Developing an Enterprise Imaging Strategy—What is the best approach?

In my last post, we explored the current state-of-the-art of the Enterprise Imaging (EI) industry. In this post, I will zoom in on storing and managing non-DICOM images and videos. This can be ambiguous and may confuse providers who are trying to procure an EI solution. It also results in different schools of thought among vendors.

Currently, EI content can be stored and managed in one of the following formats:

  • Original object (e.g. jpg) stored in a solution’s database and/or filesystem using the vendor’s API (Application Programming Interface)
  • Original object (e.g. jpg) stored using the IHE Cross-Enterprise Document Sharing (XDS) integration profile in a solution’s XDS Document Repository component
  • Original object (e.g. jpg) stored in a solution’s database and/or filesystem using HL7’s FHIR® Media Content specifications
  • DICOM object stored in a solution’s Image Manager/Archive component; for example, using the IHE Web Image Capture (WIC) integration profile
  • DICOM object stored in a solution’s Image Manager/Archive and XDS Document Repository components using the IHE Cross-Enterprise Document Sharing for Imaging (XDS-I) integration profile

The following diagram depicts the main steps that take place during information capture activity for each method.

storage methods

All of the above methods have corresponding pros and cons, which leads to the current divergence of opinions regarding the best option to use. Having said that, it is clear that, irrespective of the chosen method, there is a need to properly collect and manage patient, administrative and clinical context (aka metadata) for the acquired EI content.

Metadata

Each of the above methods offer different levels of metadata rigidity and extensibility which impact the interoperability:

  • DICOM, FHIR and XDS-I based methods offer a level of certainty for the vendors with respect to what information should be captured and how it should be encoded.
  • XDS takes an approach of developing specific content profiles that address specific types of content; for example, the IHE XDS-SD (Scanned Document) integration profile. At the moment, there is no content profile that is specific to the Enterprise Imaging domain. Additionally, XDS allows the original object to be wrapped in a CDA Document to capture additional metadata in case the specified XDS Document Entry attributes are not sufficient.

Is there one “right” answer?

There are two overarching clinical reasons to capture EI content:

  1. To enrich patients’ clinical record
  2. To provide reliable, authorized access to it across the enterprise (and beyond)

As the following diagram suggests, the way EI content is stored is less important then the flexibility of an EI solution’s “Capture” and “Discovery and Access” components, because it is hidden behind those interfaces.

EI Access

It seems that, currently, there is no single answer for the best EI content format given the informatics complexity of healthcare provider’s enterprises. In order to adapt and compete, vendors will be pressured to support multiple inbound and outbound methods (such as FHIR, DICOM, DICOMWeb, XDS, proprietary APIs, etc.) and only time will tell which approach will become a de-facto standard.

Working on an Enterprise Imaging project? Leave us a comment with your thoughts, or contact us.

Enterprise Imaging Industry State-of-the-Art

Based on discussions with colleagues and our clients, Enterprise Imaging is becoming an integral part of U.S. Hospital IT Consolidated Clinical Record strategies.

HIMSS-SIIM Enterprise Imaging Workgroup‘s current working definition of Enterprise Imaging is as following:

  • Diagnostic Imaging – Encompassing traditional diagnostic imaging disciplines such as Radiology and Cardiology
  • Procedural Imaging – Including images that are acquired for diagnosis or clinical documentation purposes (such as visible light photos, point-of-care ultrasound)
  • Evidence Imaging – Including images and/or videos that are acquired for clinical documentation purposes (for example, scope videos, computer aided detection)
  • Image-based Clinical Reports – Documentation that includes or entirely consists of images (for example, Pulmonary Functional Test (PFT) report, multi-media pathology report)

Despite the attention from vendors, industry focus, and provider demand, this market space is still in its early stages of development. There are two main reasons: 1) the scope of the problem domain is still being defined; and 2) the vendor community is still working out the best practices and optimal technical approaches.

Moreover, the number of the departments that generate Enterprise Imaging content and that have their own departmental workflows is quite large.

This results in significant confusion on the provider side who are left to navigate a myriad of perspectives expressed by the imaging informatics industry. There are on-going initiatives that are currently working on demystifying the field of Enterprise Imaging. For example, the recent SIIM Webinar delivered by Dr. Towbin from Cincinnati Children’s, provides a very thorough analysis of the problem domain.

In conversations with vendors and providers, we have compiled several observations that might benefit the imaging informatics community.

The Right Approach

In the SIIM 2015 Opening General Session presentation, Don Dennison presented the following slide titled “Enterprise Image Management: Making the Right Choice”

EI

With the various systems in place to manage patient record data, there is often debate as to which enterprise system is best suited to offer Enterprise Imaging services.

At the moment, there is no obvious answer to the question presented by the slide. Besides the technical capabilities of the systems, the provider’s internal IT capabilities, capacity and policies can significantly influence the decision. At some organizations, where the Imaging Informatics Team plays a prominent IT role, the choice could be the VNA, while at others, where the Enterprise IT team takes the lead, the EMR or ECM is often chosen.

The Right Functionality

During RSNA 2015, we conducted a study to identify the state-of-the-art of Enterprise Imaging technology, including methods of acquisition, management, and distribution of non-DICOM images. The following table summarizes our findings.

 

Image / Video Acquisition
Ability to capture from mobile devices The majority of current vendors opted for native applications to provide better user experience and tighter security controls. Still, image capture is the prevailing capability, with video acquisition capabilities lagging behind. Some vendors offer integration with leading EMRs’ mobile applications.
Ability to capture from visible light cameras The ability to manually (i.e. file browse, drag & drop, etc.) upload both videos and images is a commodity. Automatic ingestion, on other hand, varies significantly from vendor to vendor. Most vendors offer proprietary integration frameworks, but their comprehensiveness and real-life integration experience is very different from one to another.
Ability to capture from different scopes Most of the vendors leverage third party hardware devices to integrate with digital or analog video sources real-time.
Acquisition Workflow
Order-based Workflow DICOM Modality Worklist (DMWL) SCU support, as well as the ability to generate or receive order information, are available in most vendor’s applications.
Context-based launch of the capture application is also a well understood and supported functionality.
Many of the vendors mimic an order-based workflow (i.e. create the Accession Number) for the acquisitions that are not scheduled. The main challenge with this approach is to determine the correct method to feed the created information back to the EMR (e.g. often called an “unsolicited result”, which may not be supported at the site).
Encounter-based Workflow Some vendors, originating from the Diagnostic Imaging space, struggle with native Encounter-based workflow support.
On many occasions, departmental visit/encounter information, supplied in HL7 messages from the EMR, is sufficient to build specific acquisition worklists for different service lines.
Scenarios where information services are not available Most of the vendors offer the ability to manually create patient and procedure information. The difference lies in whether all or just a sub-set of capturing methods (e.g. mobile vs. desktop) support that functionality.
Patient identity management Standards-based methods to discover or receive patient information is widely supported, while the support for proprietary methods to connect to patient information sources varies from vendor to vendor.
Ability to Edit Images/Videos
Editing Tools Most of the vendors rely on an installed Windows OS client application to edit (e.g. crop) acquired images or videos as part of the manual upload process (e.g. drag & drop). Selected vendors also allow static image editing only (i.e. no video) during the mobile capture.
Images An ability to associate different types of metadata (including notes) is supported by the majority of the vendors. Also, basic manipulation of the acquired images such as image deletion, markups and annotation, which are stored as overlay objects associated with the acquired images is common.
Only selected vendors are capable of calibrating images on-the-fly by using recognizable objects of known size embedded in the image.
Videos A flexible and comprehensive ability to associate different types of metadata (including notes and keywords) is supported by the majority of the vendors.
Most of the vendors have very limited (if at all) video editing and capturing capabilities and rely on third party providers.
Viewer
Current state The solutions typically consist of the following viewers:

  • Mobile capture
  • Desktop image/video upload
  • Desktop image/video editor
  • Zero-footprint (ZFP) EMR viewer with very limited, if at all, editing capabilities
Privacy and Security
Current state Most of the vendors offer a range of methods to ensure PHI protection such as:

  • Information deletion/encryption from the device
  • Strong Authentication and Authorization methods
  • Auditing
Reporting
Current state The most prevalent approach is to rely on an external system, such as the EMR or specialty-specific reporting application, to create and manage reports.
Record Management
Current state Most of the vendors opt for managing image and videos in their native format, while converting the content on-the-fly for standards-based communication with external systems.

Conclusion

It seems that Enterprise Imaging is going to rapidly evolve and we are eager to see how our clients, and providers in general, will benefit from these changes.

Working on an Enterprise Imaging project? Leave us a comment with your thoughts, or contact us.

Article – Insurers will have to change to survive

I have been very interested in the changes to how Radiology revenues will be affected during the shift from volume to value based reimbursement, along with changes to healthcare business models in general. I blogged about it here.

I have also been interested in how Radiology will have to change their behaviors in this new environment of transparency and empowered consumers. I blogged about that here.

In this article, a healthcare investment firm details how insurers will have to change in order to compete for mind share among consumers (with choice).

Another very interesting point they make is about wearables. I agree that they are only used by so called Innovators (from the Innovation Adoption Lifecycle model) today.

But what if insurance companies start offering incentives in the form of reduced policy premiums for people that use them (and share the data with the insurer perhaps). This is much like having a security system on your home lowers the cost of your theft insurance, or smoke detectors lowers your fire insurance premiums. This would create a boom in the mHealth sector, and would likely improve outcomes through early detection and correcting unhealthy behaviors.

I wonder: Will providers and insurers compete for who knows the patient best?

Providers have the EMR data (for encounters with their facility), and perhaps from an HIE (if they are part of one). Insurers have info from payment transactions spanning hospitals, clinics, pharmacies and others.

Where will the data from wearables go? If the insurers are buying (by lowering premiums), I will bet that they get it more often that the provider.

Will wearables and mHealth device vendors be savvy enough to provide it to both? Will consumer-controlled PHR vendors (or information aggregation and brokering tools) have an optimized method for getting data from all a patient’s devices and apps into EMR systems? Will the provider’s EMR or HIE be open enough to receive and store the wearable’s data without manual data entry (or copy-paste)?

Will patient’s be willing to share this personal info with providers and insurers? I will bet: yes.

If I thought the data would help my outcome, and I trusted my provider, I would share it.

If it was certain to lower my premiums, I would share the info with my insurer. If the insurer reserved the right to increase premiums based on info that my wearable provided (i.e. if I sit on the couch too long, my payment goes up), I might reconsider.

Will providers supply no cost (or subsidized) wearable and mHealth devices (or apps) to patients? Will insurers and providers share this cost?

So, how can wearables help in Radiology? Other than sending out reminders on where and when to show up for the exam, and what to do (e.g. eating, etc.) prior to the procedure.

Article – CDC on EHR errors: Enough’s enough

In this article, the CDC has issued a warning on the issues of user interface design when presenting patient information in EHRs.

As the examples in the article illustrate, having information in digital form is not enough. It needs to be presented in an effective way to ensure comprehension. After the current wave of information digitization and consolidation (moving information from disparate, departmental clinical information systems into a single large enterprise system), the next wave of effort needs to be on privacy/security, accessibility/reliability, and usability, or the incredibly high potential gains will not be realized.

Users need to trust the system, it needs to be there when they need it (wherever that is), and they have to want to use it.

P.S. Here is an infographic on EHR adoption.

The Value of Hackathons in Healthcare

Having participated in the inaugural SIIM 2014 Hackathon, I can appreciate the diverse expectations that participants have. Some think of these events as a way to learn and experiment, others a competition. Some prefer to work as a team, others alone. Some are interested in integrating existing systems and data in new ways, while others want to invent something completely new.

In any case, I found this article insightful. It explores why the concept of “hacking” is so prevalent in healthcare, and also touches on why new “apps” often struggle to make it past the hackathon stage. It even posits that a hackathon can replace the traditional RFP procurement process for identifying and selecting innovative solutions.

Revenue Revolution in Radiology

I have been reading a lot recently about trends in healthcare and imaging around costs and revenues. There seems to be a perfect storm of changes in the market that will have a fundamental impact on diagnostic imaging service providers. I find this topic interesting because, unless you understand how the money is moving, you won’t understand why things are happening. Here is a summary of what I have discovered.

Medicare Reimbursement Cuts

This one is obvious. If you lower the amount of money paid for something, your revenues will go down (unless volume goes up proportionally). Here is an infographic from MITA on the cuts made since 2006.

Fewer Medical Imaging Exams being Ordered

Here is an article from MITA on the decline of the total number of CT exams being done in the U.S. Here is another one citing data published by the American College of Radiology (ACR). It states: “…physicians are calling for less, not more, imaging tests.” This shows a measurable reduction in the volume of exams performed in the U.S. And here is an article indicating a steady decrease in imaging studies being ordered for patients in the ED, following a steady increase up to 2007.

Image Sharing

The sharing of patients’ clinical records across facilities is a key part of Accountable Care, and is generally a good thing for patient care. So is sharing imaging records. With reliable options now available on the market, sites within a local referral area are rapidly launching or signing up to services to share images. The clinical benefits of comparing new imaging exams with priors are well understood, but this practice will often result in avoiding the need to perform a repeat exam. This benefits the patient (less radiation and anxiety and delay), and the operations of the receiving organization (less schedule disruption, less costs due to CD importation). The other impact, of course, is that the receiving organization loses some revenue from that avoided repeat exam. This will result in a reduction in volume of exams performed.

Adoption of Clinical Decision Support

Starting on January 1, 2017, imaging exams will require the use of Clinical Decision Support (CDS) to ensure that physicians are following Appropriate Use Criteria (AUC). In addition to clinical evidence, factors such as relative radiation level and cost of the exam are used to determine what is appropriate. All things being equal, the lower cost exam is likely to be recommended. The adoption of CDS may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Preauthorization Requirements

In some insurance plans, preauthorization is required before certain exam types can be ordered (even when CDS is used, in some cases). This may require a consultation with a radiologist or Radiology Benefits Management (RBM) company. Here is an article from 2011 on the use of preauthorization and CDS. The larger the burden on the ordering physician, the less likely they are to order the exam, which may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Patient Steerage

Last year, I did a blog post on an article on the trend of “patient steerage”. The original article is here. Essentially, patient steerage is when a payer incents a patient to use a provider that offers the imaging service at a lower cost. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

The Castlight Effect

This company received a lot of attention because of the size of its IPO, but it is also notable for what they actually do. As this article explains, they provide healthcare provider cost information for a range of healthcare services to employee health plans. The intent being that, given the choice, consumers will choose lower cost options. This is very likely to happen when the patient has a significant co-pay (e.g. 20%) and they will personally benefit from lower cost options. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

Wait, but what about Quality?

With all the talk about the shift of reimbursement from volume of procedures to quality or outcomes, I found this tweet on Castlight interesting… Castlight Tweet If we shift away from volume incentives/payment, reduce the prices paid (through policy or competition), but don’t recognize quality, the service of diagnostic imaging has been commoditized, and I don’t think that this will benefit patients, in the end.

Consolidation

I have heard a couple of opinions that believe that the strong trend of consolidation among healthcare providers will allow the largest of providers to dictate terms and pricing to payers. As it was explained to me, it works like this: The big, well-known healthcare provider, which has bought up many of the facilities in the area, tells the insurance payers, ‘If you don’t give me preferential pricing for my services, I won’t accept your insurance plan at my facilities’. If the healthcare provider is big enough and well respected, the insurance provider will have a tough time selling insurance plans to companies and individuals when the buyer learns that they can’t go to the big provider. This is called leverage. If this is true (and I think that it is), this will result in isolated areas of reimbursement stabilization or even increases. Here is an article talking about what the impact of provider consolidation means to private payers. It cites a steady increase in the number of physicians becoming employees of hospitals (vs. independent private practices)…

“…the number of doctors employed by hospitals increased to over 120,000 from 80,000 between 2003 and 2011. About 13 percent of all doctors are now employed directly by hospitals.”

A Necessary Change in Revenue Cycle Management Systems

Here is an article on the need for an overhaul of Revenue Cycle Management (RCM) systems in the U.S. It includes some stats on administration costs per transaction (compared to financial services transactions) and consolidation trends, as well as the value of analytics. Some excerpts…

“…the number of hospitals per integrated delivery system took a big jump last year from 6.4 to 7.1…”

“…the physicians who go into practice do not want to be entrepreneurs as much as they used to. When 52 or 53 percent of residents today become employees of integrated delivery systems, it tells you that the whole market has changed.”

Using Analytics to Maximize Revenues

Here is an article on using analytics and their reports to optimize financial operations.

So, what do you think?

P.S. Here is an interview that goes into the details of payer vs. provider, along with a case for more bundled payments. And here is a blog post that goes into more detail on bundled payments, including the shift from retrospective to prospective bundles.

P.P.S. Here is an article explaining the difference between charges and costs.

P.P.P.S. Here is a notice of rule changes proposed by CMS on the method by how physicians fees will be determined. “…we are updating our practice expense inputs for x-ray services to reflect that x-rays are currently done digitally rather than with analog film.”

P.P.P.P.S. Here is an article on a study on the disparity of costs for a Mammogram in the L.A. area. $60 to $254 for self-pay, with a bill of $694 to the insurance company for the same procedure elsewhere. 30% of Mammograms in the study were self-pay.

P.P.P.P.P.S Here is an article, with a nice infographic, on 5 common medical practice denials and remedies. Spoiler alert: Radiology made the Top 5 list of unexpected denials.

P.P.P.P.P.P.S Here is an infographic on the declining employment demand and income of Radiologists by a medical recruitment firm.

Article – SIIM Hackathon gives DICOMweb a coming-out party

Check out this article in Radiology Business Journal on the recently concluded Hackathon at the SIIM 2014 Annual Meeting in Long Beach, California.

Here are my other observations on SIIM 2014, in case you missed it.