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Building the Fully Loaded HIE Images on Board PAGE 18
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CONTENTS F E B R UA R Y / M A R C H 2 0 1 0 | VOLUME 3, NUMBER 1
FE ATURES 18
BUILDING THE FULLY LOADED HIE: IMAGES ON BOARD By Cat Vasko
As federal and state governments gear up to dispense billions of dollars in stimulus funds to worthy health IT projects, multiple business models are emerging for health information exchange, and savvy radiology practices are exploring ways to get involved.
28
MRI: THE NEXT GENERATION By Julie Ritzer Ross
The evolution of multichannel coils, larger-amplitude gradient systems, and parallel and rapid echoplanar MRI is shaking up pratice patterns at a time when CT is under fire.
32
FROM HERE TO ETERNITY: EXTENDING THE FRANCHISE THROUGH DISTRIBUTED-READING SOLUTIONS By Greg Thompson
Through the adoption of imaging informatics, practices and mobile imaging services are deploying distributed-reading solutions to provide interpretations and service with unparalleled speed over broad geographic areas.
38
INTEROPERABILITY: AN OPEN-SOURCE TOOLKIT By Kerry Cox, PhD, and James T. Whitfill, MD
Not for the novice or the faint of heart, open-source application software provides the practice CIO and the imaging informaticist with a toolbox full of solutions to common interconnectivity problems.
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42
THE 20 LARGEST ACADEMIC RADIOLOGY PRACTICES By Cheryl Proval
Results of the first annual ranking of academic practices.
44
THE CIO PERSPECTIVE: ISSUES IN IMAGE MANAGEMENT By Rich Smith
Gone are the days when radiology managed image data in a silo: CIOs are engaged in imaging informatics.
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4 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
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CONTENTS F E B R UA R Y / M A R C H 2 0 1 0 | VOLUME 3, NUMBER 1
PUBLISHER Curtis Kauffman-Pickelle ckp@imagingbiz.com EDITOR Cheryl Proval cproval@imagingbiz.com ART DIRECTOR Patrick R. Walling pwalling@imagingbiz.com TECHNICAL EDITOR Kris Kyes
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DEPARTMENTS 8
ADVIEW When the FDA Sneezes . . . By Cheryl Proval
10
CONTRIBUTING WRITERS Kerry Cox, PhD; Kip Hallman; Julie Ritzer Ross; Rich Smith; Greg Thompson; James T. Whitfill, MD ADVERTISING DIRECTOR Sharon Fitzgerald sfitzgerald@imagingbiz.com PRODUCTION COORDINATOR Jean Lavich jlavich@imagingbiz.com
THE BOTTOM LINE A Business Like No Other By Kip Hallman
12
ASSOCIATE EDITOR Cat Vasko cvasko@imagingbiz.com
PRIORS
12 STRATEGIC PLANNING | Implications of Reform for Hospitals: Seismic or Subtle?
14 HEALTH IT POLICY | High Hurdles for HITECH Dollars 16 LEADERSHIP | An Urgent Case for Quality 49
ADVERTISER INDEX
50
FINAL READ
CORPORATE OFFICE imagingBiz 17291 Irvine Blvd., Suite 406, Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PRESIDENT/CEO Curtis Kauffman-Pickelle VP, PUBLISHING Cheryl Proval VP, CLIENT SERVICES Steve Smith VP, ADMINISTRATION Mary Kauffman
Relationships Gone Wild By Curtis Kauffman-Pickelle
BPA Worldwide membership applied for February, 2009 Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. February/March 2010, Vol 3, No 1 Š 2010 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.
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6 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
A dView When the FDA Sneezes . . . Whipped to an overblown froth by media attention, the radiation-safety issue will, for better or worse, get the attention that it demands
A
rapid-fire series of radiation-related events, beginning in mid-2009 and continuing into 2010, culminated in the recent bombshell that the FDA would begin regulating medical radiation. Both the industry and the specialty continue to reverberate. Although these recent events were accompanied, and possibly fanned, by some confused and histrionic reporting in the popular press, inevitability is written all over this development. Radiation safety was radiology’s ticking time bomb, and radiology was not doing enough to address the issues. In response to the finding of the National Council on Radiation Protection and Measurements (NCRPM)1 that per-capita radiation exposure had increased fivefold between 1980 and 2006 (when half the cumulative dose could be attributed to CT), it was not enough to say that the benefits of medical imaging outweigh any possible negative effects. Though estimations of the risk of medical imaging were extrapolated from the atomicbomb survivors and their much higher exposures, it was not enough to point out the flaws in the linearity concept. Radiology must apply some science to these questions. The good news is that steps are being taken that will enable that to happen. Several weeks before the FDA’s announcement, Neumann and Bluemke2 announced that Radiology and Imaging Sciences at the National Institutes of Health (NIH) Clinical Center has developed a radiation reporting policy that will be instituted in cooperation with major equipment vendors of CT and PET/CT, with the ultimate goal of incorporating radiation-dose exposure into a patient’s electronic health record (EHR). NIH will work with equipment vendors to arrive at a standardized reporting algorithm to enable dose data to be entered into an image’s DICOM header and then extracted for storage, either in the RIS or in the hospital-based EHR. Neumann and Bluemke point out that these steps, in and of themselves, are insufficient to determine the radiation risks that may or may not be associated with medical imaging. They are necessary, however, for the accumulation of dose data from hundreds of thousands of patients, over many years, that
will be required. If the Obama administration’s efforts to spur widespread adoption of EHRs prevail, and if the dose data are entered therein, this would produce a large dataset for studies of the long-term effects of medical imaging. The time clearly is ripe for such investigations. Farooki3 writes about epigenetics (that mildly unnerving branch of science that probes changes in the phenotype caused by mechanisms other than DNA alteration), a field that Farooki says may have a greater role in medicine than genetics itself. It is unsettling indeed to consider the damage inflicted on oneself by what one did or does not do to one’s body, without considering the effects on our children and our children’s children. Farooki notes that the NIH has earmarked $190 million for epigenetic research over five years, and suggests that we need to understand the epigenetic effects of radiation exposure.
T HE P LAN A wide-ranging FDA initiative4 announced February 9 is intended to promote the safe use of medical imaging, support informed clinical decisions, and increase patient awareness. As described, these ambitions will leave few corners of the specialty untouched. Diagnostic reference levels (or dose reference values) for imaging procedures will no longer be the provenance of the department physicist, but the domain of everyone from technologists to radiologists to department administrators and leaders. Citing the efforts of the ACR® and the NCRPM, the FDA urges the development and use of dose reference levels; where there are no national standards, it suggests that facilities develop these locally. The FDA may require CT and fluoroscopic devices to display, record, and transmit radiation dose and to use default parameter settings that optimize radiation dose (or that emit alerts when an exam’s dose exceeds a specified reference level). The FDA may also require devices to record radiation dose automatically in a DICOM structured report and to transmit this information to the EHR or to a dose registry. Additional training for users is also a likely requirement. The FDA intends to hold a public meeting on March 30–31, 2010, to solicit input on what requirements to establish. To support referring physicians in their clinical decisions, the development of appropriate-use criteria for CT, fluoroscopy, and
8 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
nuclear procedures is also recommended. The FDA also intends to provide patients with tools to track their personal imaging histories. While organized radiology has undertaken a well-publicized dose-awareness campaign and has another underway, no one anticipated the furor that could erupt in our media-saturated environment. The collateral damage is already being felt, and this simple fact remains: When the FDA sneezes, the entire industry gets a cold. One top marketing executive at a company that makes CT systems says that the attention feels like a sunbeam, shining through a magnifying glass, on an ant. This executive welcomes the intervention of the FDA in tracking and measuring individual exposure, explaining that unless there is a standard, everyone will interpret exposure differently. Nonetheless, the scrutiny (and the costs of compliance) will be widely felt by modality and PACS vendors. Going forward, it is imperative that radiology redouble efforts to educate the public on the value of imaging and its role in medicine. No matter what epidemiologic and epigenetic studies turn up on the long-term effects of exposure to medical radiation, we know that medical imaging cheats death of many, many, many more patients than it could possibly deliver. The thought of one parent withholding a necessary CT exam, for fear of the unknown, is just as disturbing as is the unknown itself. Cheryl Proval, Editor cproval@imagingbiz.com References 1. Sinclair WK, Adelstein SJ, Carter MW, Harley JH, Moeller DW. Ionizing Radiation Exposure of the Population of the United States. Bethesda, MD: National Council on Radiation Protection & Measurements; 1987. 2. Neumann RD, Bluemke DA. Tracking radiation exposure from diagnostic devices at the NIH. J Am Coll Radiol. 2010;7(2):87-89. 3. Farooki S. Radiology and epigenetics. J Am Coll Radiol. 2010;7(2):84-86. 4. Center for Devices and Radiological Health. Initiative to reduce unnecessary radiation exposure from medical imaging. http://www.fda.gov/downloads/RadiationEmittingProducts/RadiationSafety/Radiation DoseReduction/UCM200087.pdf. Published February 2010. Accessed February 12, 2010.
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THE BOTTOM LINE
A Business Like No Other Observations, predictions, and prescriptions for the imaging-center industry BY KIP HALLMAN
H
ealth care is a business like no other because its very purpose is to extend and improve quality of life. It is a business, nonetheless, with revenues and costs, and with bills, lenders, and employees to pay. A common phrase, among even the most charitable of not-for-profit health-care organizations, is no margin, no mission. I am proud of the positive impact that our company has made on the lives of our patients, and I know that my fellow providers feel the same. As the healthcare mission has become increasingly successful, with US residents living longer and better than ever, the health-care margin has been under siege, and no segment of health care has seen its margin targeted more than diagnostic imaging has. For the past several years, freestanding imaging centers have been treated like so many piñatas at a child’s birthday party: Consider the 2006 cuts for imaging contiguous body parts, the 2007 DRA cuts, and the round of DRA-copycat cuts made by many third-party payors. Once the most recent CMS cuts have been fully phased in, Medicare payment rates for many procedures will have been cut by more than half over just a few years’ time, making this a level of payment reduction that is virtually unprecedented in health care. In many ways, the challenges faced by imaging-center operators would seem familiar to leaders of commercial airlines. High fixed costs (a used 10-passenger turboprop will set you back about as much as an MRI scanner) and steadily declining prices make for a tough environment where selling every scan (or seat) is essential for continued success. Unfortunately, the assault on reimbursement comes on the heels of other trends that would also be familiar to the airline industry: rapid growth in demand, leading to rapid growth in supply, followed by a slowdown in growth. For the first five years of this century, outpatient MRI, CT, and PET/CT volumes grew at 16%, 15%, and 122% compound annual rates, respectively. A combination of rising
demand, relatively stable reimbursement rates, plentiful capital, and (in too many cases) liberal use of in-office exemptions led to a rough doubling of the number of freestanding OICs, from about 3,000 in 2000 to more than 6,000 in 2006, the year before the DRA went into effect.
PREDICTIONS Since then, a growing focus on utilization (coupled with the worst economy in a generation) has led to a moderation in scan-volume growth to levels in the mid-single digits. How will the confluence of declining prices and slowing growth affect independent freestanding imaging-center operators, their patients, referring physicians, and their communities? What will the future hold for diagnostic imaging as a whole, and for freestanding imaging centers in particular? The demand for diagnostic imaging is likely to continue growing steadily, despite all the focus on utilization. Most projections that I’ve seen predict that MRI, CT, and PET/CT volume will grow by at least 5% per year for the foreseeable future, driven by demographics and by the importance of advanced imaging to clinical decisions. Imaging centers will continue, however, to face high levels of the uncertainties that increase risk and complicate investment decisions. These will weigh particularly heavily on smaller, independent operators lacking the resources to make the needed investments in systems and infrastructure to support subspecialty radiology, ubiquitous PACS, electronic medical record connectivity, and seamless revenue-cycle management systems, all of which are becoming increasingly critical in a rapidly evolving and challenging market. Greater uncertainty and risk will probably accelerate the ongoing consolidation of independent operators with either hospital systems or larger operators, shrinking the number of centers in many markets. This might reduce patient access to care in some markets, but it also should improve the prospects for the remaining centers, which will benefit from higher scan volumes.
10 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
The reimbursement gap between hospitalbased and independent imaging centers will probably grow, with some predictable consequences. Some freestanding imaging centers are likely to be absorbed by hospital systems seeking to capitalize on their higher rates. At the same time, payors are likely to begin steering their enrollees more proactively toward lower-cost settings, such as independent, freestanding imaging centers. As high-deductible insurance policies and higher copayments become more common, physicians and their patients probably will join in, bringing additional volume to freestanding centers.
P RESCRIPTIONS As the freestanding industry consolidates, high-quality operators will succeed, even while the number of centers declines. The operators who do best will have robust RIS/PACS; sound operating infrastructure; high-quality radiologists (preferably subspecialists); and convenient, caring service in order to build and maintain referring-physician relationships, drive operational efficiency, and ensure that they collect everything to which they are entitled. I also believe that the industry, as a whole, must do a much more effective job of communicating to payors and physicians the important role that freestanding imaging centers play in offering lower-cost imaging to their plan members and patients. We have a great story to tell, and I believe that a well-coordinated industry effort to tell it can have a much bigger impact on the continued health of freestanding imaging centers than lobbying Congress or CMS on Medicare reimbursement can have. With or without comprehensive health reform, the next few years will be challenging, dynamic, and unpredictable. Depending on your appetite for change, I think that they might be a lot of fun. Kip Hallman is president and CEO of InSight Imaging, Lake Forest, California, a provider of diagnostic imaging services through approximately 60 fixed-site imaging centers and more than 100 mobile diagnostic-imaging units.
{PRIORS} S T R AT E G I C P L A N N I N G
Implications of Reform for Hospitals: Seismic or Subtle?
H
ospitals are keeping a wary eye on Washington, and on several key payor trends with major implications for imaging service lines, for good reason. In a December 2, 2009, presentation to representatives of member hospitals in Chicago, Illinois, Shay Pratt, managing director of the Advisory Board, explained that radiology’s contribution to hospital profit exceeds, by far, the contributions of the four other leading outpatient services. In 2007, radiology accounted for $24.1 billion in hospital contribution profit, making almost three times the contribution of cardiology, the nearest competitor, at $8.2 billion. “When you have a discussion around reform,” Pratt explains, “the reason there are so many worries and concerns is that it disrupts the status quo.” The status quo has been relatively favorable for the past 10 years or so. Not only has imaging subsidized many less-profitable services, but it has been a high-growth area, despite the DRA and the effects of preauthorization. Hospitals’ concerns, however, are not unfounded. “Congress has pointed to imaging costs as a symptom of all that is wrong with health care right now, and that is a real cause for concern to all imaging providers,” Pratt says. “At the same time, there are broader proposals in play: The reform bills contain a lot of provisions that would call for greater experimentation around inpatient bundling, accountable care, and episodic bundling.” Even without reform legislation, the Advisory Board expects CMS to continue experimenting with new payment methodologies, though greater adoption of mechanisms like accountable care is a few years out. While it will be essential to prepare for these risk-sharing models, for
now, both hospital and nonhospital imaging providers are tracking payment changes that directly target radiology. The key questions are how seismic these changes will be and what their impact on outpatient share will be.
SHARE EROSION With an increase in the assumed equipment-utilization rate for high-tech imaging and reductions in practice-expense allowances, Medicare Part B global imaging payments will decrease 16% by 2013, putting further reimbursement pressure on IDTFs. For the near term, Pratt sees a flattening of the share erosion that hospitals have been experiencing (see Figure). Hospitals have been frustrated for years by the loss of MRI (and more recently, CT) to freestanding outpatient competitors, but Pratt predicts that the trend line will plateau and, in the case of PET/CT, even reverse. He cites several wild cards that could influence the site of service, one of which is price sensitivity. The economic down75%
CT
turn has the potential to change behavior/spending patterns, but how effective consumers will be at price shopping is unknown. “Just how sensitive is the market?” Pratt wonders. “How much at risk are hospitals?” The other unknown is whether radiology benefit management (RBM) companies will move successfully from preauthorization to redirection. American Imaging Management’s OptiNet® tool allows physicians to search for an imaging provider based on location, price, and a quality score. Both National Imaging Associates and CareCore offer procedure scheduling when a physician calls for preauthorization. “While there is limited evidence of price sensitivity with outpatient imaging, many MRI
PET
Nuclear Medicine
70% 65% 63% 60% 55%
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50% 52% 45% 40% 41% 35% 30% 2005
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Figure. The erosion in hospitals’ share of advanced outpatient imaging (by volume) is expected to decelerate. Reprinted with permission: The Advisory Board Co.
12 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
2013
Interoperability:
SEVENTH IN A SERIES
A fundamental necessity for adapting to healthcare’s next generation
With the quick and constant evolution of health care, interoperability is no longer primarily in the IT domain. Today, leaders throughout a given enterprise must embrace interoperability as essential to ensuring continued viability. These leaders are recognizing interoperability’s unique ability to provide faster, more comprehensive service to their key medical imaging constituencies, including physicians, payers and patients, while reducing costs and improving throughput. But what exactly does this mean? This unadulterated data movement is demanded by physicians, who have both revenue and quality considerations, supported by cost control-minded payers and increasingly expected by patients, who are assuming more control of their health care decisions. With interoperability an inevitable development, there are protocols that can be established now to prepare for the day when it will be expected. “First, these enterprises have to start embracing the new realities in health care. This is a sea change and they have to adapt to the new order or risk becoming obsolete,” said John Macfarlane, CEO of Compressus, a leader in interoperability development and implementation. “The change is being driven in part by legislators and in part by patients as consumer-driven health care takes center stage. Today, patients expect to get the best health care wherever they go and be able to share the information between those disparate entities. Health care is moving out of its cottage industry model.” The evolving health care models include scenarios that were previously unimaginable, including the quantum leap in the virtualization of patient care and data processing. “Services that were once the domain of the hospital are no longer in the hospital,” said Macfarlane. “Cardiology, pathology and other key services are now also found externally from sources that have already learned how to thrive in this new information-driven environment. To maintain their viability, hospitals, for example, will need to determine how to link to all these options that are now outside their realm. That’s where interoperability plays a vital role.”
To learn more… 0('[&RQQHFW
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Tel: 202.742.4297 Email: info@compressus.com www.compressus.com/stimulus
While grappling with the service, revenue and costcontrol issues, these enterprises also face the ongoing challenge presented by formidable competition. Today, there are fewer medical imaging resources dominating a given market, which has led to a healthy self-examination of all processes. “In a way, hospitals have lost control of where they should have been,” said Janine Broda, Compressus’ Chief Marketing Officer. “To rebound, they now need to be at the core of interoperability development and duplicate the vision of the entrepreneurial-minded physician groups in their communities.” “Hospitals should be looking to interoperability to create stronger bonds to the referral community,” said Macfarlane. “It is good policy and good policy is good business.” Typically, the questions related to interoperability have been relegated to the CIO or the head of IT. Both Macfarlane and Broda, however, see a broader adaptation as an essential part of enterprise growth. “Interoperability impacts everyone in their areas of responsibility so the decision-making process should include the CEO, CIO, CFO and COO, to name a few,” said Broda. “Leaders should look at interoperability as part of their strategic direction and it has to be at the core of their business plans,” added Macfarlane. “Health care is changing – that is a fact. The people, facilities and technology up and down the spectrum are being asked to be more efficient, more effective and certainly more available. Interoperability is at the core of that change. The health care providers who survive and thrive and act as change agents during this period will be the ones who are the earliest to embrace the inevitability of interoperability.”
About MEDxConnect MEDxConnect from Compressus offers a holistic solution to connecting disparate systems. Designed to manage the workflow of an imaging health care enterprise, the MEDxConnect system provides a suite of offerings that has the power to connect systems from multiple vendors, that offers proven interoperability, and that allows an organization with disparate multivendor systems to function as one virtual enterprise.
7 Related… Online Hospitals not ready for swell of data to come by Mike Miliard Summary: Survey shows some hospitals not prepared to process or store upcoming “wave of data.” Visit: http://www.healthcareitnews.com/news/hospitals-notready-swell-data-come
Online Government regulatory issues and financial incentives were named as the top drivers in a survey of hospital IT executives. By Marianne Kolbasuk McGee Summary: Government stimulus programs cause many hospitals in the U.S. to increase their IT budgets in 2010. Visit: http://www.informationweek.com/news/healthcare/ clinical-systems/showArticle. jhtml?articleID=222500180
Online Halamka: Give us specifics, give us time on meaningful use proposals Summary: MD and CIO writes that aggressive interoperability timelines require specific implementation guides and reference implementations. Visit: http://www.cmio.net/ index.php?option=com_ articles&view=article&id=20247
For copies of past columns, e-mail interoperability@compressus.com
hospitals enjoy favorable rates from commercial payors,” Pratt says. “If CMS is essentially stacking the deck against freestanding centers, will there be enough Shay Pratt imaging centers left for RBMs to redirect the patients? When you get to that moment, there could be some difficult decisions for hospitals and payors in contracting.”
UTILIZATION AND QUALITY Another key issue that could influence volumes in the near term is the emerging mandate to manage utilization directly, beginning with four imaging-efficiency measures that CMS will study in 2010. “Payors would like to increase the association with utilization and quality,” Pratt says. Radiology departments are not required to report, as CMS will pull utilization data from claims for these four cost-driven measures: lumbar-spine MRI
for lower-back pain, mammography follow-up, and contrast use in both abdominal and thoracic CT. “Which patients should get contrast? This is an issue for CMS, as a study pays more if contrast is used; what should this number be? They want to use this opportunity to get a decent baseline, maybe move toward a median, establish that median as a quality benchmark in the future, and hold institutions to that rate,” Pratt says. The mammography recall rate is also subject to a lot of variation, ranging from less than 10% to more than 14%, Pratt notes. “Medicare is going to be using this engine to generate data and set some standards,” he says. “There are four other imaging measures that have been proposed as well, with one including cardiac imaging. I can see, down the road, how this would open doors for more of a payfor-performance model.” CMS plans a 2010 demonstration project on the impact of electronic decision support on physician ordering behavior. “This is, I think, a huge deal for imaging
and for building the case for an expanded role for imaging providers in utilization management,” Pratt says. Utilization management could have a significant impact on volumes if CMS gets serious about implementing a program, Pratt suggests. “The Senate reform bill contains a measure that calls for CMS to begin measuring the appropriateness of physicians’ ordering behavior, which would provide a very significant boost to utilization management,” he says. “A plan presented in April 2009 actually called for a two-year phase of measurement, followed by accountability, but the current bill has a far less prescriptive model.” Pratt identifies five key drivers that could fuel pressure to manage utilization: radiation dose in vulnerable populations, such as pediatric patients and frequent flyers; emergency-department utilization; inpatient bundling; episodic bundling; and, ultimately, accountable care. “I think this is going to be an emerging key competency for imaging providers,” he predicts. —Staff
H E A LT H I T P O L I C Y
High Hurdles for HITECH Dollars
T
he indefinite path to qualifying for Health Information Technology for Economic and Clinical Health Act funds just came into greater focus, but it’s not to everyone’s liking. At the end of December 2009, HHS released two notices of proposed rule making that specify, in numbing detail, the definitions of terms associated with the meaningful use of health IT, along with the criteria that hospitals, physicians, and other qualified health professionals must meet in order to qualify for nearly $19 billion earmarked for health IT projects. HHS will accept comments on the proposed rules through March 15, but several provider associations have already begun to weigh in on them. Another rule is expected from the Office of the National Coordinator (ONC) for Health Information Technology that will define the process by which the ONC will recognize how health IT products are certified, in addition to naming the certifying organizations.
The Medical Group Management Association calls the interim rules overly complex and believes that physicians will have a difficult time meeting program requirements. The response from the Healthcare Information and Management Systems Society was more sanguine, welcoming the clarity provided by the rules, noting that they offer more to applaud than to criticize, and reminding us that the regulations are proposals and that comments are solicited.
MEANINGFUL USE While the actual definition of a qualified electronic health record (EHR) is unavailable pending the rule from the ONC (due in late February), the proposed rule for the EHR incentive program goes into great detail on meaningful use and how eligible providers and eligible hospitals will demonstrate that use. Meaningful use will be approached in three phases, which will be further defined in successive rule making.
14 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
Stage 1 (beginning 2011): Criteria in this initial phase focus on the electronic capture of coded health information to track key clinical conditions and communicate that information for care-coordination purposes in structured format whenever feasible; the implementation of clinical decision support tools to facilitate disease and medication management; and the reporting of clinical quality measures and public-health information. Stage 2 (beginning 2013): Criteria further encourage the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of test results, including those from radiology, cardiac-imaging, and nuclear-medicine tests. HHS may extend the criteria more broadly to apply to both inpatient and outpatient hospital settings. Stage 3 (beginning 2015): Criteria will further promote improvements in quality,
safety, and efficiency by focusing on decision support for national high-priority conditions, on patient access to self-management tools, on access to comprehensive patient data, and on improving population health. A good deal of money is at stake here: For example, a 250-bed hospital could qualify for almost $6 million, over four years, if it could demonstrate meaningful use beginning in 2011.1 Detailed information on payment methodology, mechanics, and timing can be found at http:// edocket.access.gpo.gov/2010/E9-31217.htm.
STANDARDS, SPECIFICATIONS, AND CRITERIA HHS also issued an initial set of standards, implementation specifications, and certification criteria for EHR technology, to which it will add through successive rule making. Initial certification criteria establish the capabilities and related standards that certified EHR technology must include in order to meet proposed stage 1 meaningful use. The rule provides definitions for a complete EHR, an EHR module, and a certified EHR. In other words, a provider can
patch together three modules to create a qualified EHR or can purchase a complete EHR. A qualified EHR must include patients’ demographic and health information and must have the ability to provide clinical decision support and CPOE, to capture and query information relevant to health-care quality, and to exchange and integrate health information from various sources. Further guidance will be offered in the ONC’s forthcoming Interim Final Rule. The short list of examples of EHR modules cited in the proposed rule includes a clinical decision support rules engine, but providers bear the responsibility of ensuring the interoperability of the modules. The rule defines certified EHR technology as meaning either a complete EHR or a combination of EHR modules (each of which meets the requirements included in the definition of a qualified EHR) that has been tested and certified in accordance with the certification program yet to be established by the ONC as having met all applicable certification criteria adopted by the secretary of the DHHS. The proposed rule’s authors wrote, “We believe that by adding the word ‘technolo-
gy’ after ‘EHR,’ Congress intended to convey an expectation that rather than adopt a complete, all-in-one solution, eligible professionals and eligible hospitals would likely adopt and implement some number of technological components or EHR Modules to extend the useful life of their legacy EHR technology or other HIT that may not provide all of the capabilities necessary to achieve meaningful use.”2 The list of certification criteria that must be met by eligible providers and eligible hospitals is quite daunting, but particularly so for physician providers, who are likely to have limited (if any) IT support. For instance, in order to support achievement of stage 1 meaningful use, an eligible provider’s complete EHR or EHR module must provide CPOE; must electronically record, store, retrieve, and manage medications, laboratory results, and radiology results; must generate prescriptions electronically; must check insurance eligibility; and must submit claims electronically to public and private payors, in addition to meeting a dozen other requirements. The proposed rules slammed the door shut on radiology practices hoping to acquire PACS on the federal dime, but clearly, referring physicians will require some assistance from radiology providers in connecting PACS to their office-based EHRs. Because the rule cites radiology CPOE, mammography reporting, and radiology quality-measure reporting in the definitions and certification criteria for stage 1 meaningful use, that same door appears to have been left ajar for those hospitals and health systems building a qualified EHR and wishing to add radiology PACS, CPOE, mammography reporting/notification systems, and decision support. —Staff References 1. Proval C. ARRA opportunities and risks. Radiology Business Journal. 2009;2(2):12-14. 2. Department of Health and Human Services. U.S. customs and border protection. Health information technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology. http://www.thefederalregister.com/d.p/ 2010-01-13-E9-31216. Published January 13, 2010. Accessed February 9, 2010.
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LEADERSHIP
An Urgent Case for Quality
G
ary Becker, MD, outgoing president of the RSNA, read members the equivalent of the riot act in his presidential address on November 29 in Chicago, Illinois, kicking off the 2009 meeting and jump-starting the quality-improvement movement in radiology. “One of the most vital priorities for our profession is the adoption of a new focus on quality improvement,” Becker says. He cites demands for individual physician transparency from patients and families, insurers, employers, hospitals, quality groups, accrediting organizations, regulators, and government. “Identifying quality and our commitment to it will be a key factor in determining our future. Fundamental to this vital priority is a habit many of us don’t yet have: the habit of measurement,” he says. Three significant hurdles currently stand in the way of meeting the quality challenge for radiologists, Becker says: ignorance of quality-improvement principles, preconceived notions and attitudes, and the lack of a culture of improvement. Radiologists have precious little time in which to embrace quality improvement, as Becker believes that the quality hourglass is running out of sand. It’s been 10 years since the Institute of Medicine1 reported that as many as 100,000 patients die each year in US hospitals from preventable medical errors, and the Joint Commission documented more than 5,600 sentinel events in 2008. Becker also cites a RAND Corp study2 that found only half of the health care delivered in the United States meets evidence-based quality standards. As the population ages and the government assumes a growing share of the national health expenditure, it will also have greater voice in all aspects of delivery, Becker says. Even if Congress doesn’t pass a reform bill with a new public option, more than 50% of our national health expenditure will be publicly funded by 2014. “Ponder, for just a moment, what will happen in a predominantly publicly funded system: If we radiologists and all physicians wish to avoid ceding all medical regulation to government and other external stakeholders, we must earn the public’s trust,” he warns.
THE ULTIMATUM If radiologists wish to maintain a portion of their privilege to self-regulate, they will have to deliver high-quality, affordable care; Gary Becker, MD engage in physician assessment and improvement; and demonstrate their competence through public reporting, Becker says. While the Physician Consortium for Performance Improvement, the National Committee for Quality Assurance, CMS, and the Joint Commission are currently measuring and assessing care delivery, other (less rigorous) outfits such as HealthGrades and Angie’s List stand in the wings. “When price is the differentiator, quality fades from view, and we must not let that happen,” Becker says “As stewards of the profession, we must not permit radiology to succumb to commoditization. Instead, we must safeguard professionalism, develop our quality focus, and take control of radiology’s destiny by delivering value.” In health care, quality improvement depends on making measurement an integral part of the work routine. Becker cites a RadioGraphics paper3 published in 2009 that distilled radiology’s quality-improvement goals into four objectives: safety, process improvement, professional performance assessment and improvement, and satisfaction. Physicians, in general, are likely to be surprised by the results of performance assessment, Becker says. “We physicians tend to have very little insight into how well (or more correctly, how poorly) we are actually doing in practice,” he says. He shared the example of the American Board of Internal Medicine’s experience in launching its practice improvement modules (PIMs). As part of its maintenance and certification program, practicing internists were, for the first time, required to evaluate their compliance with established practice guidelines by reviewing the charts of 25 of their patients with a given condition, such as diabetes, asthma, or hypertension. Before completing the PIMs, physicians commonly complained that they were
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already doing this well, or that their patients with diabetes were doing just fine, “but after the baseline measurements, many internists were astonished in the gaps they discovered in their own practices,” Becker says. “What they had not previously measured, they could not have known. Following implementation of improvement measures and completion of PIMs, 73% said they had changed their practice and 82% said they would recommend the PIM to a colleague.” The two biggest barriers to radiologist participation in quality-improvement initiatives are lack of knowledge and preconceived notions and attitudes. Add to those barriers erroneous beliefs or perceptions about personal-practice quality, such as the statement, “my patients are doing just fine”; concerns that these efforts will take extra time and add another unfunded practice expense; and the fear of reprisals for mistakes, and it is no wonder that physicians have not embraced quality improvement. “In a culture of blame, every adverse event has a responsible person,” Becker says. “In a culture of improvement, we work to make the system better.” It is Becker’s contention that a decisive commitment to a culture of quality improvement is not only a good idea; it is imperative: “The nation has awakened to medical error; it has grown intolerant of waste, weary of fragmented health-care delivery, and impatient with a system that not only doesn’t serve it well, but often seems designed to serve the providers,” he says. —Staff References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2. Marshall M. Measuring General Practice: A Demonstration Project to Develop and Test a Set of Primary Care Clinical Quality Indicators. Santa Monica, CA: Rand Corp; 2003. 3. Johnson CD, Krecke KN, Miranda R, Roberts CC, Denham C. Quality initiatives: developing a radiology quality and safety program: a primer. RadioGraphics. 2009;29(4):951-959.
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HIE | Images on Board
Building the Fully Loaded HIE: Images on Board As federal and state governments gear up to dispense billions of dollars in stimulus funds to worthy health IT projects, multiple business models are emerging for health information exchange, and savvy radiology practices are exploring ways to get involved By Cat Vasko
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W
ith a health IT stimulus package valued at $19 billion1 in play, one of the least controversial subjects in the health-reform debate is the potential of health information exchanges (HIEs) to lower health care costs while improving efficiency and quality of care. A handful of players in health IT have been developing some form of exchange for a decade or more (supported, in part, by the occasional grant), but images typically have not been included. With this year’s planned disbursement of federal stimulus money to ramp up health IT infrastructure, health-care providers around the country are scrambling to find the best and most economically viable way to connect with one another, and radiology practices with foresight are working toward making imaging part of these efforts. “I think Indiana might be the mecca for HIE,” Chuck Christian says of his home state, reflecting a sense of regional pride shared by many around the country who were attempting to implement local HIEs long before the concept hit the mainstream. “My comments may be biased,” he adds, “but I’ve been involved in this for quite some time. We have five exchanges in Indiana that have been up and running for 10 years.” Christian is CIO of Good Samaritan Hospital in Vincennes. He has been involved with the Indiana Health Information Exchange (IHIE) and others for several years, and is now a board member of the Indiana Health Informatics Corp (IHIC). This group was created by the Indiana state legislature in 2007 to determine how best to provide HIE services for the entire state of Indiana, integrating HIEs such as the nonprofits HealthBridge and the Indiana Network for Patient Care (INPC). Good Samaritan Hospital connects to the latter, which shares information about emergency care. “INPC gives the
One of the linchpins of making health care better is HIE. Thirteen states have been awarded funding to do HIE planning, but we’ve already planned and implemented on a regional basis. —Chuck Christian, CIO, Good Samaritan Hospital, Vincennes, IN
As an early adopter of PACS, we were very interested in electronic sharing of information and saw this as an opportunity to enhance our services to our area physicians’ offices. We provide hosting services, network design, and architecture services. —Todd Thomas, CIO, Austin Radiological Association, Austin, TX
emergency-department physicians a 24hour window of access to all the data available on a given patient, so they can log on using a Web browser and see it all: laboratory results, DICOM images (if shared), transcriptions, discharge summaries, and more,” Christian says. “We showed the INPC data to our emergency-department physicians and they wanted them yesterday.” Christian’s not the only one who’s been involved with HIEs since the 1990s. Austin Radiological Association (ARA), Austin, Texas, got involved with a regional exchange called CriticalConnection® 10 years ago. Todd Thomas, CIO of ARA, says, “We believed in the concept and were interested in participating from the beginning. As an early adopter of PACS, we were very interested in electronic sharing of information and saw this as an opportunity to enhance our services to area physicians’ offices. We provide hosting services, network design, and architecture services.” These informatics specialists have known for years what is, today, still making headlines in the consumer press as a
new idea: that HIEs will be key to unlocking new efficiencies in health care. “One of the linchpins of making health care better is HIE,” Christian says. “Thirteen states have been awarded funding to do HIE planning, but we’ve already planned and implemented on a regional basis. We did it on our own, because we knew it was the right thing to do.”
Adding Images The Carolinas also appear to be fertile ground for HIE development, spurred in part by the Duke Endowment, which has funded four HIE projects in the region since 2006. These include Data Link, an HIE established four years ago by the Western North Carolina Health Network (WNCHN). The exchange was built on a 16-hospital federation founded more than a decade ago to collaborate on qualityimprovement goals and, later, to achieve economies through group purchasing. Today, Data Link provides approximately 1,500 physicians in the region with access to admission/discharge information and to laboratory, microbiology, and radi-
www.imagingbiz.com | February/March 2010 | RADIOLOGY BUSINESS JOURNAL 19
HIE | Images on Board
We needed to get it down to one platform that the radiology business controlled. —Stephen Willis, CIO, Greensboro Radiology, Greensboro, NC
ology reports (as well as other transcribed reports), according to Dana J. Gibson, MPH, CPHIT, CPHQ, vice president, Data Link Services, WNCHN, Asheville. WNCHN hired a software developer in Birmingham, Alabama, to create an application that sits on top of each hospital’s server and communicates with the Data Link server, which periodically queries the hospital information system of each of the 16 member hospitals to retrieve the basic patient information that populates the index. Andrew Wells, MD, a radiologist at Margaret R. Pardee Memorial Hospital, Hendersonville, describes the system as a large electronic card catalog full of patient records that occur across any of the 16 hospitals. “The application creates the master patient index and the locator tool, which allows any provider with the proper credentials to log in, query a specific patient, and then get the results back from the card catalog saying they have events across two hospitals or six hospitals,” Wells told Radinformatics.com. “At that point, no data are pulled; it’s just that the pointers are identified, so it’s extremely fast to find the events and the history.” He continues, “It’s really important that so far, you haven’t pulled anything out of the host computer system: All you are doing is turning the crank on the card catalog and indexing tool. It’s extremely quick, and it’s not until you say, ‘I want to see this,’ that it actually engages the host repository or host archive to pull it out and then present it. It’s a small question and a small file, and it gets there quickly.” While grant money from the Duke Endowment and the Health Resources and Services Administration (HRSA) paid for software development and infrastructure costs, the 16 hospitals support Data Link, both administratively and financially, by paying a monthly fee and by appointing one staff member to be an administrator
within the hospital, assigning access and monitoring use. The next steps will be to add physicianoffice electronic medical records (EMRs) to Data Link and (significantly for all of the radiology practices that contract with network hospitals) to provide access to diagnostic-quality medical images. According to Wells, “We are in the process of identifying specifications and identifying companies that would like to participate in that development and deployment.”
Distributed Reading In Greensboro, North Carolina, Greensboro Radiology has created a network that connects the radiology practice to local hospitals and multispecialty practices. This hub-and-spoke approach might be limited, but it’s a vast improvement over the way that the practice exchanged health information before, Stephen Willis, CIO, explains. “We’ve repositioned ourselves here in the region,” he says. “Around four years ago, we decided it would be nice to expand our footprint, but every time we read for a different facil-
Greensboro Radiology’s PACS, which creates a DICOM worklist to be used at the facility in question. When scans are complete, an HL7 message notifies the radiology practice’s system to expect the images, which are then read by the radiologists. Greensboro Radiology archives the studies on its own PACS, while adding patient data, reports, and images to an archive accessible to any provider treating that patient. “The big win in all of this is really quality of care,” Willis says. “It keeps us from doing another scan when a prior study is already available, so quality goes up and health-care expense goes down. When we bring on small practices, they get quite a lot of benefit from having all these imaging data in the same place.” James T. Whitfill, MD, CIO of Scottsdale Medical Imaging (SMIL) in Arizona, was hoping to attain similar efficiencies when his practice implemented its own hub-and-spoke network. SMIL wanted to connect to referring providers’ EMRs, but HIEs can be hard to get off the ground, especially since, Whitfill notes, “Every party thinks some other party should be paying for it.” Two HIE projects by for-profit groups are still struggling to gain traction in the greater Phoenix region; SMIL is working with them in the hope of getting in on the ground floor with whichever project takes off, but the practice’s short-term business objectives aren’t being met, at this juncture. SMIL’s response has been to connect
There’s not a cloud out there yet, but we’ve gone ahead and made spoke connections. —James T. Whitfill, MD, CIO, Scottsdale Medical Imaging, Scottsdale, AZ
ity, it had a separate PACS, billing system, and dictation system. We needed to get it down to one platform that the radiology business controlled.” The model established by Greensboro Radiology enables any local practice or hospital to exchange information with the radiology group for a fee that, Willis says, is as close to cost as possible. HL7 orders from connected facilities are pushed to
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to its referrers’ EMRs one by one. “In the absence of anyone else having one, we’ve worked to integrate our clinical information systems with about 50 EMRs here in Phoenix,” Whitfill says. “There’s not a cloud out there yet, but we’ve gone ahead and made the spoke connections.” Marlene Smitherman, CEO of for-profit CriticalConnection Inc, Austin, Texas, saw, early on, the importance of engaging radi-
HIE | Images on Board
ology providers in HIE initiatives. “Almost from the beginning, ARA has been one of our partners,” she says. “It has such a strong need to link with all the physicians. It’s major in providing financial resources to help make this happen.” In its recently concluded proof-of-concept project, which ran for 2.5 years, CriticalConnection created a physician-centered cluster, connecting a local geriatric care group with all the organizations to which it refers, including Quest Diagnostics® and ARA. “Our team created the technology to connect to physicians using whatever workflow exists in their offices,” Smitherman says. “Then, the link was made to radiology and to laboratory, and we’re getting ready to integrate the hospital data.” CriticalConnection’s IT solutions are proprietary, she says, and include both established vendor technology and new software and technology created in-house. The database is SQL; the front end is Java. “Our system was developed specifically for this project and is unique to it,” Smitherman says. IHIE does not yet handle DICOM images, so Good Samaritan Hospital has held off on exchanging image datasets among facilities. “There are some medicolegal questions that need to be answered before we allow other facilities to start shoving studies into our PACS,” Christian says. “The hospitals want to transfer the datasets via virtual private networks (VPNs) directly into PACS, but I’m uncertain as to whether that’s the best approach. Then, we would need VPN tunnels connecting us to everybody, and we would need to give other facilities access to our PACS, potentially creating licensing issues. We have to think about the ramifications for when patients transfer to other facilities and other modes of care, and HIE is going to be very important to that process. It’s not just moving documents and summaries anymore.” Whitfill highlights a critical issue when it comes to HIE development and implementation: money. “There are plenty of public and private HIEs out there, and the reality is that they either have trouble getting started or they run into problems with business models or revenue sources,” he says. “There’s a high barrier to entry into this integration world. Many people look to the payors, but the payors feel that the people who create the information should
be responsible for paying for it, and other people think the consumers should be the ones who take on the cost.” IHIE got off the ground thanks, in part, to funding from the Regenstrief Institute, an Indianapolis-based informatics and health-research organization that designed the patient-matching algorithms and security infrastructure. There have been other grant opportunities as well, and the rest of the work has been conducted on a volunteer basis by motivated players. Christian says, “Most of this infrastructure has been created privately, and there hasn’t been any state tax money involved. The IHIC board members volunteer their time to move this work forward.” Similarly, though Greensboro Radiology hopes eventually to see a return on its investment, for the time being, the practice is merely aiming to be “a goodwill leader in the region,” Willis says. “Our vision is for any provider that has a modality in this region to come and use us as its full PACS solution. From a pricing standpoint, we try to get it as close to cost as humanly possible. We’re not really looking at this as a way to pay for our infrastructure. The idea is to lower the cost for that provider so it doesn’t need its own mini-PACS.” Take that concept, expand its scale, and you’ll have some idea of what Smitherman is attempting to achieve with CriticalConnection. Each provider connected by the HIE must pay $250 annually to join the CriticalConnection co-op, an entity separate from (but related to) CriticalConnection Inc. Membership in the co-op comes with privileges that include group purchasing for services that physicians’ offices need, from office supplies to broadband Internet connections; rebates from the vendors pay the cost of operating the HIE. “The revenue model comes first,” Smitherman says. “Nobody has adequate funds to pay for this on their own, so the group purchasing helps to reduce their costs. It’s paying through saving, not spending.” ARA’s involvement in CriticalConnection has been a boon for the exchange. “We’ve been hosting all the data since the beginning,” Thomas says. “Our anticipation is that it will become hugely popular. It’s a different take on the classic model. Eventually, CriticalConnection has
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to bring on the other major radiology provider in this area, and while that represents referring physicians’ business we may not necessarily capture, our interest in helping get this off the ground will benefit all of us, in the long term.” Whitfill hopes that SMIL’s ability to interface with referring physicians’ EMRs will translate into a competitive advantage in the years to come. “What’s clear is that there’s going to be a gradual raising of the bar in terms of what EMRs need to be able to do, and part of that is being able both to send out orders and to accept inbound results,” he says. Willis concedes that the same advantage might present itself to Greensboro Radiology, although it isn’t the practice’s primary motivation for being a regional leader in exchanging health information. “We could certainly enjoy the benefit of getting more referral business by showing goodwill,” he says. Whitfill adds, “There are financial penalties set to begin for those who aren’t using an EMR that can accept results. You’re going to have decreased reimbursement, and that will be a powerful incentive for everyone.”
Meaningful Use As the government increasingly recognizes the importance of health-care connectivity, federal funding has become available for regional HIEs and related health IT projects. Smitherman is hoping to take advantage of this by applying for a grant from the $220 million Beacon Community Program, established late in 2009 as part of the American Recovery and Reinvestment Act (ARRA). These grants are designed to strengthen health IT infrastructure and help build HIEs; Smitherman hopes that a grant will help bring together several local hospital systems. “Once all these entities start working together and stop being afraid of competition, then we can actually get some things done,” she says. “It just takes staying the course and listening. Things are moving even faster now that the current administration is in place. It’s really built a fire under the physicians.” In October 2009, the State of Indiana created Indiana Health Information Technology Inc as the State Designated
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HIE | Images on Board
We do have Office of the National Coordinator (ONC) funding secured to build our National Health Information Network gateway, and we already have HRSA funding secured to link unaffiliated physician offices across western North Carolina. —Dana J. Gibson, MPH, CPHIT, CPHQ, vice president, Data Link Services, Western North Carolina Health Network, Asheville, NC
Entity (SDE), a nonprofit organization put in place to receive federal stimulus funds as part of the Cooperative Agreement Program. “We’re trying to determine where the money would best be spent, where it is most appropriate,” Christian says. “Some will be allocated to connecting hospitals, and some will go to connecting physician offices. I think that’s where the lion’s share of the work is going to be.” There’s bigger federal money to be divvied up among primary-care providers who meet the criteria for meaningful use of EMR technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the stimulus package include $19 billion in incentives for providers attempting ramp up their health IT offerings; an initial proposal from HHS on the definition of meaningful use of this technology stresses that it must be used to improve the quality, safety, and efficiency of health care services. Whitfill cautions radiology groups that they are not eligible for stimulus funds. “By the way the law’s designed, there’s really not a way for our physicians to work with us that would be a meaningful use of their electronic records, so we’re not expecting to see any funds,” he says. There’s an upside to SMIL’s investment, though: As more Phoenix-area practices take advantage of the offer, SMIL’s network will extend even more, and its competitive edge will expand. “Our community-relations department lets the referring physicians know that we can set up the interfaces as they’re putting in their EMRs,” he says. “The number of people who have adopted EMRs is really starting to grow.” Gibson also believes that CMS ARRA funds cannot be used to build out Data Link linkages or to create radiology PACS connectivity, and the HIE is not one of the SDEs that will receive HITECH Act fund-
ing through the state. “We do have Office of the National Coordinator (ONC) funding secured to build our National Health Information Network gateway, and we already have HRSA funding secured to link unaffiliated physician offices across western North Carolina,” Gibson says. “Going forward, we will be applying for more funding for both of these goals from the ONC Beacon Community Program, which is part of the ARRA provision. We also hope to apply for more funding from HRSA and the Duke Endowment to help us achieve these goals, should we be unable to secure the Beacon Community Program grant.” Greensboro Radiology is also focused on how its referring physicians’ offices can capitalize on stimulus money. “The EMR has never been any hotter than it is now,” Willis says. “There’s not really any money for us in the radiology arena, but for pri-
“and when that happens, image exchange becomes that much more difficult. We’ve been talking with a lot of folks about being a hub and spoke in the same way for Mayo Clinic, Cleveland Clinic, and Wake Forest University Baptist Medical Center. We’re going to solve that problem.” In fact, two faculty members at Wake Forest (Winston-Salem, North Carolina), Yaorong Ge, PhD, assistant professor in the Department of Biomedical Engineering, and John Carr, MD, professor of radiology, have received a grant from the National Institutes of Health to do just that. Their approach to the long-distance exchange of DICOM images pivots on patient-controlled decentralization of medical data, as Carr explains: “The need for sharing images is pretty well defined. Not every image needs to be shared all the time. Generally, the patient knows who his or her care team will be, and can specify whom he or she wants to see the images.” Ge adds, “When the patient says that he or she wants the images to be shared with a physician or hospital, then our infrastructure can send an approval to start sending the relevant images. We want to coordinate sharing only when sharing is needed.” The beauty of this approach, Carr and Ge note, is that it can be overlaid on existing HIEs, treating each as an individual database from which data can be exchanged as nec-
Not every image needs to be shared all the time. Generally, the patient knows who his or her care team will be, and can specify whom he or she wants to see the images. —John Carr, MD, professor, Department of Radiology, Wake Forest University, Winston-Salem, NC
vate physician practices and small hospitals, it’s definitely there. We haven’t gone so far as to advertise to them about how they might capture those funds, but we have answered a lot of their questions.”
Pushing Forward Greensboro Radiology’s ultimate goal is to create a regional archive of patient data accessible to all providers, including superspecialists nationwide, with patients from the region. “Our referring physicians refer outside this area quite a bit,” Willis says,
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essary. “In our network, regional HIEs become a node,” Ge says. “We envision that our infrastructure will work very well on top of all the regional efforts.” In the meantime, Willis says, there have been discussions within Greensboro Radiology about expanding the project by including more health information and potentially by reaching out to other radiology practices in the region. “We’ve talked quite a lot lately about how we need a better formal definition of our network, capitalizing on the relationships we’ve built through
In our network, regional HIEs become a node. We envision that our infrastructure will work very well on top of all the regional efforts. —Yaorong Ge, PhD, assistant professor, Department of Biomedical Engineering, Wake Forest University, Winston-Salem, NC
RBMA and by knowing folks around town,” he says. “We’ve been discussing whether we need to take it to the next phase, where we’ve got branding and marketing behind it. It’s a tight balance for us because this isn’t really a profit center yet. We’re just trying to do something that’s good for everyone.” SMIL’s aim is to continue expanding its network, which currently links the practice to around 15% of its total referral base. Whitfill looks for a more broad-based solution in the future, but acknowledges significant obstacles on the road ahead. “It would be wonderful if there was just a single metropolitan, statewide, or even national cloud that linked everyone,” he says. “For now,
In addition to facilitating the ability to shift work within the practice, Wells can imagine an image-enabled HIE offering opportunities to shift work between unrelated (but collegial) practices as well. “If this federated access to images can be built, there is the possibility of work shifting within practices, “ he says, “and, perhaps, if the access to diagnostic original images for dictation would be available as well, of work shifting between practices to provide service to each other over an electronic platform.” For Smitherman, the next step is taking CriticalConnection from the proof-of-concept phase to widespread physician and hospital engagement. “We just started our
If this federated access to images can be built, there is the possibility of work shifting within . . . and between . . . practices. —Andrew Wells, MD, Margaret R. Pardee Memorial Hospital, Hendersonville, AL
though, the next challenge is this: How do you have an HIE of image data when the dataset sizes are so large? You can either duplicate the studies everywhere, or you can have some massive central repository of all image data. Right now, we can’t even do a common patient identifier.” Wells sees the addition of images to the Data Link HIE as both a boon for patient care and an opportunity for the potential expansion of his practice’s reach. “A platform that will allow distribution of images, perhaps through an application service provider or other business relationship, would accelerate our service delivery and might provide us with a platform to expand our service area,” he says. “Perhaps within the Data Link federation of hospitals, we will need more radiology services, more cardiology services, or other types of image expertise, and this type of platform could expand that footprint.”
Central Texas co-op last year, and we’re looking at North and South Texas this year. Then, we’ll start looking outside the state,” she says. “Eventually, we hope to be able to reach out and actually to provide additional dollars for health care for the community, including indigent care and care for the working uninsured. In five years, this co-op could be running a surplus of $50 to $70 million a year. One of our main goals is to keep the physicians’ offices financially viable.” This is no small concern, given ever-declining reimbursement levels and the escalating cost of remaining in business. Christian’s goals are to see Indiana’s five HIEs connected to one another and to see physician practices come on board. From there, he says, the HIEs will be able to redouble their focus on improving patient care, and will ideally be able to begin exchanging DICOM datasets. “We’re still early in the game,” he says. “It can be done,
and other people are doing it, but we’re not there yet. There weren’t enough people with PACS initially, but now most people have it, and the ability to exchange data is becoming far more important.” He adds that just as Indiana’s five HIEs will be able to learn from one another as they continue the process of exchanging data among themselves, so will other HIEs nationwide. “There has to be a standard method of information exchange in use,” he says. “We’re creating more of an opportunity for collaboration this way. Each and every HIE has some unique service offerings, and we can all learn a lot from one another.” Until then, an anecdote from Smitherman illustrates the potential of image-enabled HIEs to increase efficiency while lowering costs; it also underscores the breadth of the challenges to come. “We had an ice storm not too long ago,” she says, “and during the storm, the primarycare physician group at the core of our proof-of-concept project got a call from an elderly patient who thought he might be having a stroke. His physician called up the community record from home and saw a brain scan ordered during a visit to the neurologist two weeks ago. He was able to determine that the emergency department was not where the patient belonged.” In the end, the physician was able to persuade the patient that he didn’t need to go to the emergency department, and should instead make an appointment to see the physician after the storm had subsided. “That 15-minute phone conversation probably saved CMS about $35,000, but there’s no compensation for the physician whatsoever. How do we compensate physicians better for what they’re stepping up and doing with this access? In five years, things are going to look pretty different, and we hope that physicians will have some say in how it turns out,” Smitherman says. Cat Vasko is associate editor of Radiology Business Journal and editor of ImagingBiz.com. Reference 1. Zwillich T. Hefty health spending in stimulus bill. WebMD Web site. http://www.webmd.com/news/20090217/ hefty-health-spending-in-stimulus-bill. Published February 17, 2009. Accessed February 7, 2010.
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MRI | Technical Advances
MRI:
The Next Generation The evolution of multichannel coils, larger-amplitude gradient systems, and parallel and rapid echoplanar MRI is shaking up practice patterns at a time when CT is under fire By Julie Ritzer Ross
M
RI has come a long way since its inception, and it has yet to cease evolving. New developments continue to surface, bringing with them changes in radiology practice patterns and opportunities to bolster revenues by attracting new patient populations. The evolution of multichannel coils ranks among the most significant developments. Systems with 32 and 48 channels are considered standard; 120- and 128channel systems, as well as wireless coils and specialty surface coils, are emerging. Robert Lenkinski, PhD, is vice chair of radiology and director of radiology research, experimental radiology, and the 3T MR Spectroscopy Program at Beth Israel Deaconess Medical Center, Boston, Massachusetts. He says, “Multichannel coils, which bring improved signals and greater reliability, are having an enormous impact on MRI in general. They enable parallel imaging, higher-quality scans in a shorter time period (by an average of a factor of four), and broader coverage of body parts with very good signal strength.” Reduced scan time, stemming from access to additional channels, reduces
motion-related problems and increases patient compliance. This, in turn, is spurring physicians to make MRI their study choice for a wider range of patients, including pediatric, elderly, and severely debilitated individuals. Richard Semelka, MD, says, “It is much easier now to perform MRI studies on patients who, in the past, could not or would not remain still long enough to complete the process, or presented some other kind of challenge.” Semelka is professor, director of MRI services, vice chair of clinical research, and vice chair for quality and safety of the Department of Radiology at the University of North Carolina Hospitals in Chapel Hill. He continues, “The less time patients must remain in the machine, the easier to perform MRI studies on them, and the greater the likelihood of compliance.” Lawrence Wald, PhD, of the Department of Radiology’s Martinos Center for Biomedical Imaging at Massachusetts General Hospital (MGH) in Boston, is director of the MGH NMR core. He adds that new multichannel phased-array coil systems also permit users to execute different, more exotic imaging procedures. He
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notes that while such procedures were previously impractical because of the amount of time needed to encode captured images, large coil arrays and multiple channels remove that factor from the equation. “For example, with a higher number of coils, spectroscopic imaging that once took three hours has a 16-fold acceleration, into the 10-minute range,” Wald states. “Capturing 0.75-mm isotropic, high-resolution 3D images of the brain can take 15 minutes, rather than many times that. The more channels, the more MRI will become a replacement for CT, because users are able to get patients in and out in comparable time, with heightened image sensitivity, and without compromising image quality.” See Figures 1, 2, and 3.
Diffusion Imaging Migrates The advent of multichannel coil systems and parallel imaging, coupled with such hardware and technical advances as rapid echoplanar imaging and largeramplitude gradient systems, has also paved the way for the use of diffusionweighted imaging, not only for evaluating intracranial abnormalities, but for imaging other parts of the body.
Images courtesy of Lawrence Wald, PhD, Massachusetts General Hospital in Boston.
Bachir Taouli, MD, director of body MRI at Mount Sinai Medical Center, New York, New York, says, “The combination of all of these factors helps to overcome many limitations that previously precluded the application of diffusion-weighted imaging to areas beyond the brain.” For example, prior to recent hardware and technical advances, inherent limitations in signal-to-noise ratio (SNR) and image
shorter echo time, reduced echo-train length, and more rapid k-space filling) made possible by advanced technology has reduced artifacts and rendered diffusionweighted imaging a more viable option. Radiologists are beginning to use diffusion-weighted imaging in abdominal and pelvic oncologic MRI studies, with single-shot echoplanar imaging employed in assessing lymphadenopathy and renal, hepatic, ovarian, and peritoneal masses, as well as prostatic, colorectal, uterine, and pulmonary tumors. Taouli notes particularly positive results using diffusion-weighted imaging in assessing patients with liver disease. “The next-generation hardware and coil systems mean the diffusion-weighted option can be applied to liver imaging with improved image quality,” he reports. “Diffusion-weighted imaging allows qualitative and quantitative assessment of tissue diffusivity without the use of gadolinium chelates, which makes it a highly attractive technique, particularly in patients with severe renal dysfunction.” Some radiologists now simultaneously apply diffusion-weighted and conventional abdominal and pelvic MRI for betFigure 1. A 96-channel brain-array prototype constructed at Massachusetts General ter detection of many types of primary Hospital in Boston; the detector uses very small loop detectors placed on a close-fitting hel- and metastatic tumors. “There seems to met. The high density of small detectors improves image sensitivity and increases the abil- be improved sensitivity for tumors here because they are more conspicuous with ity of parallel-imaging techniques to decrease scan time. diffusion-weighted imaging than with conventional T1, T2, and gadoliniumenhanced imaging,” Taouli says. “When diffusion-weighted imaging comes into play, background tissues are somewhat suppressed; most forms of tumor show restricted water diffusion, so tumor conspicuity becomes moderate to marked. Just as important, adding breath-hold diffusion-weighted imaging to routine abdominal MRI works much better at detecting additional tumor sites in oncology patients, compared with conventional MRI.” Diffusion-weighted imaging is also beginning to have clinical applications on resolution tended to compound artifacts when patients were evaluated in diffusion-weighted imaging mode. Moreover, the larger fields of view necessary for abdominal imaging generally accentuate many of the artifacts inherent in diffusion-weighted imaging, as well as in single-shot echoplanar imaging. Now, however, the rapid imaging fostered by multichannel coil systems (along with
Figure 2. Section from a T1-weighted whole-brain volume acquired with a 32-channel brain-array prototype constructed at Massachusetts General Hospital in Boston; in this case, the scan time was conventional (8 minutes), but at a voxel volume that was four times smaller. In-plane resolution is 0.4 mm and partition thickness is 1.5 mm.
Figure 3. A T2-weighted image acquired with a 96-channel brain-array prototype constructed at Massachusetts General Hospital in Boston; in this case, the highly parallel array was used to speed up the acquistion fourfold and reduce distortion artifacts. Each slice was acquired in 150 milliseconds, allowing a whole-brain acquisition in nine seconds. In-plane resolution is 1 mm and slice thickness is 2 mm. www.imagingbiz.com | February/March 2010 | RADIOLOGY BUSINESS JOURNAL 29
MRI | Technical Advances
Wide-open MRI
A
dvances in the field strength of open-bore MRI systems are also opening new doors for imaging providers. Systems with a field strength of 1.2T (and hence the ability to produce clearer images than their counterparts with lower field strengths) allow MRI studies to be performed in populations of patients who are not candidates for traditional closed-bore procedures. These include bariatric and claustrophobic patients, according to Daniel Chernoff, MD, PhD, director of radiology services, Adirondack Imaging, Glens Falls, New York. Open MRI of Glens Falls, one of Adirondack Imaging’s three imaging cen-
the whole-body front when employed with background body signal suppression. Cancer staging represents a case in point because primary tumors and distant metastases alike show restricted diffusion, and suppression of background tissues permits small metastases to be seen easily. Evaluating the responses of primary tumors and metastases to chemotherapy or radiotherapy constitutes another such application, as does the evaluation of lymphadenopathy in patients whose metastases are predominantly nodal (Figure 4). What’s more, physicians are reportedly incorporating whole-body diffusion-weighted imaging into their surveillance protocols for lymphoma and leukemia; background tissue suppression, Taouli notes, allows
ters, has also begun leveraging higher-caliber open-MRI equipment to perform image-guided needle biopsies. “With openbore MRI, we can leave the patient in position and reach in from the appropriate side with the needle, rather than sliding the patient in and out,” Chernoff explains. In addition, Chernoff sees the potential of using open-bore MRI to study the extremities. “We always want images to be dead center, which is easier to achieve in an open-MRI mode because the extremity can be easily repositioned,” he says. “Although the field strength is slightly lower than with closed 1.5T systems, one still gets a better image with a centered extremity.” —J.R. Ross
lymph nodes to be shown with very high tumor-background contrast, and even small nodes are easily seen. In addition, the volumetric display of the whole-body diffusionweighted dataset is more accurate than routine planar anatomic MRI in portraying nodal tumor distribution.
Field-strength Advances The development of MRI equipment with higher field strength is also affecting the use of MRI technology and the variety of case types where it is applied. While machines operating at field strengths of 1T and 1.5T are still very much in use, manufacturers are releasing 3T equipment intended not for research settings, as has traditionally been the case, but for clinical
Figure 4. Transverse fat-suppressed, breath-hold, single-shot echoplanar diffusion images of a 43–year-old woman with breast cancer treated with chemotherapy, obtained using b values of 0 and 500 s/mm2, with corresponding apparent diffusion coefficient (ADC) map and postcontrast image; the higher–signal-intensity necrotic center of the tumor on the b 0 image shows greater signal attenuation on the b 500 image with higher ADC (asterisk), compared with the cellular enhancing rim, which has restricted diffusion and lower ADC (arrows). Images courtesy of Bachir Taouli, MD, Mount Sinai Medical Center, New York, New York.
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ones. The heightened availability of coils and pads to increase signal and counter artifacts is pushing the envelope as well, as are such innovations as computer-aided detection and protocols for specific 3T MRI studies (for example, spectroscopy for prostate evaluation). “3T for all clinical applications is becoming very much a reality,” based partially on its general benefits, Semelka says. The SNR produced by 3T MRI is up to four times better than that generated by 1.5T MRI. Resolution with 3T imaging is also superior; together, improved SNR and higher spatial resolution lead to improved image clarity and diagnostic utility. “With 3T MRI, we can also use decreased scan times to reduce data artifacts related to motion,” Semelka notes. “This means we can perform more body MRI studies (as well as studies on children, geriatric patients, and anyone who can’t control movement for more than a very short duration) in a compressed interval while preserving image quality.” Lenkinski concurs, adding that the SNR of a 3T body coil is about the same as that of a 1.5T phased-array coil. “Adding a surface coil gives much more SNR headroom, which allows faster image acquisition and patient throughput or higher image resolution while revealing fine anatomic details and physiologic parameters,” he says. Other general advantages also are encouraging physicians to use 3T in clinical settings. For instance, 3T MRI technology permits radiologists to discover subtle abnormalities not seen using 1.5T imaging. Wald cites the example of a 3T MRI scan performed on a seizure victim; it showed heterotopic gray matter associated with a developmental problem. A previous 1.5T scan revealed no such abnormalities. Other benefits are easier identification of changes in metabolite peaks, as well as improvements in fat/water-suppression imaging techniques. Moreover, 3T MRI is said to enhance advanced functional MRI sequences, among them diffusion-weighted, diffusion-tensor, and blood oxygen level dependent imaging.
Benefits and Body Parts As for more specific, individual applications of 3T MRI in nonresearch environ-
Image courtesy of Robert Lenkinski, PhD, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
ments, Lenkinski cites scanning of the brain as a particular area of interest. “The fact that conventional brain imaging at 3T can be completed in the same exam time and can achieve a higher SNR than at 1.5T is just part of it,” he states. “With an SNR three to four times higher, 3T MRI more precisely localizes areas of activation, permitting accurate mapping of brain function in patients more than 90% of the time.” Lenkinski adds, “Diffusion-tensor imaging at 3T, unlike diffusion-tensor imaging at lower field strengths, makes it possible to view brainstem structure clearly. Contrast-enhanced studies performed at 3T allow significantly better differentiation between the brain and a tumor, and venography offers a better view of tumor environments than is obtainable at 1.5T.” The improvements offered by 3T and a combination of endo-rectal and surfacearray coils are quite marked in the prostate, he adds (Figure 5). Musculoskeletal imaging using 3T MRI is also growing. Radiologists are finding that the improved SNR not only speeds up imaging of the joints, but yields an enhanced view of trabecular detail and improves fat saturation of the joints. A combination of fat saturation and contrast is said to enable users to perform more sensitive studies of inflammation, tumors, and healing. Breast imaging, particularly for women who are at risk for early breast cancer, is among other promising 3T body-imaging applications now making their ways into clinical radiology. Proponents of 3T breast MRI claim that it generates more detailed images (which are crucial for seeing tumor borders and ductal anatomy) and higher resolution, resulting in clearer/sharper images that are vital to the detection both of subtle cancers and of less-subtle cancers at earlier stages. Radiologists also consider 3T images more accurate because they exclude the whites of fatty tissue while leaving cancerous cells visible and are twice as sensitive as 1.5T images when it comes to contrast enhancement. Similarly, manufacturers of 3T scanners report that their equipment scans contiguous 1-mm slices, allowing up to 30% more of the
Figure 5. A T2-weighted axial fast-spin echo image taken of a prostate at 3T using an endorectal coil in combination with an external pelvic array; the high spatial resolution available using this combination allows the visualization of both detailed anatomy and small abnormalities within the gland.
breast to be scanned and reducing the likelihood that lesions could be missed due to skip (the scanning of alternating 1mm slices instead of all slices). Additional applications of 3T MRI made possible by hardware and software developments include whole-body MRI, dimensional high-resolution cholangiopancreatography, staging of cervical carcinoma and evaluation of its extension beyond the cervical stroma, staging of rectal carcinoma, staging of prostate cancer, and high-resolution MR angiography for evaluation of the renal and mesenteric arteries. For MR spectroscopy in the abdomen and pelvis, 3T imaging with parallel acquisition might be preferable to 1.5T imaging in that the chemical-shift effect is doubled, producing improved spectral resolution of metabolites that are obscure at 1.5T.
MRI Versus CT Recently, rising concerns about radiation exposure and the cost of PET/CT have led radiologists to question whether MRI might replace CT as a study mode of choice. There appears to be no clear answer. “With modern MRI advances, the faster speed of data acquisition, and clearer imaging without artifacts, there can
certainly be more MRI procedures performed than is the case now,” Semelka says. “For example, there are a tremendous number of CT studies performed on children with seemingly minor injuries to ensure that there has been no undetected injury to the spleen, kidneys, and so forth. The ability to obtain higher-quality images, in less time and without sedation, would be a selling point for using MRI in these cases instead. By contrast, in major trauma cases, I don’t see MRI replacing CT completely any time soon.” Some analysts also believe that because diffusion-weighted imaging does not provide true metabolic information, it will probably be used to complement, rather than entirely replace, PET/CT. “MRI, together with diffusion-weighted imaging, can more realistically supplement PET/CT in cancer imaging, with initial evaluation using PET/CT used to zero in on primary and metastatic tumor sites and follow-up diffusion-weighted imaging used to monitor tumor response to therapy,” Taouli says. Still, he notes, the promise of next-generation MRI is seemingly unlimited. Julie Ritzer Ross is a contributing writer for Radiology Business Journal.
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PACS | Distributed Reading
From Here Extending the Franchise to Eternity:Through Distributed-reading Solutions Through the adoption of imaging informatics, practices and mobile imaging services are deploying distributed-reading solutions to provide interpretations and service with unparalleled speed over broad geographic areas By Greg Thompson
F
ew developments in radiology have been more productive (or disruptive) than the advent of PACS. To PACS, radiology owes its ability to increase productivity dramatically during the past 10 years, thereby conserving income levels at a time of diminishing reimbursement. To PACS, radiology also owes the very real threat of commoditization. Nonetheless, the remarkable evolution of PACS technology is slowly but surely making its way back to old-school referrer interaction through distributed-reading solutions in a variety of settings. As prices drop and vendors leverage Web-based architecture, PACS has become a necessary tool for radiology practices seeking to expand service through the distributedreading model, perhaps including on-site consultation with referring physicians. One example of a personal touch melded with technical savvy can be found at Advanced Medical Imaging Consultants (AMIC) PC, Fort Collins, Colorado. Raym Geis, MD, is part of this group, which covers 22 sites from Casper, Wyoming, to Sidney, Nebraska. AMICâ&#x20AC;&#x2122;s 29 fellowshiptrained radiologists offer full service for 32 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
facilities with several hundred beds (and others that are much smaller). It’s a bit like traditional radiology, except that it is distributed over a wider area. AMIC sends radiologists to contracted sites at least every other week, when biopsies or interventional procedures can be performed. Most studies are read remotely, and on any given day, AMIC has radiologists at up to seven different sites doing subspecialty interpretations. The distributed-reading workflow has improved through the years, and various sites are tweaking it as needed. “In the ideal world, we would be able to read from any type of workstation,” Geis, a veteran of many RSNA lecterns, explains. “We don’t have that situation yet. We read from basically three different PACS. One system is a fairly thin client, but I can’t just go to any computer, log on at an Internet site, have all the programs show up, and read from it. I must download things to that computer, and I must have an IT person come and set up a workstation.” Through interfaces, AMIC’s radiologists are able to read images for all but two of the company’s 22 clients from its own Web-based PACS. Radiologists covering all sites, therefore, must have access to three different workstations. For smaller health-care providers (such as practices and mobile imaging services) that might once have been reluctant to deal with the hassles of a distributed-reading business model, the technological barriers are not so formidable anymore. Robert Pollard, IT director at Decatur, Alabama-based Drs4Drs (www.drs4drs.com), is the technical guru behind a consortium that represents physicians and provides multiple services, including mobile ultrasound. Pollard uses a Web-client PACS to manage images from a central location so that radiologists can read the studies from standard workstations. Typically, image files are uploaded to a centralized PACS over a wireless microwave network at 5MB. “Radiologists from various locations in Georgia or Alabama log on over the Internet, and they read the studies and write the reports,” Pollard says. “We get the reports to the ordering physicians within a 48-hour turnaround time.” Pollard has two different ways to
obtain prior studies. Since not all the studies are in the system, the first way is to go back and get documents, scan them, and import them. “We mark them as mediumlevel stat, which bolds the actual study on the worklist,” Pollard explains. “The radiologists can immediately see that it is a prior study, or that it has a prior study associated with it. They open it, and in the lower left frame they can see all of the
Radiologists contracted to provide interpretations for Drs4Drs have no specialized workstations and need only standard computers and browsers. The PACS is Web based, and it includes an option for voice recognition, but Pollard currently has opted to use a transcription service instead. Radiologists email the audio files, and Pollard’s team gets the reports to the referring offices. In 2009, the organization
You log into the PACS, and the worklist is isolated to your specific login. We can customize it to show studies originating from specific clinics, or use any criteria you want. —Robert Pollard, IT director, Drs4Drs, Decatur, AL
standard documents from prior studies. If we already have a study in the system, we add another study for that patient. It is automatic; all the studies show up, and radiologists can go back and look at the prior studies anytime.”
Beating Worklist Woes With 30 years of IT experience, Pollard selected his PACS with an eye toward governing the company’s worklists, which are refreshed constantly. “You log into the PACS, and the worklist is isolated to your specific login,” Pollard says. “We can customize it to show studies originating from specific clinics, or use any criteria you want.” After the technologist completes the scan, the study and the supporting documentation are uploaded to the PACS by an employee at the central office. Only then does the study become visible to the company’s radiologists as unread. When the radiologists complete their dictation, the study is marked as read. Far more than in days past, PACS has become an affordable option for radiology groups and other health care providers. “It used to be a money pit,” Pollard says. “People would get in, but then manufacturers would ask you to add on more, and that inevitably ran up costs. It used to be six figures, and from my perspective, that is not really affordable.”
interpreted 12,233 ultrasound procedures. The situation at Oklahoma City, Oklahoma-based Eagle Imaging Partners (www.eagleimagingok.com), a sevenradiologist practice, is a bit different, especially when it comes to workstations. Interpreting from 23 sites using nine PACS and ranging from Abilene, Texas, to Tulsa, Oklahoma, the radiologists at Eagle Imaging Partners provide subspecialty coverage and an on-site presence, and all interpretations are done from a standard workstation. Eric Slimmer, CEO at Eagle Imaging Partners, says, “All of our workstations at all of the centers are identical. When our physicians log in, they are able to access all the images that are on their worklist on that same multifunction workstation. We do not have other workstations lined up anymore, and we have been able to consolidate all of those under one worklist.” With sites scattered throughout Oklahoma and Texas, Eagle Imaging Partners locates its physicians in areas close to the hospitals and imaging centers that they serve, making it easier to provide the necessary on-site coverage. “All of our physicians are working on the same network, no matter where they are,” Slimmer explains. “The physician may go to one imaging center one day and one hospital another day, and those are 30 to 45 miles apart. The system and the workflow are
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PACS | Distributed Reading
the same at each location. All of our clients’ cases come into the same centralized worklist, and the physicians work off that worklist no matter where they are.” With seven physicians in the group, Eagle Imaging Partners contracts with a major teleradiology provider for afterhours coverage, as well as for the use of its technology and workflow expertise. “With its teleradiology software and after-hours
own archives and use the interpreting practice’s PACS. “Institutions pay all this money for a PACS, and nobody uses it, because they use ours,” he says. “Instead of buying a PACS, they should buy their own archive, which is cheap. Save everything in standard format. If you become dissatisfied someday with your distributed-reading provider, you can simply go to another radiologist.”
The system and the workflow are the same at each location. All of our clients’ cases come into the same centralized worklist, and the physicians work off that worklist no matter where they are. —Eric Slimmer, CEO, Eagle Imaging Partners, Oklahoma City, OK
coverage, and our on-site presence, we can go to rural facilities and provide 24/7, turnkey workflow that is seamless,” Slimmer says. “Our group takes care of all the daytime studies. We provide the rural United States with high-quality care, and we do that by using image distribution, coupled with our on-site presence and after-hours coverage.” Slimmer searched for, and ultimately found, a system that allowed physicians to filter worklists by subspecialty or privileges/credentials. “If the physician is not properly credentialed, he or she may not be able to see cases from a certain facility,” Slimmer says. “Our group uses the sort function of chronological order. The studies are on the worklist based on when the case arrived. All urgent cases go to the top of the list and are interpreted within 30 minutes. Each physician, when he or she logs into the worklist, will only have cases that he or she reads and is credentialed/privileged for, in order of urgency.” Eagle Imaging Partners eschews archiving images for the facilities that it serves, but the system does keep reports permanently. It usually preserves images for 30 to 60 days, depending on the facility.
The Tables Turn In fact, distributed reading has rendered PACS such a requisite tool, Geis says, that facilities that still do not have a PACS might do well simply to buy their 34 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
If a facility has its own PACS (or just an archive), AMIC will essentially serve as a backup for just that purpose, and the backup is actually the version from which Geis reads. In the future, he predicts, all images might be stored via cloud computing, allowing capacity to be purchased from third parties only as needed (and reducing capital expenditures). “Not only are you going to have the images archived in the cloud, but people are going to start providing a lot of the image-viewing software as a Web service,” Geis says. “AMIC sees its future not only as radiologists, but as a consolidator and provider of Web services for PACS, RIS, report generation, advanced image processing, the knowledge base, and outcomes data.” At Slimmer’s central facility, autorouting works hand in hand with a centralized worklist. “When they log in, all physicians will see the worklist that they are willing and credentialed to interpret,” he explains. “Those cases immediately begin caching to their systems, and they read from the top of the list. Once a radiologist selects a case, another radiologist cannot select that case. The same case could be on multiple radiologists’ worklists. As soon as it is selected, that image is captured and that radiologist interprets it off the worklist.” Centralized worklists and image-distribution systems, if implemented properly, can dramatically increase productivity. In Slimmer’s case, they have also lessened
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PACS | Distributed Reading
If you don’t have the worklist sophistication, you will end up doing things that you don’t get paid for. —Raym Geis, MD, Advanced Medical imaging Consultants, Fort Collins, CO
radiologists’ daily errors and interruptions because the radiologists are no longer working on three or four different systems. “The new system has also given us the ability to consult easily with other partners in the group, since we are all working on the same system,” Slimmer says. “Physicians can pick up the phone and have a look at the same images. The ability to work on the same system, with the same worklist, has really unified our group, even though we are spread out all over the state.” Geis agrees that the filtering mechanisms of sophisticated worklists can add efficiencies to today’s distributed-reading solutions. In addition to accounting for privileges/credentials and subspecialties, filters can be set up based on whether the radiologist is reading for an IDTF or whether the patient is a Medicare enrollee. “If you don’t have the worklist sophistication, you will end up doing things that you don’t get paid for,” Geis says. “Remember that the insurance companies are notorious about changing the rules, and as nearly as I can tell, their goal is not to pay us.” AMIC radiologists currently are unable to read all images from one workstation, and Geis contends that some of the big software manufacturers probably want it that way; that is, they are likely to prefer that radiologists stay on their proprietary systems. There are a number of small companies, he says, that are working on image-viewing software that could interact with disparate archives and multiple lists. The images might be on a large company’s PACS, but small companies are increasingly learning how to interface with all of those. “Half the places we read from have their own PACS; we can plug our system into theirs, and it works robustly,” Geis says. “We can get the information we need. Our smaller system
plays well with others, and you have to have that nowadays.” The workstation that Geis uses at home is essentially the same as the one that he has at the hospital. It’s an off-the-shelf computer with inexpensive medical-grade monitors. He says, “When we first started, the monitors cost tens of thousands of dollars for medical grade.” Now, he reports, they can be bought inexpensively online.
Beyond Teleradiology Slimmer notes that advocates of pure teleradiology, as opposed to distributed reading, might have been inclined to use teleradiology specifically to avoid having to work on-site. Instead, the Eagle Imaging Partners model involves forming a group that is actually spread out all over the state. This system allows the company to send physicians to different locations, but they still use the centralized worklist. Eagle Imaging Partners contracts with hospitals and provides the radiologists with the workstations that it requires the physicians to use. “Teleradiology certainly has its place, with huge benefits to the facilities for nights and overflow coverage, but it has its limitations,” Slimmer says. “That is exactly why we have structured our operations the way we have in partnering with a teleradiology company to accomplish both tasks. I think the on-site model will always have a place in radiology. The ability to provide on-site coverage changes the level of care that the facilities can give patients. I don’t think the on-site presence will ever be eliminated.” Some patient-care advocates might agree that relentless technological progress in radiology must be tempered with respect for the on-site physician. Pollard predicts that better distributed reading (through improved access and standardization) is one way to make this a reality.
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“There is no doubt that in the future, everything will be more easily transported and shared,” Pollard says. “Radiologists will be able to read anywhere they want, and more devices will integrate seamlessly with PACS as well.” Slimmer adds, “We will become more and more wireless, using mobile devices (which our physicians do not use right now) to give preliminary interpretations. Voice recognition will be mandatory, if it is not already, and it will improve. Wireless consultation with the referring physician, and the ability to look at the images and do a mobile consultation with the referring physician, will be right around the corner.” Distributed images will get better (as images always do), but what about reporting the circumstances around these images? A big problem, Geis reports, is that information about the imaging process is needed. “Historically, radiologists provided information about the images, and that is what we’ve been doing for 100 years,” he says. “For radiologists to continue to play an important role, we need to provide information about the whole imaging process. Not only do I interpret the images, but I can tell you about the patient’s radiation dose, assure you that we did the right study, and provide the data needed to follow up and determine how well I’m doing.” Geis continues, “Trying to collect relevant data is the big issue right now. I don’t think most of the big manufacturing companies get it. They have all of their best software engineers working on how to make a prettier 3D image. There is a need for that, but I want them to use their best software designers to tackle the problem of collecting the data.” Greg Thompson is a contributing writer for Radiology Business Journal.
INTEROPERABILITY | Toolkit
Interoperability: An Open-source Toolkit
Not for the novice or the faint of heart, open-source application software provides the practice CIO and the imaging informaticist with a toolbox full of solutions to common interconnectivity problems By Kerry Cox, PhD, and James T. Whitfill, MD
W
ithin radiology, interoperability and sharing information are among our most challenging and important tasks. Not only does the coming wave of adoption of electronic medical record (EMR) technology mean that we need to be able to exchange electronic information with other providers and health-care software systems, but even within our enterprises, we need to connect disparate data sources as a critical part of how we take care of patients. Historically, IT professionals have relied on proprietary software packages to provide health-care software, but a growing movement toward opensource software signifies new options for health-care providers in selecting the best tools to meet our software needs. Open-source software has been licensed to allow the end user to view and
modify its source code; often, the license requires changes in the code to be made available to a group named in the license. It is fairly typical for the software, or at least the source code, to be available without cost. Some might equate open-source software with free software, which can be misleading. Some free software is not open-source software: You can use the software without paying, but you cannot see or alter the source code. Similarly, there are companies that profit from open-source software, usually by providing support for the software under some type of maintenance package. There are myriad applications available for radiologists that border on the cheap, but they might not be the best choices. Likewise, there are still plenty of vendors committed to giving you the very best solution at the most expensive price.
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How the IT department makes software decisions of this magnitude depends on several variables: • the willingness of management personnel to entrust the bread and butter of the business to open-source alternatives, • overall budgetary restrictions or costsaving expediencies, and • the knowledge of the IT staff. This final factor is the most crucial, as that staff will be maintaining this infrastructure. Managers need to sleep well, knowing that the IT department has all the bases covered and is willing to care for open-source applications as though they were its own. Open-source solutions are viable if the five following conditions can be met. First, the institution must have a very knowledgeable IT staff versed not only in healthcare software, but also in Linux, MySQL®,
and other open-source applications. The IT departmentâ&#x20AC;&#x2122;s personnel must be committed open-source advocates who have been trained appropriately and are dedicated to the open-source cause. Only then will they have a vested interest in making open-source solutions work. Second, a limited budget and a need for enterprise-ready solutions (without the software cost) should be present to inspire the pursuit of open-source solutions. Third, server-class hardware must be in place. Throwing open-source software at shoddy hardware is the worst thing that can happen in a project of this kind. Managers will be quick to blame the software (rather than the hardware) if something fails. Fourth, a stable backup solution must be in place. Should anything fail, you must be able to restore any lost data/func-
tion quickly. Again, it is best not to have managers blaming the software rather than the process. Fifth, plenty of documents, communities, and people must be in place to support the software. All companies are ready to cast blame when things go wrong. If a software supplier is being paid for its services, then it will naturally be first to take the hit. If, however, you are using open-source software and there is no cost for it, then the next person to be blamed is you (since you are drawing the salary).
Making the Leap If all these conditions have been met completely, a great opportunity exists for your facility to begin using some of the more productive and cost-saving applications on the open-source market (or, at least, to test drive them). There are free
alternatives, readily available, that can further the interoperability of disparate image workflows. Our recommendation is to test new products in conjunction with existing applications. If you see similar performance from the open-source software and the proprietary software, then you can begin the migration process. Of course, not all free software is right for every setting, and being free can stigmatize a product, in the view of many business-minded executives. If, however, you can give your IT staff the necessary leeway and incentives to develop and take ownership of the software, cost savings and performance improvements will become possible. There is an additional consideration in choosing an open-source application: the stack (the collection of supporting applications on which the principal application runs). Commonly, this stack is composed of an operating system (OS), a Web server, a scripting package, and a database. This can be important because not all open-source applications run on open-source stacks. For example, the LAMP stack, consisting of the Linux OS, the Apache Web server, the MySQL database, and the PHP scripting engine, is all open-source software. Other open-source projects, however, might use a well-known proprietary OS, Web server, and database, in which case none of these stack components are open source, even if the database can be used free. Paying attention to the stack is important because running an opensource application on a proprietary stack might entail purchasing additional licenses for terminal services, antivirus software, client access, and the server OS, even when the open-source application is free. Open-source alternatives for the OS include a Linux or BSD variant. Linux and BSD are both free, beating initial proprietary-software costs (with licenses and renewals) while allowing you the freedom to modify the software as needed. No matter what open-source OS you choose, the cost savings are remarkable, and this allows for investment elsewhere (for example, in hardware). When information is shared among systems in radiology, it usually is in two forms: HL7 and DICOM. In general, HL7
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INTEROPERABILITY | Toolkit
Similarly, when exchanging information among DICOM archives at different institutions, there often is a need to alter the DICOM header before accepting a foreign study into a PACS. Kerry Cox, PhD
is the standard used for exchanging text information, while the DICOM standard allows the exchange of image data. It follows that a number of open-source products exist to allow the exchange of either HL7 or DICOM information. Myriad options exist that we have used in our institutions; what follows is a sample drawn from these. There are many other solutions that might be equally valuable, and we do not mean to do any disservice to the communities that develop, foster, and use those solutions.
Open-source PACS There are two open-source options for a DICOM-compliant PACS. These are tools that even organizations with full-blown proprietary PACS might want to adopt, as both products can be very useful in exchanging information among disparate DICOM entities. Two important features that both systems offer are autoforwarding and DICOM header manipulation. Autoforwarding allows the user to define, in advance, various algorithms for sending DICOM studies to different desti-
nations based on information found in the DICOM header. Many PACS versions lack the ability to perform complicated, rulesbased autoforwarding. For example, a radiology department might want to send copies of all CT and MRI studies to a DICOM archive in a cardiology department if the ordering physician is on a list of cardiologists. In a similar vein, outside institutions might want DICOM studies sent to their archives only during off hours, and only based on ordering physician, modality, or other items in the DICOM header. Similarly, when exchanging information among DICOM archives at different institutions, there often is a need to alter the DICOM header before accepting a foreign study into a PACS. Most PACS software expects the DICOM object to come from a modality within the enterprise and, therefore, to have the correct medicalrecord number (MRN), study description, and exam number already embedded within it. Such a PACS cannot handle values that did not come from the in-house order
40 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
placer. For example, an imaging study done at institution A will have an MRN and a unique exam number that do not exist at institution B. These numbers might require alteration in the DICOM header before the study is imported into the PACS at institution B. While this is the most obvious example, other elements of the DICOM header often need to be cleaned or altered before a PACS will accept a study. PACSOne Server: This is a DICOM 3.0 compliant PACS application combining a DICOM server, a PACS server using the open-source MySQL database, a Web server using the open-source Apache 2.0 HTTP server, and the PHP scripting engine for the Web-user interface. PacsOne, in the basic edition, is free. It is less complicated than some of the proprietary PACS solutions because it requires only a single server, instead of multiple servers that must be maintained. It also runs on the hardware platform of the institutionâ&#x20AC;&#x2122;s choice, whether that is a workstation, a server with RAID, a blade server, or even a laptop. In addition, it can run on either open-source Linux or a proprietary OS. ClearCanvas: This company offers open-source PACS, RIS, and workstation/viewer applications. ClearCanvas software, however, runs on a mixed stack of Windows plus an opensource database. Built on an extensible application framework, it is useful not just to radiologists and clinicians, but also to researchers wishing to create new, cutting-
edge tools that can be tested easily in a clinical environment. ClearCanvas Workstation is free; as with PACSOne, users can purchase optional support for the software.
An HL7 Interface Engine Interfacing with other clinical systems can be a complex, expensive proposition when multiple parties try to work together. By using an open-source interface engine, one can bring powerful tools inhouse to provide interconnectivity.
James T. Whitfill, MD
offices. It’s simple to install and configure, and it has a wide range of options, such as message transformation, segment substitution, and PDF creation, as well as FTP and SFTP socket support,” he says. As it is for many open-source software packages, however, finding and using documentation for Mirth can sometimes be challenging, and unpaid support might require the end user to be creative. Anderson says, “While some of the more advanced uses and configurations are somewhat cumbersome, and lack of ade-
Interfacing with other clinical systems can be a complex, expensive proposition when multiple parties try to work together. By using an open-source interface engine, one can bring powerful tools in-house to provide interconnectivity.
In addition, the Health Information Technology for Economic and Clinical Health (HITECH) Act requires providers with EMRs to send orders, and to be able to receive results, electronically. At first, the HITECH Act gives health care providers incentives to make these functions available, but within a few years, CMS will reduce payments to providers that cannot meet this need. Most radiology providers, therefore, must either establish what are potentially hundreds of interfaces in the near future or face some very unhappy referring offices. Mirth: This interface engine runs on an Apache/MySQL/PHP stack that can be hosted on Windows or Linux. In this sense, it can be open-source software from application to stack. Roger Anderson, the HL7 engineer at Scottsdale Medical Imaging in Arizona, notes that Mirth provides a second layer of interoperability to round out the proprietary interface engines both on the radiology side and for the ordering providers’ EMRs. Anderson reports that Mirth is “a very versatile and stable open-source piece of software that provides a number of functions that many HL7 interface engines don’t. We use it mainly as an HL7 receiving engine at our referring physicians’
quate documentation and examples is apparent, these problems are easily overcome by visiting the user boards,” in addition to employing trial-and-error methods.
PACS Viewers While most US PACS users run their viewers on a proprietary OS, in other parts of the world, users (including governments) have pushed to avoid the proprietary OS, and they seek alternative viewers for this reason. Even in the United States, on occasion, referring offices might ask for a viewer that does not require a common proprietary OS. Open-source adopters on the bleeding edge might also look for a completely open-source solution, from stack to viewer. In all of these cases, there are options. Aeskulap: In companies that have fully embraced the open-source revolution (for example, those that are using Linux on the desktop and running servers on Linux or BSD), some consideration might be given to Aeskulap, a medical image viewer. It can load a series of special images stored in DICOM format for review. In addition, Aeskulap is able to query and fetch DICOM images from archives or PACS over a network. The goal of this software project is to create a
fully open-source replacement for commercially available DICOM viewers. Though Aeskulap was designed to run under Linux, versions of it are available for different platforms. K-PACS: Though its author’s Web page states that for legal reasons, this software should not be used for any medical purposes, K-PACS is a fully functional DICOM viewer. It features a patient level table and thumbnail previews, modifiable annotations, and CD or DVD creation with an internal library. If a DICOM viewer/burner is required to address patients’ requests for images, K-PACS is a full-featured solution.
A DICOM Utility For testing and monitoring existing systems, financial justification of the purchase of costly DICOM utility software can be difficult. Fortunately, opensource utilities are available. Before you can even start working on interoperability with DICOM, the ability to connect at a basic level must be confirmed to avoid a complex troubleshooting process for the exchange of information among DICOM nodes. DICOM PiNG: This is a fast, robust, full-featured, and free DICOM utility used for testing connections among DICOM routers, modalities, and other DICOM-based services. It can be used to determine whether a server is reachable or to test advanced TLS (SSL) connections for servers supporting the secure transmission of images. Organizations that are committed to open-source solutions will find that open-source software can be quite useful as they seek greater interoperability, both within the organization and across the care continuum. Migration to any of these recommended software packages might not only save on cost, but make your company more robust and nimble in the current turbulent economy, where all cost savings and performance improvements are welcome bonuses. Kerry Cox, PhD, is CIO, Mountain Medical, Murray, Utah. James T. Whitfill, MD, is CIO, Scottsdale Medical Imaging, Scottsdale, Arizona.
www.radbizjournal.com | February/March 2010 | RADIOLOGY BUSINESS JOURNAL 41
RANKING | Largest Academic Practices
The
20 Largest
Academic Radiology Practices
E
ditor’s note: Radiology Business Journal brings you this inaugural list of the largest academic radiology practices with our usual caveat: We know that this list is not complete. We publicized the survey through our e-journal ImagingBiz.com, and participation was completely voluntary. We extend our sincere gratitude to the representatives of those institutions that took the time to complete the survey. Massachusetts General Hospital (MGH) in Boston claimed the top spot in our first
By Cheryl Proval
annual ranking of the 20 Largest Academic Radiology Practices. Cosponsored by LarsonAllen (Minneapolis, Minnesota) and Radiology Business Journal, the survey ranked the participating practices by the number of FTE radiologists plus the number of FTE PhDs to reflect the academic mission more fully. Because the revenue numbers shared were confidential, they were not factored into the ranking. Due to the varied missions of the participating institutions, revenue did not necessarily correspond to our size ranking.
Group Name
MGH weighed in with 88 radiologists and 89 FTE PhDs, for a department total of 177. With 774 FTE employees in support, the practice interpreted approximately 670,000 procedures for one client hospital last year, as well as performing an additional 110,662 final teleradiology interpretations for five clients. The University of California–San Francisco (UCSF) Department of Radiology and Biomedical Imaging ranked second in size, with 74 FTE radiologists and 70 FTE PhDs. The practice employs 225 FTEs, and it performed 550,000 procedures for four hospitals. The UCSF practice either is not performing teleradiology outside the institution or elected not to share those numbers. Our third–highest-ranking practice was also the practice with the most FTE radiologists: Mayo Clinic, Rochester,
Location
Lead Physician
Lead Nonphysician
FTE Radiologists
Boston, MA San Francisco, CA
James H. Thrall, MD Ronald L. Arenson, MD
Denise Palumbo, RN, MSN Catherine Garzio, MBA
88 74
1. Massachusetts General Hospital 2. University of California–San Francisco Department of Radiology and Biomedical Imaging 3. Mayo Clinic 4. University of Texas MD Anderson Cancer Center 5. Brigham and Women’s Hospital 6. New York University Faculty Practice Radiology 7. Indiana Radiology Partners, Inc 8. Diagnostic Radiology/William Beaumont 9. Yale University 10. University of Maryland Diagnostic Imaging Specialists, PA 11. Northwestern Medical Faculty Foundation 12. University of Virginia Department of Radiology 13. Thomas Jefferson University Hospital 14. Rhode Island Medical Imaging
Rochester, MN Houston, TX
Bernard King, MD Donald A. Podoloff, MD
Russ Rein, MBA Christine B. Capitan, MBA
122 100
Boston, MA New York, NY Indianapolis, IN Royal Oak, MI New Haven, CT Baltimore, MD
Steven Seltzer, MD Michael Recht, MD Valerie P. Jackson, MD Duane Mezwa, MD James A. Brink, MD Reuben Mezrich, MD
Brian Chiango, RT, MBA Felix Okhiria, MPH Randall J. Luckey, MBA Victoria Hollingsworth, MS Sandra Stein, MBA Penny Olivi, MBA
100 90 85.4 80 41 55
Chicago, IL Charlottesville, VA
Eric Russell, MD Alan Matsumoto, MD
Blair Faber James Carnes, MBA
53 45
Philadelphia, PA East Providence, RI
Vijay Rao, MD Richard Noto, MD
Victor Sarro Elizabeth Simas
49.9 52.2
15. Cedars–Sinai Medical Center
Los Angeles, CA
Barry D. Pressman, MD
Lynne Roy, MBA
33.6
16. Boston Children's Hospital
Boston, MA
George A. Taylor, MD
Edmund Reidy
31
17. The University of Mississippi Medical Center; University Physicians Department of Radiology
Jackson, MS
Timothy McCowan, MD
W. Daryle Heath
26.5
18. Albert Einstein Healthcare Network 19. University of Illinois at Chicago Physicians Group 20. Cooper University Radiology
Philadelphia, PA Chicago, IL Camden, NJ
Terence Matalon, MD Masoud Hemmati, MD Ray Baraldi, MD
Tina Sawycky Arnim Dontes, MBA Gerard A. Mullen, MSA
26 21 20
42 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
Minnesota, with 122 FTE radiologists and 21 FTE PhDs. The practice interprets a million procedures for one hospital, plus an additional 7,500 final teleradiology interpretations for one client.
Averages and Outliers The participating practices employ an average of 79.1 FTE radiologists and PhDs, and all but four operate in an employed practice business model. The median number of procedures performed was 477,566 (considerably lower than the median number of procedures performed by the nationâ&#x20AC;&#x2122;s largest private practices, which was 1.1 million for the eight largest practices and 481,947 for the 14 private practices at the bottom of the largest-50 ranking). All but three of the largest academic practices reported providing in-house FTE PhDs
FTE Employees
nighttime coverage, but given their subspecialty expertise, surprisingly few academic practices appeared to be providing teleradiology services outside the hospitals that they cover. All but two of the nine practices that reported at least one teleradiology client provided those services in one state, presumably their own. An exception was the University of Maryland, which reported doing 263,625 final teleradiology interpretations in 25 states. Academic practices lag behind private practices in imaging-center ownership, with an average of two per practice, but this is a number skewed low because half of the practices reported owning no imaging centers. By comparison, the median number of imaging centers owned by private practices ranged from two for those practices with fewer than 35 FTE radiologists to six for practices
with more than 65 FTE radiologists. As we looked at the data and talked with various practice managers, we recognized the opportunity to add questions that could add further clarity to the various missions of these practices. For instance, should we differentiate between clinical income and research income? Should we include the number of residents along with FTE radiologists and PhDs next year to reflect the pedagogical mission better? Please let us know your thoughts while they are fresh. Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, for imagingBiz, Tustin, California. To ensure that your academic practice is considered for the 2011 ranking, email cproval@imagingbiz.com.
Imaging Centers
Hospital Contracts
Procedures
Final Teleradiology Interpretations
Teleradiology States
Teleradiology Clients
Business Model
89 70
774 225
3 0
1 4
670,000 550,000
110,662 -
1 1
5
Employed Employed
21 40
1,000 658
0 0
2 1
1,000,000 520,000
7,500 -
1 1
1
Employed Employed
25 21 18 2 40 9
450 259 34.4 600 250 -
2 5 0 7 0 0
4 4 9 3 1 7
850,000 384,690 974,154 770,449 415,000 865,303
0 3,500 263,625
1
10
1 1 1 25
27 1 2
9 14
61 400
0 1
1 2
471,200 455,000
5,400 27,300
1 1
Employed Employed Employed Employed Employed Independent radiology practice Employed Employed
3 0
230 250
7 9
4 4
337,706 700,000
0 0
10
432
0
1
483,931
-
10
-
0
4
200,000
0
4
11
0
4
287,385
6,200
1
7
4 -
5.6 165
1 0 3
2 2 1
300,000 160,000 220,000
0 0
2
2
1
Faculty practice plan Independent radiology practice Independent radiology practice Independent radiology practice Multispecialty university physician group Employed Employed Employed
www.imagingbiz.com | February/March 2010 | RADIOLOGY BUSINESS JOURNAL 43
THE CIO | Image Management
The CIO
Perspective: Issues in Image Management
Gone are the days when radiology managed image data in a silo: CIOs are engaged in imaging informatics By Rich Smith
I
t is taxing enough for radiology and IT decision makers to contend with the image-management consequences of multidetector CT, high–field-strength MRI, 3D reconstructions, and various recent other trends responsible for a rising tide of diagnostic data. Added to this are the burdens created by other disciplines across the enterprise when they use imaging systems of their own and send the output to a common archive in an environment where the goal is universal access, not just from one corner of the organization to the other, but bidirectionally from multiple points of contact. It’s not surprising, then, that the departments of radiology and IT at a growing number of institutions are working together more cohesively these days. The challenges that they face are held in common, rising from a customer base that is larger and broader than ever.
The Medical University of South Carolina (MUSC) in Charleston has an exceptionally big imaging environment (with at least 89 separate buildings on a 76-acre parcel) and a growing number of disciplines across the enterprise (including cardiology, oncology, pathology, rheumatology, and orthopedics) that want to get in on imaging. To address this expanding customer base, the first concern of Frank C. Clark, PhD, MUSC’s vice president of IT and CIO, is ensuring that the enterprise has adequate archival capacity. “We have a SAN storage solution built up now to almost 500 terabytes,” he says. “Because of the explosion of imaging here, we’re adding to that storage capacity at the rate of about 15% annually.” Even at that, MUSC has found it necessary to tier the archive to facilitate efficient retrieval of images and help hold the line
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on costs. “Basically, the newest or most important images are placed on fiber channel, older or less important ones go to a SATA archive, and the oldest or least important are archived further down the performance chain,” Clark says. The catch is that image users are permitted to define the tier where they want their images to be stored. Since the natural impulse is to want image retrieval to be nearly instantaneous, most users automatically load everything onto the fiber channel. “That, of course, is unrealistic,” Clark acknowledges, “so we try to help users make better choices by providing education about which types of images should be placed where, ideally, among the tiers.” The help that Clark describes is delivered through a governance process that, among other things, encourages each clinical user to articulate his or her image needs. “We use a suite of automated tools
that constantly monitors the different storage tiers to measure frequency of use and also storage growth within specific applications and segments over a protracted period of time. These not only help us identify and track the largest archive consumers, but also help us home in on what it is each user is actually trying to accomplish, so that he or she doesn’t make tierselection choices in a vacuum,” Clark says. “We believe this is key to being able to effectuate significant savings.” Related to image-retrieval speed is bandwidth, and MUSC has been working to improve that as well. “Our radiologist workstations operate on at least a gigabyte of bandwidth; we’re attempting to provide as close to that same amount as possible out at all the desktop-based viewers used by the clinicians across the enterprise,” Clark explains, adding that it helps to have a thinclient PACS viewing application. “This is allowing us to extrapolate PACS very economically across the enterprise,” he says. Still, the shift to thin-client PACS is not without a price. “We have 10,000 or so desktops to maintain and upgrade, rather than a handful of high-end workstations confined just to the radiology reading rooms,” Clark says. “The good news is that most of our viewers are managed using a thin-client model, which allows us to push out software upgrades remotely from a central point. This saves us from having to go out and physically touch each desktop in order to implement the changes. We still must send out IT personnel, however, any time hardware is due for replacement, or if we want to expand the device’s storage, so there still are logistical issues to be dealt with here.” Images acquired from modalities throughout MUSC are ultimately funneled into a centralized clinical data repository, where they then are aggregated with each patient’s laboratory results, chart, and other data into a longitudinal electronic medical record. It is not just key images, but all images that are accessible by means of this record. “From within the repository’s clinical results viewer, one can link back to our PACS to access images fully,” Clark explains.
From within the repository’s clinical results viewer, one can link back to our PACS to access images fully. —Frank C. Clark, PhD, CIO, vice president of IT, The Medical University of South Carolina, Charleston
has image-management concerns of its own. On any given day, no fewer than 2,000 users concurrently access BJC’s data repository to view clinical results, and they do so by means of a homegrown portal called Clinical Desktop (ClinDesk) that features an embedded viewer of nearly diagnostic quality. David A. Weiss, senior vice president and CIO, says. “ClinDesk is an electronic health record (EHR) strategy, image-viewing functionality being one important component of this system. We don’t believe you can have an effective EHR solution without a strong image-storage, -distribution, and -viewing solution component.” The ClinDesk system was conceptualized in 1993 and made partly operational in late 1996, with full activation achieved by 1998. Today, it contains information on approximately 4.5 million patients. “We foresaw the emergence of integrated health delivery networks, which led us to begin thinking about how information could be managed, distributed, and accessed across such a network,” Weiss says. ClinDesk was pieced together in cooperation with selected vendors; none of it featured off-the-shelf technology. Weiss continues, “PACS is really not a part of ClinDesk, but represents another data source, similar to a laboratory system or a nursing-documentation system. Radiology PACS, cardiology PACS, ultrasound, and so forth all have their diagnostic-quality image-interpretation systems integrated within their PACS solutions. These images are automatically fed to a long-term image-archive system, with the patient context tied to the enterprise’s master patient index and the subsequent radiology report.” He adds, “Within ClinDesk, these images are available for viewing through a separate image viewer (in order to deliver images to all physicians in a review mode, Resource Optimization BJC Healthcare, St Louis, Missouri, although the quality of these images is of
nearly diagnostic quality). Via ClinDesk, these images are integrated with the other key clinical results for a patient to deliver a holistic view of the patient’s medical condition and to outline aspects of care planning, including clinical events intended to happen outside the traditional inpatient setting: follow-up outpatient care, home care, and so forth.” In the main, though, ClinDesk is (and will continue to be) a homegrown product. “Hopping aboard a different train while the one you’re on is rolling along the track at speed is very difficult to do,” Clark says. “Not only that, but we haven’t yet seen anything on the market that is compelling enough, in terms of greater features and functionality, to make us want to attempt such a changeover.” As an enterprise, BJC consists of 13 community hospitals (including its anchor institutions, Barnes–Jewish Hospital and St Louis Children’s Hospital) stretching from Western Missouri to Southeastern Illinois. “Our goal is to distribute clinical information and images cost efficiently to the user, wherever he or she is, so that faster and better medical decisions can be made,” Weiss says. One way that the costs linked to the fulfillment of that mission are being held in check is the optimization of existing resources and assets. That optimization includes virtualizing as many servers as practical. “At present, nearly 40% of our servers have been virtualized,” Weiss reports. He cannot yet say, however, whether the virtualization is living up to its fullest potential. “If you ask me if we’re receiving all of the benefits virtualization promises, I can’t answer. True, after two years of virtualizing, we have fewer servers on the floor, and that does translate into reduced maintenance requirements, but it is unclear whether we’re maximizing the compute cycles of the servers that remain.”
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THE CIO | Image Management
Weiss explains his concern this way: “Let’s say my unvirtualized server is operating at 10% of processor capacity and reaching peaks of 30%. Adjacent to it is another unvirtualized server running at about 7% of processor capacity and also peaking at 30%. These would appear to be ideal candidates for virtualization on a single server, so I go ahead and virtualize, only to end up with even less processor throughput and utilization. Is that plausi-
ble? Yes, if I yield to the temptation to replace one of the virtualized servers physically with something even larger,” he says. Weiss continues, “Application vendors sometimes encourage this very thing because they’re concerned that, in a virtualized world, their products will not perform as contractually promised and certified. What they fear is that their product will end up sharing a virtualized server with another product, and the result will
be a bottleneck or constraint on the hardware resources their product needs to perform as contractually promised. For them, the easy way to get around that risk is to push you to overbuy on the hardware side (the capacity side).”
Cloudy Outlook Another trend with the potential to lower medical IT costs is cloud computing. “The idea behind cloud computing is
HIE on the Horizon
I
n an attempt to aggregate health information beyond the proprietary realm of the Medical University of South Carolina (MUSC) in Charleston, Frank C. Clark, PhD, MUSC’s vice president of IT and CIO, currently is spearheading efforts to partner with several other health care organizations in the area to form a health information exchange (HIE). Startup funding was provided in the form of a grant from the Duke Endowment. “We think that the health care organizations best positioned for success in the years ahead will be those that can most readily facilitate the flow of clinical data, within their walls and beyond,” Clark says. The HIE that Clark is helping to construct links nine emergency departments operated by MUSC and three run by other not-for-profit and for-profit hospitals. “When a patient presents at any of these emergency departments, the clinicians there can perform a search across these other hospital organizations to see if residing in their hospital information systems are any relevant clinical data pertaining to the patient, such as laboratory results,” Clark says. “If such data are found, they will be retrieved and presented to the requesting clinicians. This is potentially a tremendous benefit to patient care. At some point in the future, we plan also to make images available through this HIE.”
No Walk in the Park On paper, HIEs seem like a straightforward proposition. In reality, constructing one can be daunting in the extreme. A major hurdle is bringing together multiple enterprises that, in their usual context, might be rivals. Clark suggests that the most effective way to overcome their competitive impulse is to appeal first to self-interest.
“An HIE model sets the stage for better control of costs,” he says. “For example, we’re looking to the HIE to reduce the need to perform tests such as MRI scanning and chest radiography on emergency-department patients, especially those who are frequent visitors. When such a patient presents, it will be helpful to see if recent MRIs and radiographs exist for him or her at any of the other facilities participating in our HIE. If these studies have already been done, it would be economically advantageous to avoid needlessly repeating them.” An even stronger appeal is to competitors’ better instincts. “There is a very definite public good to be advanced by hospitals coming together to share patient information easily,” he says. “Most hospitals see it as their responsibility to promote better care across the community, and they would be likely to be open, at least, to considering an HIE model as the mechanism for that.” Difficult, too, is finding a way around the inertia that quickly becomes evident in partnership-formation efforts on this scale. “It takes an enormous amount of effort to build an HIE, but the organizations involved may already be expending enormous energy on internal initiatives and have little left over to spare,” Clark says.
48 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
Harder to sidestep is the not-insignificant matter of data sharing. “Each participating organization will have its own set of data-management technologies, policies, and procedures, which will need to be harmonized with those of the other organizations,” Clark says. He notes that on the plus side for his own organization’s HIE development, MUSC has a prior commitment to systems interoperability. “Our clinical data repository is, effectively, an open-system toolkit consisting almost exclusively of HL7-compliant technology. Adherence to that standard gives us confidence our systems will be robustly malleable enough to work bidirectionally with our partners in the HIE,” he says. It is still early in the game, and much work remains to be done before MUSC and its local partners can proclaim their HIE a success. Nevertheless, the time is already right to gaze forward and ponder whether this HIE can be financially self-sustaining once its startup grant money is exhausted (around 2012). “I’m optimistic that we have an economically viable concept here,” Clark says. “It promises to contribute to reduced lengths of stay, improved quality of care, and improved patient satisfaction, which should help lower costs and encourage business growth.” —R. Smith
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ADVERTISER INDEX
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Organizations with limited operatingbudget flexibility may find that the cloud-computing model makes little fiscal sense if they turn out to be large consumers of the service. —David A. Weiss, CIO, senior vice president, BJC Healthcare, St Louis, MO
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that you avoid capital expenditures on hardware and software by renting access to servers in a third party’s infrastructure,” Weiss says. “You access that rented infrastructure over the Internet, with a browser. You pay for access either on a per-click basis or by subscription fees.” While cloud computing does promise initial savings and a way to escape the overbuying of capacity/hardware, Weiss suspects that it might prove more costly in the long run, when the rent comes due. “Organizations with limited operating-budget flexibility may find that the cloud-computing model makes little fiscal sense if they turn out to be large consumers of the service,” he says. Weiss also expresses doubts about the viability of cloud computing for healthcare organizations because of security issues. “You’re sending private, patientsensitive medical information into a cloud that you neither own nor control,” he says. “I think there is rightly some nervousness about all of this.” Cloud computing has not yet captured much interest at MUSC. “We’re waiting to see if this is one of those faddish things that burns brightly for six months and then goes out of fashion,” Clark notes. “We’ve certainly given it thought, but haven’t done anything meaningful with it.” Caution appears to be the order of the day, no matter which enterprise imagemanagement strategy is under consideration. That’s why Weiss recommends that radiology and IT join in lockstep to grapple with these issues. “When it comes to supporting the image-management needs of various departments that make up an enterprise, I see IT’s role being to ensure integration of all clinical-care components of a patient’s coordination of care,” he says.
“This should be viewed in a broad perspective and, as such, would include all key elements of medical imaging,” Weiss adds. “Here at BJC, we have been fortunate to have a healthy working relationship between radiology and IT. The result has been that information strategies and products have been designed with the patients’ best interests uppermost in mind.” Clark has cultivated the relationship between IT and radiology by assembling a team of 50 cross-trained IT specialists, available at a moment’s notice to help users of imaging modalities and services resolve problems in the field. Typical calls for help involve matters such as images that fail to move into the work queue, radiologists’ notes that do not become attached to the images, Web access to PACS that is oddly limited, voice-recognition functions that perform poorly, and systems that become sluggish. “An advantage of having this team is that it all but ensures a higher level of interaction with the clinicians who generate or use images,” Clark explains. “This interaction equips us to understand the needs of our customers better. We want to be as attuned as possible to the business of care delivery, to the workflow, and to the processes that our customers live by; this also helps us bring more to the table with our radiology partners. Our attunement to clinicians’ needs gives us the ability to assist radiology’s decision makers in focusing on process redesign and workflow improvement, rather than just looking at technology as something they can layer on top of existing workflow and processes.” Rich Smith is a contributing writer for Radiology Business Journal.
www.radbizjournal.com | February/March 2010 | RADIOLOGY BUSINESS JOURNAL 49
FinalREAD
Relationships Gone Wild All across the country, we are seeing the dissolution of long-time hospital–practice relationships that are part of the community fabric By Curtis Kauffman-Pickelle
A
ll across the country, in markets large and small, a drama once considered unimaginable is unfolding in ways that are shaking the confidence of many radiology practitioners and creating tension within the ranks of hospital administrators. The issue relates to the unilateral breaking apart of longstanding exclusive contracts with radiology groups, contracts set in motion by group founders, many years prior, that were seemingly bulletproof and tantamount to annuities. In Orlando, Florida; Toledo, Ohio; San Antonio, Texas; Roanoke, Virginia; and, most recently, Sacramento, California, radiologyhospital relationships that have been part of the fabric of these communities’ respective institutions for decades have melted down, seemingly overnight. Some of these changes have had no shortage of acrimony and bitterness, and this has damaged the entire local health-care community. Friendships have been poisoned; careers, ruined. What is going on here? The answer is not an easy one, and in fact, these practice–hospital relationships came apart for different reasons, some obvious and some not so obvious. In looking for a common thread among these and other, similar relationships currently under stress or experiencing some dysfunction, however, one finds a pattern that emerges and that relates to the shifting cultural landscape now manifest in the health-care arena. The very essence of relationships has changed dramatically, requiring new skills and empathy if relationships are to succeed. First, some perspective: All businesses, products, and markets evolve, over time, according to some fairly predictable patterns and benchmarks seen throughout the life of the enterprise. These are subject to cycles, and the cycles themselves are subject to certain traits and criteria; the market’s development can be traced by these visible signs and conditions. Among these
milestones is a market that moves from a growth phase to a phase identified as maturity.
EMERGENCE OF COMMODITIZATION A mature market (which is characterized by broad adoption, acceptance, rational pricing, supply/demand balance, and so on) is also marked by the emergence of commoditization as a driving factor in the exchange of goods and services. The only thing that breaks through the commoditization perception is true differentiation: a completely unique value proposition that can set your enterprise apart from the sea of similar products or services. Players in mature markets who are unprepared for the new demands placed on them are doomed to be eclipsed or marginalized by those who have prepared for, and who understand, such a change in their marketplace. Further, the players who embrace (or are catalysts for) such changes are those who will truly thrive. Such is the case with the changing nature of the hospital–radiology relationship, which now exists within a maturing medical-imaging marketplace. Hospitals are customers of the radiology groups, and these customers have been sending messages, for some time now, that their expectations from those under contract have changed significantly. Sometimes, these messages have been subtle (benign neglect), and sometimes they’ve been downright confrontational (contentious contract negotiations that turn toxic). A few have resulted in termination of long-standing contracts and relationships. A key driver, of course, is the ready availability of alternative subspecialty radiology coverage via teleradiology services. Hospital executives have weighed the risks associated with such a strategy of confrontation and have concluded that they have many more options today than they did just five years ago. They seem more than willing to excise what they perceive as a problem provider, especially one that they feel is not meeting the strategic needs of the institution, one they view as more competitor than
50 RADIOLOGY BUSINESS JOURNAL | February/March 2010 | www.imagingbiz.com
partner, or one that they see as draining revenue that the hospital views as rightfully its own. They are definitely no longer willing to be taken for granted. For their part, many hospital executives are dispassionate about the very real benefits to be derived from cultivating a new type of relationship that takes advantage of the history and stability that a long-standing, quality-oriented radiology practice brings to the institution. Contrary to the outward appearance of commoditization of radiology, all groups are not made the same way, and some are manifestly better than others. Typically, though not always, the hospital executive views the radiology relationship as strictly a business deal, with no emotional attachment and no real animosity, either. Quite often, radiology groups view the same relationship through the lens of the personal, letting anger and perceived affronts drive actions and reactions, in some cases. In order to avoid a disastrous situation in which a mutually beneficial, long-standing relationship melts down, both entities need to rekindle a healthy next-generation relationship based on service, loyalty, mutual respect, and a give-and-take approach to the new realities facing both the practice and the hospital. For the hospital executive, that means placing a premium on the quality and institutional knowledge that long-standing relationships can bring. For the radiology group, it means understanding that the new market realities will require a sense of urgency, and that partnership with the hospital will not be dependent upon the status quo. It is time for these key relationships to be redefined rather than destroyed, but it will take a new strategic vision, a lot of give and take, a move beyond the politics and urban legend, and a commitment to work at building a next-generation model of communication and action. It’s good business. Curtis Kauffman-Pickelle is publisher of ImagingBiz and Radiology Business Journal, and is a 25-year veteran of the medical imaging industry. He facilitates strategic planning retreats for radiology groups.
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