millions of dollars to do that, at $1.99 per study.”

Given the situation, Marion says, “What I’ve suggested is that they consider leveraging the XDS [cross-document sharing] standard as an alternative, and set up an XDS-based archive, because it would have much more broader appeal for imaging across all –ologies, DICOM-based or not. And also, the way that the XDS is structured, facilitates the easy sharing of diagnostic images, documents, faxes, any format of information that’s a document. And there’s an extension called XDSI, for imaging. In fact,” Marion notes, “most of the VNA [vendor-neutral archive] vendors are beginning to embrace the XDS standard as a more universal way of being able to access images, documents, all content. So my point is that if they embrace that, there are two elements associated with the definition. One is a repository, where the data is physically stored. The other is the registry, like at a store—it’s a means of identifying the information. So you can have one registry and multiple repositories. And that’s where we’re headed, towards semi-universal registries.”

The advantage, Marion adds, is that “The registry knows about every study, and the repositories can study them. The advantage is that let’s say you have three competing hospitals, and the economics of combining their archives is not there; but with an XDS-based registry, and it would connect all communications. And so you’d know that Mary Smith had four different studies in four different places.” He adds that he is already working with integrated health systems across the country on such efforts—for example, the UMass Memorial Health System, based in Worcester, Mass., to create data- and image-communication systems across diverse IT environments within the same health systems. “if you go to a VNA strategy with an XDSI protocol, you can build a common registry,” he adds; and that is exactly what he is helping the UMass folks do.

Focusing on image availability

Still, says Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative (MAeHC), “There is no single best answer to the question [of centralized image storage versus point-to-point facilitation], because it depends a lot on imaging utilization patterns and what systems are already in place.  Jumping towards creating the facilitation of point-to-point sharing of images and data is a big step, and probably the option of last resort.  Storage is cheap, but I would focus in any case on an approach that unifies access to distributed imaging information, rather than on the consolidation of the images themselves,” he says.

Drilling down one more level, Tripathi emphasizes that there are layers to the issue. He cites the following as important layers to consider:

  • Imaging information availability: Imaging information availability – some ability to know that a relevant imaging study has been done and where to go for the results/interpretation (followed by a manual process to chase down the results, as needed and relevant)
  •  Imaging interpretation access – some ability to gain electronic access to relevant imaging results/interpretations
  •  Image access – some ability to gain electronic access to the images themselves
  •  Imaging utilization information – some ability to identify patterns in utilization of high-cost imaging

“The very first question an ACO needs to answer,” Tripathi says, “is how important imaging utilization is in their risk calculus.  There may be other areas of risk that are higher-impact and easier to tackle.  Or utilization of imaging may already be well-managed, through payer-required pre-authorization processes, for example.” In that context, he says,  “The next step for any ACO is to determine how many imaging sources may be involved, and here I would recommend doing some type of Pareto analysis (‘80-20’).  If there are relatively few systems –say, two or three— that account for the vast bulk of images, it’s probably a lot easier and more feasible to figure out how to enable uniform imaging results delivery to ordering providers, allowing an ordering provider to ‘cc’ other providers on imaging results, and enabling some type of uniform SSO access to the distributed PACs systems.”

On the other hand, Tripathi continues, “If it turns out that there are a lot of important radiology source systems, there are commercial image-sharing companies that are expert in this area, and that can provide rock-solid services pretty quickly.  If there is an organized HIE activity already in place in the area, there might be some synergy in integrating EMPI and provider searches between the HIE activity and the commercial image sharing service, for example.”

A data warehouse that allows imaging utilization analysis and identification of high-cost imaging services is important for ACOs to identify this risk and determine action steps for shifting utilization to a smaller set of lower cost imaging providers, Tripathi adds. Indeed, he says, it may be easier to get providers to refer to a smaller set of imaging sources than it is to figure out sharing across multiple imaging sources.

“Finally,” Tripathi says, to the extent that HIE activities/organizations can provide value here, I would suggest that it’s in record location (identifying that a relevant imaging study has been done somewhere), providing access to the reports/interpretations, and lastly, perhaps providing access to distributed PACs systems or to commercial image sharing providers, through SSO enabled by the HIE activity.  I would not go to having the HIE activity handle/store images themselves.”

One non-technological, yet very important, factor in all this, says Jim B-Reay, will be for healthcare leaders to consider the impact on radiologists’ medical practice (and business) generated by the forward progress of HIE development. Specifically, more advanced HIE development will almost certainly continue to reduce the number of redundant diagnostic imaging procedures and studies going forward. With recent federal reimbursement mandates to bring down healthcare utilization, radiologists are beginning to feel unfairly targeted. “The reimbursement trendline is very clear,” says B-Reay, a Minneapolis-based principal at the Pittsburgh-based Aspen Advisors consulting firm. “And radiology really is at the tail end of that, but it’s going to hit the radiologists hard over time. They’re going to see, and probably are seeing, a decrease in tests ordered. And it’s like, wait, I did five fewer than last year at this time, right? And it’s because we won’t do that third MR on the knee, right?” Though such personal reactions to the advance of technology having nothing to do with the technology itself, they inevitably will influence physician (and especially radiologist) acceptance of such changes in the coming months and years, he says.

Meanwhile, radiologists and referring physicians themselves are beginning to see that creating big boxes full of images and reports doesn’t really make sense. “I was talking to someone in radiology recently at a major medical center,” B-Reay says. “And essentially, he was telling me that creating the imaging part of an HIE at that health system was turning out to be a kind of bust. The value of creating a centralized repository for all images ended up not really being there. It was sufficient to know that a test had been done, and then one needed to do a point-to-point transfer of images. So the shared-tank concept of imaging repositories has proven to be kind of a flop.”

At the same time, as patient care organizations and HIEs move forward on multiple fronts in the accountable care and population health spheres, experts say it will continue to be very important to get the basic “blocking and tackling” right in terms of image-sharing, and that includes the correct matching of patients and their images, studies, and reports, a set of tasks that remains challenging. “The key piece,” says GHHC’s Becket—is the whole master-patient index aspect. And that is a challenge for everyone, in HIEs, ACOs, you’ve got to be able to match a patient across facilities. And that’s not an easy task. We’ve all got mistakes and duplicates internally. But now you’ve got to be able to match up the imaging study with the master-patient index, so I can get a list back of everything that’s been done to one patient. So you need that meta-data.”

As UPMC’s Shrestha underscores, “Population health means having the ability to define patient populations, identify gaps in care, and risk-stratify, especially in the accountable care context. So when you identify gaps in care and risk-stratify, and this is where imaging comes in, you need to manage care and identify gaps intelligently. So it’s not just ordering a study, but understanding why that study is happening for that patient at that time,” he says. “It’s also about care coordination, which implies the right levels of communication between the radiologist and the referring physician. And last but not least, it’s also about measuring outcomes. And having that level of transparency through all of these different steps, is really critical.”

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