Radiology Business Journal | February/March 2013

February/March 2013

Idea in Search of a Business Model:

Solving the

Image-sharing Dilemma page 16

Featured in this issue

The ACO Around the Corner: Closer Than You Think page 14 Cloud Computing: Applications in Radiology First-person Account: The Virtues of Imaging IT

page 26

page 34

www.imagingBiz.com

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February/March 2013

Idea in Search of a Business Model:

Solving the

Image-sharing Dilemma page 16

Featured in this issue

The ACO Around the Corner: Closer Than You Think page 14 Cloud Computing: Applications in Radiology First-person Account: The Virtues of Imaging IT

page 26

page 34

www.imagingBiz.com

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CONTENTS

February/March 2013 | Volume 6, Number 1

16

Features

16

Idea in Search of a Business Model: Solving the Image-sharing Dilemma

Ample justification exists for the exchange of images among providers, but early adopters are struggling to finance it.

26

Ahead in the Cloud

Distributed-reading solutions, subspecialty radiology, and the difficulty of moving large datasets make cloud computing and radiology perfect bedfellows, with the proper security—and if the price is right.

34

Commodifiable Me: A First-person Account of the Virtues of Imaging Informatics

Take advantage of informatics to prevent shipwreck on radiology’s rocky shores.

By George Wiley

By Greg Thompson

By Sundeep Nayak, MD

26

4 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

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CONTENTS

February/March 2013 | Volume 6, Number 1

Publisher Curtis Kauffman-Pickelle · ckp@imagingbiz.com

Departments

8

AdView

Anatomy of a Pay Cut

10

The Bottom Line

EDitor Cheryl Proval · cproval@imagingbiz.com Art Director Patrick R. Walling · pwalling@imagingbiz.com Technical Editor Kris Kyes Associate Editor Cat Vasko · cvasko@imagingbiz.com

By Cheryl Proval

Online Editor Lena Kauffman · lkauffman@imagingbiz.com

Cardiac Imagers: Pay Attention to Clinical Trials

12

Priors 12 Strategic Planning | Disruption Survival Guide 14 Accountable Care | The ACO Around the Corner

40

Advertiser Index

42

News Editor Thanh Le · tle@imagingbiz.com Contributing Writers Saurabh Jha, MBBS, MRCS, MS; Sundeep Nayak, MD; Mark Stellingworth, MD; Greg Thompson; George Wiley

By Saurabh Jha, MBBS, MRCS, MS, and Mark Stellingworth, MD

Associate Publisher Sharon Fitzgerald · sfitzgerald@imagingbiz.com Production Coordinator Jean Lavich · jlavich@imagingbiz.com Webmaster Robert Elmquist · relmquist@imagingbiz.com

Final Read From the imagingBiz Web Journals

12

34

Corporate Office imagingBiz 210 W. Main St., Suite 101 Tustin, CA 92780 (714) 832-6400 www.imagingbiz.com PResident/CEO · Curtis Kauffman-Pickelle VP, Publishing · Cheryl Proval VP, Administration · Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 210 W. Main St., Suite 101, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. February/March 2013, Vol 6, No 1 © 2013 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, 210 W. Main St., Suite 101, 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.

Please address all subscription questions to Jean Lavich at jlavich@imagingbiz.com.

6 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

AdView

Anatomy of a Pay Cut A search for the perpetrator who purloined the technical component reveals a bigger truth

M

y initial reaction was to flinch and move on, like a punchdrunk fighter, when I heard about the 90% assumed equipmentutilization rate in the omnibus bill intended to avert the fiscal cliff. Instead, I bear witness to the latest in a series of cuts to the technical and professional components of radiology reimbursement. Passed on January 1, 2013, the American Taxpayer Relief Act of 2012 increases the utilizationrate assumption for imaging equipment costing more than $1 million from 75% to 90% of a 50-hour work week (45 hours), resulting in a savings to Medicare of $800 million over the next 10 years.

Phil Russell, MBA, is CEO of South Texas Radiology Group in San Antonio (a practice with exposure to technical-component cuts). I ask him what he did after learning that Congress had raided the radiology kitty (again!) to help pay for the sustainable growth rate (SGR) fix. He says, “Nothing: I learned, long ago, to spend my time on things on which I can have some influence or impact.” He adds that the time to invest effort in this rule passed many months ago, when Medicare first proposed the idea.

He wrote letters and contacted his elected representatives then, but now, it’s in the hands of Congress and the ACR®.

“I haven’t spent one moment on it,” he says. “What does it matter? We’re not going to stop providing the services.” Not for a minute do I believe that Russell didn’t at least assess the impact of the law on revenue, but he is far too discreet to discuss practice finances. By some estimates, however, the hit to the technical component of MRI and CT would range from 10% to 20%.

What he says next drips with irony: “In the eyes of the bureaucrats, if everybody has to go to a hospital to have radiology services, fine. They’ve got to keep the hospitals open anyway, so people might as well go and sit in lines at a hospital. They

don’t care if there’s an independent center on the planet.”

Inside the Beltway Cynthia Moran, assistant executive director of the ACR, provides a blow-by-blow account of the cut’s dramatic prologue.

High hopes for a preholiday resolution during talks between Speaker of the House John Boehner (R–OH) and President Obama ended with Boehner’s exit from the talks.

“Then it became a Vice President Biden–Mitch McConnell (R–KY) act,” she reports. “That started to be put together immediately before Christmas; then—and this had never happened before—Congress reconvened after Christmas.” On December 31, the dealmakers outlined what they were going to park, what they were going to try to address, and which tax rates would be increased, and they came up with the idea of moving the sequestration to March 1.

By 10 pm, just a few dealmakers remained, meeting in a small office.

According to Moran, there had been tacit agreement (between both chambers and both parties) on what was going to pay the $25 billion to $27 billion cost of the oneyear SGR fix: They were going to go back to the Patient Protection and Affordable Care Act (PPACA) to revisit some of its formulae.

“Diagnostic imaging was not a pay-for item,” Moran adds. “We were on a list, but we were way down on the list.” At the top of the list were items such as Medicaid eligibility and evaluation/management payments to hospital outpatient departments.

What came next was a directive from the White House that prohibited opening the PPACA to pay for the SGR; then, the staff of Senate Majority Leader Harry Reid (D–NV) walked in and sent everyone back to the drawing board. That’s when the new list came out: $800 million (over 10 years) from the 90% equipment-utilization– rate assumption; $400 from radiationoncology treatment payments to hospitals; reductions in bundled payments for endstage renal disease; and multiple-procedure payment reductions for all therapies.

8 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

Why It’s Us Again Did RADPAC give too much money to Republican candidates? “We are the poster child for why there is no quid pro quo in contributions to candidates,” Moran says.

Every Republican incumbent in the House and every Democrat in the Senate received radiology’s largesse.

Is the technical component within the college’s purview? Moran asserts that the ACR walks arm in arm with the manufacturing community on the subject of cuts to the technical component, but allows that it is a big, attractive, irresistible target.

“If you are in Congress, and you need hundreds of billions of dollars of savings for the Medicare program, you go where the money is,” she says. “The money always has been in the technical component of diagnostic imaging: 80% to 90% of reimbursement has been for the technical component. That’s why it has been the piñata for all these years.”

A sequestration is looming that could result in $84 billion more in cuts to the domestic budget, and Moran believes that it is time to broaden the college’s agenda beyond reimbursement issues. “We need to develop public policies that make sense, that really advantage the beneficiaries, and that don’t penalize specialty medicine,” she says. To that end, the ACR is going to be pushing a utilization policy that mandates the appropriate ordering of diagnosticimaging studies, Moran says.

I urge you to jump on that bandwagon, radiology. Imaging appropriateness not only is the right policy for our time, but is an activity that you are uniquely suited to administer— one that sits squarely within the Hippocratic Oath. This may be just the avenue, as Moran says, to putting the wheels back on the road and advancing to a state in which medical imaging is valued by every US resident (even legislators)—and is not used by Congress as a piñata to whack for cash.

Cheryl Proval cproval@imagingbiz.com

The Bottom Line

Cardiac Imagers:

Pay Attention to Clinical Trials “Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where—” said Alice.

“Then it doesn’t matter which way you go,” said the Cat. Lewis Carroll (Charles Dodgson), Alice’s Adventures in Wonderland

T

he cardiac-imaging community, indeed any imaging community, should pay close attention to clinical trials. Why? The results of the trial will determine the rationale for imaging. The rationale will determine reimbursement, reimbursement will influence demand, and demand will affect supply. This is the new economics of imaging.

Two trials, one completed and one ongoing, could radically alter the landscape of noninvasive cardiac imaging by making us question (a question more likely to be asked post ACA) why we are imaging in the first place.

Cardiac imagers will be familiar with the battle lines in the imaging of patients with suspected stable coronaryartery disease (CAD): Which is the most effective gatekeeper? SPECT, stress MRI, cardiac CT, or stress echo? Is anatomical imaging superior to functional imaging?

Is the gold standard for obstructive CAD catheterization angiography (CA), fractional flow reserve, or does it really matter?

These questions are so pervasive that it is impossible to escape a cardiac-imaging meeting without witnessing two imagers on the parapet extolling the virtues of their respective modality; the smaller the difference (and they do tend to be quite small), the more the fervor in their advocacy.

It is difficult to denigrate a modality with a sensitivity of 88% and specificity of 82% just because another one has a sensitivity of 90% and a specificity of 84%. One does not throw away the old iPad just because Apple’s annual upgrade produces another with incremental benefits. What is true for iPads is also true for advanced cardiacimaging modalities, and certainly true for interpreters of these modalities.

Why do we image patients with suspected CAD? So that patients most likely to have obstructive CAD are

subjected to CA, an invasive test with measurable morbidity.

Why CA? To select patients for revascularization, a costly procedure that has its own morbidity and mortality.

Why revascularization? Because it makes people live longer than polypharmacy.

Well, that’s what we thought until a trial1 randomized symptomatic patients with proven CAD to percutaneous coronary intervention (PCI) and optimal medical therapy and found little difference in hard endpoints.

Pills did just as well as stents (well, almost).

If stents are no better than pills, then why perform the CA? Why not start the patients on optimal medical therapy? Moving upstream, if there is no need for CA, there is nothing to gatekeep—ie, no need for either SPECT or stress MRI. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug aptly abbreviated Evaluation trial,2 to COURAGE, left hope for stents and gatekeeper tests. A subgroup analysis showed that patients who benefited most from PCI had the most amount of objective ischemia on nuclear imaging. Searching for ischemia could still have value.

The International Study of Comparative Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial3 will determine whether the subgroup analysis ought to bail out the stent industry. Patients with stable angina with ischemia documented on physiological imaging will be randomized to revascularization (PCI or bypass) or polypharmacy. Then, a primal question will be asked: Any difference?

What if the ISCHEMIA trial says no benefit of revascularization over optimal medical therapy? The ramifications will extend beyond the industry for stents, for which it will only be a partial death knell; stents will still be used for unstable angina. The findings would be portentous for gatekeeper tests. Imaging for objective ischemia would become an academic exercise. In the

10 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

by Saurabh Jha, MBBS, MRCS, MS, and Mark Stellingworth, MD

era of constrained resources, paying for knowledge for the sake of knowledge may not be CMS’ highest priority.

Imagers could find themselves having the following dialogue with the referring clinician: Imager: “What will you do if the test shows objective ischemia?”

Clinician: “Optimal medical therapy.”

Imager: “What will you do if the test shows no objective ischemia?”

Clinician: “Optimal medical therapy.”

Do you see the problem here? If it is a straight road to your destination, of what use is a GPS? Imaging is the diagnostic cart that is pulled by the therapeutic horse. If the horse is suspect, it is unlikely anyone will pay deference to the cart. Cardiac imagers passionately debating the relative merits of stress MRI and SPECT must appreciate they might be flogging a weak horse or, even worse, a dead horse.

Saurabh Jha, MBBS, MRCS, MS, is assistant professor of radiology at the University of Pennsylvania School of Medicine. Mark Stellingworth, MD, a cardiologist, is assistant professor of medicine and director of noninvasive cardiac imaging at the Louisiana State University School of Medicine in Lafayette.

References 1. Boden WE, O’Rourke RA, Teo KK, et al.

Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.

2. Shaw LJ, Berman DS, Maron DJ, et al.

Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemia burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy.

Circulation.

2008;117(10):1283-1291.

3. ISCHEMIA. https://www.ischemiatrial. org. Accessed February 3, 2013.

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{priors} st r at e g i c p l a n n i n g

Disruption Survival Guide

I

n a fast-paced market, the ability to defend a business against (and to take advantage of) disruption is crucial for staying ahead of the competition.

Disruptions have traditionally altered the trajectory of many industries: Digital photography has rendered film obsolete, music downloads have diminished CD sales, and tablets have largely replaced netbooks. Health care is no exception. The field is constantly changing, with new developments in both policy and technology. Competitors are consolidating, alternative business models are emerging, and technology is improving. Some would say that the digital revolution in radiology has led to its own disruption, in the form of teleradiology.

Fortunately, disruption is not a single event. It can take years, or even decades, before legacy markets disappear. People still go to movie theaters despite online streaming, cargo ships are still used despite the speed of air transport, and brick-and-mortar stores are here to stay (despite the presence of online retailers).

These legacy markets persist because they offer advantages that disruptive competitors cannot: Theaters are a social experience, cargo ships can carry much more than planes can, and physical stores allow consumers to check products before purchase.

In a recent Harvard Business Review issue, Wessel and Christensen1 outline a systematic method for formulating a strategy to guard against disruption.

First, identify your competitor’s strengths; second, identify your own relative advantages. After that, evaluate the conditions that will help (or hinder your competitor from adopting your current advantages) in the future.

Wessel and Christensen borrow a definition of innovative disruption from Michael Raynor, DBA, business writer

and Deloitte® consultant: Technological and business-model advantages change the dynamics of the market. This is not competition through pricing, but through innovation. In one example provided by Wessel and Christensen, in the early days of computing, manufacturers achieved radical cost savings by using standardized components to assemble desktop computers. In contrast, the computing solution of the time—the larger microcomputer—was built using more expensive and customized hardware. As performance and cost savings increased for desktop computers, microcomputers were eventually phased out of production.

It is important to identify the strengths and weaknesses of a disruptive competitor (in terms of the jobs that it can do for customers) and then do the same for your own organization, the authors advise. For instance, many computing solutions other than desktop computers are available, from laptops to tablets to smartphones. These devices can browse the Internet, stream content, and access

12 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

apps anywhere. Their portability and ease of use have allowed them to supplant desktops for general multimedia use, but for office networking, high-end graphic design, and software development, desktops are often the only solution (because of their power and versatility).

No matter how advanced tablets become, they are unlikely to be as powerful as the desktops of the same year.

An effective strategy predicts the impact of a disruption—and whether or not it represents a definitive shift in the market. Wessel and Christensen present five barriers to disruption that competitors have to overcome: momentum, technology implementation, the ecosystem, new technologies, and the business model.

The momentum barrier concerns whether the behavior of general consumers is likely to change and how comfortable they are with the status quo.

The technology-implementation barrier is the challenge of making the best use of existing technology, which can make new technology cost prohibitive. The ecosystem barrier takes into account existing infrastructure and channels of distribution. The new-technologies barrier determines whether or not the technology needed to change the competitive landscape exists. For the business-model barrier to be overcome, the disruptor would have to take on your cost structure in order to compete.

Disruption Strategy After determining the nature of disruption, you must devise a strategy to deal with it. Gilbert et al2 propose a method of dual transformation for companies for which legacy markets make up a large percentage of revenue.

Their strategy (which they have found most effective) is to preserve the core businesses, emphasize legacy advantages,

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priors

and adapt to new market conditions— but, at the same time, to lay the groundwork for future growth in new market opportunities. This dual approach maintains operational capacity while positioning the company for innovation.

The key to making both transformations work is a process called capabilities exchange, which calls for a division of resources and structure between two efforts: one for retaining legacy markets and one for taking advantage of disruption. Capabilities exchange is laid out in five steps: establish leadership, identify resources that the two organizations can share, create exchange teams, protect boundaries, and scale up and promote the business.

Strong leadership is required to propel the transformation effort. The person with the most authority should take charge and lead both organizations; this typically means the CEO. Cohesion is necessary, and only authority from the top can enforce it.

Next, identify resources that can be shared between the two efforts. Anything

that gives one side a competitive edge should be shared. Assets such as branding, logos, and marketing materials are examples given by Gilbert et al; they include hard data, performance measurements, and survey results as well.

In capabilities exchange, resource allocation is the responsibility of exchange teams, which should be composed of carefully selected and highly qualified individuals. Keeping small teams focused on one resource maintains flexibility, minimizes the distance between points in the chain of command, and allows groups to break up and form again fluidly.

Each organization must operate independently, with its own procedures and structures and with no interference from the other. By protecting these boundaries, organizations ensure that conflicts are reduced. This requires strong leadership, since mediation has to come from the top, allowing both organizations to work unencumbered by the concerns of the other side.

The last step is to scale up and promote the new core (the disruptive side

of the organization). Once repositioned, the legacy business should become selfsufficient, but the disruptive core is the source of future growth. Over time, resources should gradually shift to this side of the company.

Within the ever-changing landscape of health care, practices need to manage their transition properly into a world that might see new technologies on the rise, severe cuts in reimbursement, radical changes in practice culture, and new business models. With meaningful use, accountable-care organizations, patientcare initiatives, and the shift from feefor-service to value-based payment, organizations will have to be more nimble than ever.

—Thanh Le References 1. Wessel M, Christensen Surviving disruption. Harv Bus 2012;90(12):56-64.

2. Gilbert C, Eyring M, Foster Two roads to resilience. Harv Bus 2012;90(12):67-73.

CM. Rev. RN. Rev.

ac co u n ta b le c a r e

The ACO Around the Corner

P

erhaps because they don’t hang a sign out front, they aren’t located in one place, and they are (in a sense) virtual, accountablecare organizations (ACOs) have quietly blanketed nearly half the nation, according to a report1 from the managementconsulting company Oliver Wyman. In an attempt to identify all ACOs currently operating today, the authors found, to their surprise, that more than 40% of the US population lives in primarycare service areas with at least one ACO (following the announcement in January 2013 by the DHHS of 106 new ACOs, the authors recalculated the percentage of the population living in markets with at least one ACO to be 52%).

For the purposes of the census, an ACO was defined as a group of providers participating in a value-based caredelivery and reimbursement model.

Providers participating in bundled

pilots were not included because they are not population oriented; neither were providers simply receiving pay for performance or care-coordination payments (because they were considered insufficiently value based). Only providers with value-based shared-savings or -risk arrangements for the total cost of care for one or more sets of patients were counted.

In the report, the authors estimated that 25 to 31 million US residents (or about 10%) received care through ACOs. Following the recent announcement, that number was revised upward to between 37 and 43 million (or about 13%) and includes four million patients in 260 Medicare ACOs: six Physician Group Practice Transition Demonstration organizations, 32 Pioneer ACOs, 27 initial applicants for the Medicare Shared Savings Program (MSSP) announced in April 2012, 89 second-round MSSP participants announced in July, and 106

14 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

new MSSP participants (half of them physician-led organizations) added in January 2013.

At least 15 million more non-Medicare patients were being treated by the 154 ACOs counted in 2012, and an additional eight to 14 million patients of nonMedicare ACOs were contracting with private payors. The authors estimated that there were approximately 150 nonMedicare ACOs providing care.

The authors remark on the speed with which ACOs have reached this milestone, but their bigger point is this: 13% of the population is just a fraction of those potentially affected by these multiprovider-network ACOs. They discovered that 52% of the population lives in primary-care service areas having at least one ACO (see figure), including the 106 announced in January, and 28% of it lives in areas served by two or more ACOs.

Residents with access to accountable-care organizations: < 25% 25%–50% > 50% Figure. More than half of the US population lives in primary-care service areas with at least one accountable-care organization.1

The past is littered, however, with unfulfilled potential, and it remains to be seen whether ACOs can improve quality and reduce the cost of care in the United States. The authors point out that just 89 of the government-approved ACOs are assuming upside and downside risk for the cost and quality of services provided to patients under their care.

Early standouts in this experiment (as cited by the authors) are the Blue Cross Blue Shield of Massachusetts Alternative Quality contract (which achieved 1.9% savings in its first year) and the ACO developed by Blue Shield of California, Dignity Health, and Hill Physicians (which delivered no premium increase to members of the California Public Employees’ Retirement System in the ACO’s first year).

It is the contention of the authors that the standout ACOs are the game changers, the models to watch, and the ones to emulate. “They will change the rules of the game in the regions where they operate, leading purchasers to expect lower costs, higher quality, and

greater patient satisfaction,” they write.

“As that happens, there will be a race to adopt the best models. Providers that fail to do so—or that commit half-heartedly to real change—will stand no chance.”

What are the factors that will differentiate the game changers from the also-rans? The authors offer these characteristics: • clinical transformation is treated as an organizational priority; • the accountable care is more important than the organization, as the organization puts aside parochial interest and shifts care to settings of less-acute care; • patients are at the center in the shift away from body-part medicine and toward a

focus on overall health needs; and • physicians and other caregivers are engaged and compensated in a new way that supports patient-centered (not physician-centered) care.

The advantage lies with those first to the party, as early adopters will have the opportunity to partner with payors—and, therefore, to shape the model. Payors, the authors strongly suggest, will need to step up to the plate and help with capital and other partnership responsibilities.

—Cheryl Proval Reference 1. Ghandi N, Weil R. The ACO Surprise.

New York, NY: Oliver Wyman; 2012.

e r r at u m

“The 100 Largest Private Radiology Practices,” published in the December 2012 issue of Radiology Business Journal, misidentified the most productive practice in the country. According to the reported figures, it is—in terms of procedures performed per FTE radiologist per year—Desert Radiologists (Las Vegas, Nevada). Its 46 FTE radiologists performed 1,250,000 procedures, for an average of 27,174 studies per FTE radiologist.

www.imagingbiz.com | February/March 2013 | Radiology Business Journal 15

Image SHaring | Business Models

Idea in Search of a Business Model:

Solving the Image-sharing Dilemma Ample justification exists for the exchange of images among providers, but early adopters are struggling to finance it By George Wiley

T

he deftness of data movement between sites creates a deception that it’s easy; it’s not. Leaving aside technical problems with integration, servers, and storage, the more central problem might be this: Who pays the bill to set image exchange in motion?

In the case of image exchange, especially as part of an electronic health record (EHR) network, who pays hasn’t been determined. The day when entering an identifier and a clearance code will let a physician in Utah see prior studies for a New York patient on vacation hasn’t arrived. For now, the best many patients can do is to carry CDs of prior images with them.

The opportunity is tantalizing: The data are there to be transferred. Perhaps trillions of image datasets are stored digitally—somewhere. The rationale is there as well: In the interest of efficiency, to curtail unnecessary imaging, to limit radiation exposure, or (especially) to stop unnecessary patient transfers, hospitals, specialists, insurers, and patients all want image transmission made quick and easy.

The flow of imaging data is held back, though—stopped at the crossing by financial inaction. Who will pay to open the switches?

Nonetheless, HIEs are popping up everywhere, and planners want image exchange to be part of them. All 50 states have some sort of HIE activity underway. There is even an unspoken competition among states to be first with a comprehensive HIE that includes medical images. Maine, for instance, is claiming the first-with-images title.

James F. Leonard, deputy director of MaineCare (the state’s Medicaid program)

Preload: Preview v Demand for image exchange among disparate entities exists, but the will to pay lags behind it.

but a grant from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) currently pays the bill.

v As Maine builds user trust and enables its health-information exchange (HIE) to manage images, the HIE hopes that hospitals will eventually pay the exchange to archive their image datasets.

v An Alabama image exchange hopes to piggyback on a nascent state HIE (one of the rare state exchanges to receive federal seed money).

v The RSNA and several partner hospitals are exploring a patient-centered model,

16 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

v Insurers are engaged, to some extent, but are dragging their feet when it comes to providing financial support.

You build the trust model and the business model. That’s a hard process, but it got us to where we are today.

—Shaun Alfreds, HealthInfoNet

and director of Maine’s health IT program, says, “Maine has, for a long period of time, been a leader of innovation, when it comes to measurement and information about health care. The providers in Maine are always looking for ways to improve, and for them, an HIE is another tool.”

HealthInfoNet Maine organized what has become a robust, statewide HIE in 2005, when it put in place a private, nonprofit entity— HealthInfoNet—to oversee formation of an HIE. By 2008, HealthInfoNet had the HIE up and running. In 2010, Maine received a $6.6 million federal grant to build capacity in the exchange, and Leonard predicts 100% provider participation by 2014.

As a private entity, HealthInfoNet is able to contract with health-care providers to pay for the HIE’s services.

Many of Maine’s large providers have been glad to pay for access to the HIE. Shaun T. Alfreds is COO of HealthInfoNet; he says that 36 of Maine’s 38 hospitals are under contract with HealthInfoNet, although four of those are not yet connected to it. The hospitals pay an average of about $1,000 per bed, per year. Ambulatory clinics can join, too, and their rates are approximately $300 to $600 per provider, Alfreds adds.

HealthInfoNet also collects separate fees for data and IT support.

He says, “We offer services that are a perceived value: transitions of care, notifications, and other tools in client management.” The fees that HealthInfoNet collects offset about 60% of its operating costs, leaving the rest to be made up elsewhere. This is one of

We are right in the middle of the integration work and installing the hardware. We also are putting the local storage on-site and getting everything set up in our data centers.

—Todd Rogow, HealthInfoNet

HealthInfoNet’s challenges; in addition to having a federal grant, it also receives funding through private charitable foundations.

Imaging Pilot Until now, Maine’s HIE has contained radiology reports only, but that is about to change, with the launch of what is believed to be the nation’s first statewide image archive. HealthInfoNet hopes that the image archive will become a service that it can sell to providers to make up some of the 40% of funding missing from its sustainability projections, Alfreds says.

As director of IT at HealthInfoNet, Todd Rogow is responsible for the technical rollout of the image archive.

He reports that about half the state’s hospitals are participating in the pilot program. The image exchange will use a centralized archive, but each hospital also will maintain seven years’ local storage for site-generated images. Hospitals will be able to access images through local PACS and through the HIE image archive. The redundancy is in place so that the local sites will come to trust the HIE imaging network. They will see that it’s as reliable as local access, Rogow adds.

Trust building has been a vital element in getting the HIE itself up and running.

“You build the trust model and the business model,” Alfreds says. “That’s what justifies the collection of data on behalf of the patients. That’s a hard process, but it got us to where we are today.”

The imaging pilot will be done without cost to participants, but once the network has been implemented statewide, HealthInfoNet intends to charge for the service. “After we go live, hospitals will pay per image stored on the archive (a one-time payment),” Alfreds says. “They will get access through the HIE, and that will be seamless, with their PACS integrated on the back end.”

The actual collection and storage of images probably will start in spring 2013. “We are right in the middle of the integration work and installing the hardware,” Rogow explains. “We also are putting the local storage on-site and getting everything set up in our data centers. As we get toward May, we’ll bring in the images and start the validation and final testing.” The image archive will be stored in the cloud through a commercial vendor, with disaster recovery storage at two other US sites.

www.imagingbiz.com | February/March 2013 | Radiology Business Journal 17

Image SHaring | Business Models

Whether it’s one or multiple vendors, all of these networks should be able to talk to each other and use the XDS-I exchange mechanism. All you have to do is authenticate that you have the right exchange.

—David S. Mendelson, MD, FACR

Maine’s strategy in building an HIE has been to rely on private vendors to provide the necessities, from equipment to integration. It has a vendor to manage a common health registry that has established a master person index to ensure that patient records are correctly matched, for example. Other vendors will provide an integration engine for the HIE and EHR, terminology content and mapping, hardware and software services, cloud-based business services, a secure cloud platform, and a electronic prescribing network.

HealthInfoNet sees itself as a neutral third party between vendors and providers, and that’s why it has opted for a buy-versus-build strategy. Maine is not currently attempting to integrate its HIE with those of other states. Alfreds says, “We’re further along than the other states. We have 1.1 million residents in our repository, out of a state population of 1.3 million. We are leading the curve in data collection and in a centralized model. There’s not much to connect to in other states, at this point.”

Mount Sinai Medical Center David S. Mendelson, MD, FACR, is director of radiology information systems and senior associate for clinical informatics at Mount Sinai Medical Center (New York, New York). He also is cochair of Integrating the Healthcare Enterprise (IHE) International, a collection of hundreds of health-care organizations that have designed and are advocating the use of industry-wide integration profiles (including standards and workflow) in several domains.

One of the essential profiles for image sharing is IHE’s Cross-enterprise Document Sharing for Imaging (XDS-I),

which allows image and radiology-report sharing through a common registry (such as an HIE). The beauty of the IHE profiles, Mendelson says, is that they available to any health-care entity or commercial vendor. They are not vendor-specific or proprietary.

“Whether it’s one or multiple vendors, all of these networks should be able to talk to each other and use the XDS-I exchange mechanism,” Mendelson says.

“All you have to do is authenticate that you have the right exchange. The notion is a common platform, using common standards and common authentication— and then, you have to make sure everything is moved securely.” If all vendors make their products compliant with IHE profiles like XDS-I, the door will open for HIEs to transport data among themselves, and the foundation will be in place for what could become a national HIE, Mendelson says.

Patient Control As HIE activity ramps up, who will control all of the shifting data? One way to minimize privacy intrusions would be for patients to control access to their own electronic personal health records (PHRs).

18 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

Along with several other hospitals, Mount Sinai Medical Center is participating in a pilot study, funded by the NIBIB, that will investigate whether patients can act as their own gatekeepers for an image-sharing network. The study is being conducted through the RSNA, using its IHE-compliant Image Share network.

Mendelson says that the study was funded with one underlying motive—to dispense with giving patients their images on CDs. At Mount Sinai Medical Center, Mendelson estimates, 5% of arriving CDs turn out to be unreadable. In addition, CDs can be damaged, or the person who prepares the disc can get the patient’s identification wrong. The facilities receiving the CDs have to store them, creating another headache.

The RSNA study is designed move the image data of 2,000 patients into the cloud, where they will be stored in electronic PHRs offered by two vendors; patients alone will control access. To date, Mount Sinai Medical Center has enrolled 419 of its patients in the study.

The patients must have Internet access and must be savvy enough, for instance, to make a purchase online..

For now, the study is paying for the PHRs, but at some point, paying for the PHR could become the responsibility of the patient. This is one option for funding image sharing, Mendelson says.

He estimates that patients might pay $5 to hold an image set for a couple of years or $25 to hold it permanently.

Mendelson says that it’s too soon to determine how effective it will be to have patients managing their own images as part of an imaging network.

The four other hospitals participating in the project are in the work’s early stages, too. Anecdotally, Mendelson says, patients have said either that Web storage is long overdue or that it’s too complex (depending on their own skills). “People who have cancer and go from office to office to get treatment—people who have a real problem moving images—tend to like this,” he says.

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Image SHaring | Business Models

We have linkages that connect the registries and the depositories within each province or region, but a crossprovince, trans-Canadian image-sharing network has not happened yet.

—Eugene Igras, IRIS Systems

image-sharing network, Mendelson acknowledges that a business plan for sustaining that network has not yet been devised. “In another model, the radiology office pays on a per-transaction basis when it sends images out to the PHR or an HIE,” he says. “The real cost of putting an exam on CD is $10 plus. It might be cheaper if you use the Internet, but my numbers aren’t rigid. I think the real cost to the radiologist’s office is lower than the cost of making and shipping CDs.” Mendelson says that another sustainability option for image sharing is to convince insurance companies to pay all or part of the cost of an image exchange. So far, that does not appear to have happened—but if unnecessary imaging is curtailed, if patients receive better treatment when images are quickly available, and if there is less radiation exposure, payors will be saving money.

“Any way we can get these exams distributed will prevent unnecessary redundancy,” Mendelson says.

Reducing redundancy, however, entails reducing volume, which makes some institutions or providers hesitant to join a network, Mendelson says. “The professional organizations are clearly articulating the message that we must do the right thing,” Mendelson explains.

“Sharing images in the appropriate fashion is the right thing. At Mount Sinai Medical Center, by doing this, we do lose some imaging, but we have to take a leadership role.”

Mendelson adds that health planners are looking at the feasibility of a national HIE, including a national image-sharing network. He’s optimistic that common, open-source standards and a common infrastructure platform, such as that offered through the IHE project, can

bring about a national network. “I hope that in two to four years, there will be a way of hopping on this network,” he says.

Canadian Guide Can Canada’s national health system offer a guide to developing image-sharing networks in the United States—including a national network? Eugene Igras is founder and president of IRIS Systems, a health-care IT and informationmanagement company. In 2002, Igras says, the Canadian government formed Canada Health Infoway, an entity to catalyze health-care information transfer through the adoption of EHRs, along with relevant standards and communications technologies.

IRIS Systems has worked on several Canada Health Infoway projects, including the construction of EHR and diagnostic-imaging repositories, as well as a telehealth project that extended telemedicine to remote areas of Northern Canada. “We have linkages that connect the registries and the depositories within each province or region,” Igras says, “but a cross-province, trans-Canadian imagesharing network has not happened yet.”

EHRs, in the Canadian context, are secure, private lifetime records that encompass a patient’s health history and the care that he or she has received. They are stored in repositories and registries that comply with the national Electronic Health Record Solution Blueprint.1 Diagnostic images, reports, and other information from imaging equipment, RIS, and PACS are integrated with other components of a person’s health record, stored in the repositories, and shared among authorized care providers via uniform, secure access mechanisms provided by the EHR solution.

Although the EHRs currently in use are built to share information within each jurisdiction, information sharing between areas can be achieved through

Four Guiding Principles for Image-network Architects

H

aving had a hand in several Canada Health Infoway programs, Eugene Igras, founder and president of IRIS Systems, offers a few rules to guide image-networking projects. First, know where you’re going before you go there. Develop a solid business case, a sound strategy, and an architecture/ standards framework before the network is deployed, using both top-down and bottomup approaches.

Second, adopt and follow proven methods and systems-engineering principles. There is no silver bullet that will solve the problems at hand as efficiently and effectively.

Third, focus on business interoperability: alignment of goals, strategies, and priorities among stakeholder groups. Strike a good

20 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

balance among competition, collaboration, and ensuring consensus.

Fourth, develop and use workable solutions over and over. If something works well in one jurisdiction, it is likely to be applicable elsewhere. In the Canadian projects, the development and adoption of reusable components saved a great deal of money.

The choice between open-source and proprietary products is always challenging, Igras says. It is important to realize that there are good and not-so-good products in both categories. “Typically, we go through in a disciplined, systematic way to select products or platforms,” he says. “We also see if a product is supported or not (whether the vendor is stable). In Canada, I don’t see many open-source products.”

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Image SHaring | Business Models

[Payors and large employers] are not closed minded; we just haven’t had success in coming up with a pilot structure they feel good about— we’re a few months away from giving the insurance companies what they want in proof of concept.

—Don Lilly, University of Alabama at Birmingham Health System

the implementation of the EHR Locator, a service that makes the discovery of specific EHR solutions possible across a network of EHR systems. Canada’s EHR solutions are evolving, Igras reports.

Some regions are working on expanding their capabilities beyond information sharing to include collaboration, business-intelligence, and knowledgemanagement tools. There also is growing pressure to provide access to the public, so that individuals can actively participate in information exchange with their care providers.

In the public sector, the integration of health information is complex enough.

Igras notes, however, that Canada also has a sector of privately owned clinics and radiology practices that have to be integrated as well. This task has its own set of challenges, including a clear definition of which components of the medical record can actually be shared.

In addition, funding for health IT in the private sector can be challenging. Because the US health-care system is bigger and more fragmented than Canada’s system, sound planning (see sidebar) would be critical to the development of a national

image-sharing network in the United States, Igras says.

Uncertainty in Alabama Alabama (like Maine) is among the first states to have a statewide HIE underway.

It is attempting to add image-exchange capabilities—if funding develops to sustain them. In Alabama, the question of who pays to transport images over a network has come front and center.

In 2009, the University of Alabama at Birmingham (UAB) received a grant from the NIBIB of roughly $2 million to establish an image exchange among several Central Alabama hospitals— with the UAB Medical Center (UABMC) serving as the hub. That grant has now expired, and the Central Alabama Health Image Exchange (CAHIE) is only partially completed.

In seeking the NIBIB grant, UAB administrators had stressed the efficiency of an image exchange, but with particular emphasis on cutting down on the unnecessary transfer of patients. Too many patients were being sent to UABMC from outlying hospitals when images on hand at those hospitals would have prevented transfer—if UABMC radiologists had been able to see them. They weren’t able to see them because no electronic image exchange was in place. The unnecessary transfers were wasting money and time and were especially unnerving to patients.

Don Lilly, vice president for clinical development for the UAB Health System, says, “The transfer of those patients can be overwhelming.” He adds that since the NIBIB funding expired (near the end of 2012), CAHIE has been seeking financial sustainability through other means. “We

22 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

are searching for additional grant funding to expand, or we will have to make do with our own funding, or with funding done jointly with the outlying hospitals,” he says. “We are trying a couple of different paths to get this widespread. We are, from a UAB standpoint, approaching our strategic hospitals, where the patient flow is pretty high.”

Those hospitals are already connected to the CAHIE pilot network, which is in operation, and have paid fees to participate, but whether those will be enough to sustain the image exchange, over the long term, remains to be seen. “If we’re going to expand, then we’ve got to figure out a way to keep it funded,” Lilly says. “We don’t have all those answers yet.”

State Help Lilly reports that one potential avenue of collaboration might be the state’s budding HIE, One Health Record, which has shown interest in using CAHIE. Intervendor integration issues are being analyzed.

Another means of funding might be the contributions/fees paid by insurers and large, self-insured employers, which would save money if there is less redundant imaging. Lilly would like to see more interest from payors and large employers that could fund image exchange. “They’re not closed minded; we just haven’t had success in coming up with a pilot structure they feel good about,” he says. “We’re a few months away from giving the insurance companies what they want in proof of concept.”

Joan C. Hicks, MSHI, RHIA, is CIO for the UAB Health System. Her department is providing the IT expertise needed to get the outside hospitals connected to CAHIE. To date, Hicks says, two outlying hospitals with sizable transfer rates have been connected to CAHIE. Two more are in the pipeline to be connected. For now, CAHIE is handling only images, not radiology reports.

Like Lilly, Hicks is deeply concerned about CAHIE’s financial sustainability.

She says that through the use of the CAHIE image network (in addition to the expertise and advice provided by UAB physicians), UABMC has been able to avoid a few transfers from referring

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Image SHaring | Business Models

Financial support of CAHIE is our most pressing challenge. UAB and the organizations using CAHIE are funding the project.

—Joan C. Hicks, MSHI, RHIA, University of Alabama at Birmingham Health System

organizations. “We all agree it is the right thing for patients,” she says, “but right now, it’s the organizations that are participating that are sustaining CAHIE.” Currently, the costs of maintaining the network are not reimbursable, she says. “Financial support of CAHIE is our most pressing challenge,” Hicks says. “UAB and the organizations using CAHIE are funding the project.” One of the key objectives of CAHIE is to support the determination of whether a transfer is clinically necessary, perhaps saving payors significant amounts of money.

“The current model and the objective are misaligned,” she notes.

One Health Record Gary D. Parker, MBA, JD, is director of health IT for One Health Record, Alabama’s HIE. One Health Record is being run through Alabama’s Medicaid agency and is in the early stages of implementation. “We’re still connecting hospitals for our pilot,” Parker says.

“We’ve got one, and in three months, we’ll have four. UABMC will be one of them.”

Unlike CAHIE, One Health Record has funding: a $10.6 million grant from the Office of the National Coordinator for Health IT, Parker says, adding that Alabama is one of only a few states to have an HIE that is federally certified. Parker wants CAHIE to be included. “CAHIE is just a natural partner for us, and we want those images on our exchange as well,” he says.

The problem is getting them there.

The ball is in CAHIE’s court, Parker says, because its infrastructure vendor has to figure out how to interface with systems from One Health Record’s vendor. “What do they need to do? If they can’t do it, what can we do to help them get there?” he asks.

He reports that the vendors have been talking, but haven’t yet arrived at a solution. He remains optimistic, however.

He says, “We’ve got to get connected and then see what happens. We’ll probably connect in late spring.”

Parker says that radiology reports, as part of the continuity-of-care documents required for federal funding, are already contained in One Health Record.

has committed to this, but it hasn’t given us money. It does have a representative on our commission,” he says. “It is aware of the challenges. I think it will be a viable partner, at some point.”

In the meantime, CAHIE administrators are hoping that the network will survive. The funding question could break either way. As Hicks says, agencies could provide further

I guess it’s kind of like cable television. Do you only want continuity-of-care documents? If you want images, add a few dollars per month for those services, and we provide services for those who wish to access them.

—Gary D. Parker, MBA, JD, One Health Record

Funding for One Health Record (after its grant expires) is yet to be determined. “I guess it’s kind of like cable television,” he explains. “Do you only want continuityof-care documents? If you want images, add a few dollars per month for those services, and we provide services for those who wish to access them. Maybe there will be a regional demand in Birmingham.”

Parker says that he’s optimistic that insurance companies will eventually step forward to shoulder some of the cost of HIEs and image exchange. “Blue Cross

24 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

incentives for information and imaging networks. On the other hand, they could begin to impose penalties for not having such networks in place.

George Wiley is a contributing writer for Radiology Business Journal.

Reference 1. Office of the Auditor General of Canada.

Electronic health records in Canada. http://www.oag-bvg.gc.ca/internet/docs/ parl_oag_201004_07_e.pdf. Published April 2010. Accessed February 8, 2013.

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Cloud Computing | Applications in Radiology

Ahead in the Cloud Distributed-reading solutions, subspecialty radiology, and the difficulty of moving large datasets make cloud computing and radiology perfect bedfellows, with the proper security—and if the price is right By Greg Thompson

T

he data-intensive nature of radiology has long kept the specialty on the cutting edge of IT. That’s why cloud computing is a relatively old concept among imaginginformatics veterans.

While the term might be showing signs of wear, its applications are just getting started. Teleradiology and other forms of telemedicine are generally good uses for the cloud. Others include image sharing within and across enterprises, as well as what James Philbin, PhD, calls visualizing information, which amounts to clinical and diagnostic viewing from the cloud.

Philbin is codirector of the Center for Biomedical and Imaging Informatics at the Johns Hopkins University School of Medicine. He says, “Radiologists can read a cardiology study from another hospital in their system that’s 500 miles away or 30 miles away; physicians become independent of the location where the imaging study is actually performed. That’s where you’re going to have the biggest impact—and work can be scheduled for people at different locations across an institution.”

To reduce the cloud to mere hardware or software is a disservice, in 2013.

William F. Rowell, vice president and CTO, Companion Data Services (CDS), says, “There is so much misinformation out there stating that the cloud is technology, but it is not. Cloud computing is a business decision on how you will consume IT resources. It is multiple delivery mechanisms for IT services.”

Within this broad realm are public, private, community, and hybrid cloud versions that are all essentially methods of service delivery. From a radiology perspective, the cloud can provide a central area where images—and imagemanagement and visualization systems— can be securely located.

Preload: Preview v Let’s get it right: The cloud is neither hardware nor software, but a method of consuming IT resources.

v A cloud offers the potential to reduce costs by sharing them; theoretically, having more users lowers costs.

v Security can be addressed through encryption, authentication, and limiting security-attack surfaces (all geographic sites that have access).

v Less expensive than the private clouds deployed in data-sensitive and cashrich industries, the community cloud provides health-care providers with a more economical option.

26 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

Playing It Safe Why, then, isn’t more health-care information deployed to a cloud? Security concerns are shared by all data-sensitive industries, including energy and finance.

While those industries have addressed this concern by deploying the more expensive option of private clouds, too much security limits accessibility in the health-care sector (and increases cost).

Rather than inhibit accessibility, Rowell believes that cloud security

The community cloud is like a public cloud in that resources are pooled and shared; thus, it costs less than the private cloud.

—William F. Rowell, Companion Data Services

should make possible the use of images in a more community-oriented manner.

He explains the use of a community cloud (versus a private/public cloud) regularly to CDS clients, including CMS, in an effort to lessen the complexities of securing data in a public cloud—and to lower the cost of a private cloud.

Today, CMS uses a private cloud and traditional hosting. Rowell points out that switching CMS to a communitycloud concept would be no small change, considering that CMS, the DHHS, the Centers for Disease Control and Prevention, the National Institutes of Health, and other health-care agencies would have to come together to reduce cost and increase flexibility.

According to Rowell, CDS is one of three enterprise data centers (CDS, HP, and IBM) for CMS. CDS processes 62% to 65% of Medicare claims for the nation. In the same data center, CDS hosts the CMS National Level Repository (containing information about meaningful-use participants and payments) and the 1-800-MEDICARE National Data Warehouse.

“The public cloud is not considered a residence where sensitive data should be placed, due to the increased risk of exposing the data,” Rowell says. “Therefore, the approach is being taken to deploy private clouds,” which are open only to the users who create them, he explains.

In Rowell’s experience, private clouds are an expensive option that not all providers and organizations can undertake.

This is where a community cloud brings value to users. “The community cloud is like the public cloud in that resources are pooled and shared; thus, it costs less than the private cloud,” he explains. “If it costs less, and more members continue to reduce rates, the adoption level is higher. Likewise, the community cloud provides the security of a private cloud for its members—again, encouraging more consumption.”

Private clouds are secured based on the requirements of the consumer and of the cloud service provider. Since there is no sharing of storage, network, and computer resources, the consumer pays a higher price.

“Public clouds are just that,” Rowell adds. “They are open to anyone with a credit card, and the security is always an unknown. The prices, however, are normally commodity based. Community clouds are the best of both worlds, but the most difficult to get started. The issue here is finding a community of interest that has members wanting to join together to determine a risk profile that all can live with—and then, to share in the cost savings.”

The Technical Side Security mechanisms employed to protect sensitive imaging data are

www.imagingbiz.com | February/March 2013 | Radiology Business Journal 27

Business Intelligence Series #7

Strategic Positioning for Optimal Patient Care: Imaging Healthcare Specialists Imaging Healthcare Specialists (“IHS”), a 30-radiologist practice based in San Diego, California, has a simple ethos driving its business decisions. “We view ourselves, first and foremost, as a medical practice,” Thomas Cleary, president and COO of Imaging Healthcare Specialists, explains. “Every day, every employee who works for us—from the person who schedules the patient, to the technologist who provides the exam, and from the radiologist delivering the report to the IT person—is making an impact on patients’ lives.”

“Zotec mines the data in the information systems, which we find very useful in improving our efficiency.” — Thomas Cleary, president and COO of Imaging Healthcare Specialists

Cleary’s philosophy of care involves attention to three key tenets of patient satisfaction. “We make sure we address the three needs of the patient,” he says. “I learned, a long time ago, that when patients are coming to you, it’s not because they woke up that morning and thought they would get an MRI. They have an immediate medical concern, a financial concern as a result of the treatment plan, and a spiritual side that may or may not be affected by the first two.”

The IHS philosophy of patient care makes it a natural fit for accountable-care organizations (ACOs), which have been springing up in San Diego since the passage of the Patient Protection and Affordable Care Act

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(PPACA). “We are working to position ourselves as a specialty provider for these ACOs,” Cleary says. “At the end of the day, that means we need the ability to provide excellent care under a capitated payment arrangement.”

Efficiency Imperative Efficiency has always been important to the group, Cleary says—which is why, nine years ago, it entered into a relationship with Zotec Partners, enabling the company to take over billing for IHS. “We decided our core business was imaging,” he recalls. “Accounts receivable should be someone else’s business.” IHS currently staffs two hospitals—one a tertiary-care facility and the other a community hospital—and operates 10 outpatient imaging centers in San Diego County. “We’re always trying to become more economical, to deploy more efficient technologies, each year, than the year before,” Cleary says.

The group’s relationship with Zotec has evolved accordingly, and today, it is about much more than back-office efficiency. As IT capabilities advanced, IHS began feeding information from its PACS platform into a business-intelligence software module developed and maintained by Zotec. “All of our information is fed to them, and we use it to look at our services in the inpatient and outpatient environments, in the emergency department, by payor, by patient, and by employer,” Cleary says. “Zotec mines the data in the information systems, which we find very useful in improving our efficiency.”

“Using the Zotec system makes us more productive and more efficient.” — Thomas Cleary For instance, Cleary says, IHS uses a night-hawk service for some of its night and weekend hospital staffing, but business intelligence from Zotec has enabled the practice to conduct its staffing more efficiently. “We use our night-hawk service for fewer hours than we did two or three years ago,” he says.

“Using the Zotec system makes us more productive and more efficient.”

In addition to the measurements that are automatically generated by Zotec’s software, Cleary says, at last count, IHS was receiving between 150 and 200 customized reports from the company. “That represents their approach: If you ask for it, you can get it,” he notes. “It’s one of the big reasons we stay with Zotec. We’ve never heard the phrase, ‘To get that would be an enhancement.’”

Positioning for Post-PPACA Business Business intelligence has become particularly vital to survival in the post-PPACA era, Cleary observes.

“With the changes in health care and payment that are happening now (and will happen for the next several years), we have to understand our business to the best of our ability,” he says. “We have to demonstrate that we are having positive outcomes, if we want to continue our business. There are more regulations to meet every year, and they are not going to go away; your business has to have the tools to adapt and grow.”

With Zotec and other informatics solutions in place, Cleary says, IHS feels prepared for participating in an accountable era in health care. “When we think about participating in a capitation model, we have Zotec to

help us look at those arrangements,” he says. “The company does the modeling for us. That gives us the ability to understand exactly what we can expect to be paid—and then, to determine whether we can deliver those services for less than that amount.” As a result of this modeling capability, he adds, “We’re performing profitably with several capitation arrangements in place right now—one for the inpatient practice and others for work done on an outpatient basis.”

“We take care of the whole patient, and Zotec is one of our partners in making that happen.”

— Thomas Cleary

Looking forward, Cleary says, IHS is hoping to grow its market share by 5% to 10% over the next three to five years. “Under the PPACA, there’s a large portion of the population in San Diego that will now have some kind of insurance, and if those people have insurance, there will be some kind of compensation for us,” he says. “Of course, we are physician owned, and one of the ways we think we can gain market share is that we make being a medical practice our first priority.”

That means maintaining the high patient-care standard that the practice has established, in spite of the reimbursement vagaries that it has already endured (as well as those to come). “We take care of the whole patient,” Cleary says, “and Zotec is one of our partners in making that happen.”

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Cloud Computing | Applications in Radiology

Over the next five years, it’s going to become significantly cheaper to use a cloud-based PACS than to buy your own hardware and maintain the PACS yourself. When you add up the total cost of ownership, I think it will be 25% cheaper to use the cloud.

—James Philbin, PhD, Johns Hopkins University School of Medicine

generally the same as those used for HL7 data. Rowell describes these measures as a guiding architecture that positions a security perimeter around the data, providing layers of security (defense in depth) between the potential consumers of the data and the data themselves.

This concept also includes identity management.

“The differences can be within the application that is delivering the service, such as an imaging application,” Rowell adds. “There is a level of security responsibility that is placed on the application developers to ensure that they also protect the data they are presenting to consumers. It is here that you may see differences in security between an image and HL7 data, in a few ways—such as in the requirements for the application and the developer’s maturity in the security milieu.”

From the CDS standpoint, a community cloud is only effective if it meets the needs of its members.

Therefore, it can be “a little difficult to pre-position a community cloud, without knowing the members that would be using it. The CDS approach is, first, to locate a community of interest— providers, payors, or others—sharing a set of common objectives and willing to support the good of the community (versus themselves),” Rowell says. Once this community of interest is established, the IT provider can begin to determine the required security posture.

According to Rowell, once the provider/payor environment is known, baseline security comes down to three components. The first is encryption that would be applied for sensitive

data, at rest and in flight, using an encryption system that at least supports the AES-256 algorithm. The second is an authentication mechanism that, at a minimum, serves as a role-based system that supports the ability to enforce a multifactor authentication process. The third is the existence of policies and procedures that follow National Institute of Standards and Technology (NIST) guidelines, such as those of Special Publication 800-531 (SP800-53).

Rowell notes that NIST SP800-53 includes different controls for various security levels (high, medium, and low).

Another minor security concern, he adds, is the concept of a security-attack surface: the portions of a secure system—in this case, a community cloud—that are exposed to the outside world. “If there are many geographic sites,” Rowell says, “the security-attack surface is expanded.”

The Right Environment In its work with CMS, CDS provides the environment where an imaging application can be deployed. As it has done with CMS, CDS can provide an infrastructure environment where a radiology application could be securely deployed, managed, and used to deliver direct value to the health-care community.

“We don’t sell or offer an imaging system, but instead, we provide the infrastructure and environment where that imaging system can live,” Rowell explains. “We see a community of interest that could be formed by those sharing images in the provider world. It allows radiologists to increase security and reduce the costs of the image information.”

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Philbin agrees with Rowell that the potential to reduce costs significantly using the cloud is there—but it’s buyer beware, in many cases, because third parties are trying to capitalize on users’ interest. “Vendors are trying to make as much money as they can,” he says. “Over the next five years, however, it’s going to become significantly cheaper to use a cloud-based PACS than to buy your own hardware and maintain the PACS yourself. When you add up the total cost of ownership, I think it will be 25% cheaper to use the cloud.”

Due to the economies of scale routinely found in today’s large-scale business models, many facilities can realize these savings. “Today, a hospital with 90 radiologists probably has 120 workstations for radiologists,” Philbin says. “Each one is a separate computer, but when you go to the cloud, you can use virtual machines and probably lower that number from 90 to 10. You can manage things more effectively if they are virtual machines in a cloud than if they are physical machines, out in the field.”

From a physical-security point of view, having fewer workstations means that there is a reduced risk of unauthorized access to patient data. “A lot of equipment walks away, in a health-care environment,” Philbin adds, “and you’ll have a HIPAA event if equipment walks away with patient data on it.”

Philbin favors an open-source framework that provides excellent security and flexibility. It’s a softwaredevelopment environment that is in the cloud and that allows Philbin to work remotely. “Most of the Web is running a cloud (remote services), these days,” he says. “We’ve been building cloud-based vendor-neutral archives (VNAs) at a startup joint venture. VNAs are likely to be the first place that medical clouds have an impact. The second place is image sharing.”

Boosting the Odds Like all new endeavors, realizing anticipated cost savings might take time.

Prior to investing time and money, Rowell recommends that administrators assess their hardware, software, and intellectual capital. “You must ask, ‘Do I have the IT

skill set that can maintain a system and its security?’” he says. “That’s a talent set you would have to acquire, and that adds costs.”

Asking members of the existing IT staff to shoulder the burden might move them into an area outside their core competency, Rowell says, taking time away from their health-care work. The other necessity is the staff’s ability to trust the cloud enough to relinquish control.

Getting several aspects of the community’s imaging operations into the cloud configuration is one way to avoid problems—and make the change work, the first time. “If you have a community come together in a place where it can deploy these applications—and trust that they are secured—it can get a reduction in price, versus the centralized view of things,” Rowell believes. “It’s a lot more cost effective to do it one time and secure it than to have 20 providers doing it themselves. That’s 20 implementations versus one.”

The full purpose of the cloud, in many industries, might well be to let the cloud-service provider take most of the responsibility, as a third-party specialist.

“That’s how you drive the cost down,” Rowell says. “You become specialized, standards based, and efficient.”

At Physicians Medical Group of Santa Cruz County (Santa Cruz, California), which operates the oldest health information exchange (HIE) in the country, main servers are hosted in the cloud by the group’s vendor. Bill Beighe, CIO, reports that the overall investment amounted to about $1.2 million in startup funds the first year, with ongoing running of the HIE adding up to $750,000 per year. That figure includes all vendor fees, cloud fees, and staff time needed to build and run interfaces with electronic medical records.

The HIE serves its users radiology reports and virtually all clinical data exchanged across the community of care—including laboratory reports, narrative reports, and consultation notes.

The HIE makes data-backed transitions of care possible, and more than 700,000 electronic referrals and transitions of care have been performed since the exchange began operating, in 1996.

We connect five different radiology centers through the HIE. The ability to perform a referral, order across facilities, and share radiology reports through the HIE/cloud is the key to moving patients’ care.

—Bill Beighe, Physicians Medical Group of Santa Cruz County

I can’t think of a reason to hesitate in implementing a cloud. We can save patients time and keep them from having to be the mule who takes the CD from location to location.

—George Tudder, MBA, CIIP, University [of Utah] Hospital

“We connect to five different radiology centers through the HIE,” Beighe says.

“The ability to perform a referral, order across facilities, and share radiology reports through the HIE/cloud is the key to moving patients’ care among primarycare physicians, radiologists, orthopedic surgeons, and others who need to see reports. The stakeholders are evaluating community-wide VNA solutions, in addition to currently installed PACS implementations.”

Radiology Image Exchanges George Tudder, MBA, CIIP, is director of Imaging Informatics at University Hospital in Salt Lake City, Utah. He describes the cloud as centralized storage that is decentralized from the enterprise.

A radiology image exchange, for example, would “send images into the cloud and then give access to those who are in need,” Tudder says. “Those in need could be other radiology departments, referring physicians, or even patients (who can have those images sent into the cloud, where they can download them and/ or forward them to someone else). This would take the place of fetching a CD.” Eliminating the patient-as-courier mentality could do away with several time-wasting transactions. “Today, I walk

in with a CD, and perhaps I get to the appointment at 11 am,” Tudder explains.

“I hand over my CD, and now the physician must take 10 minutes to look at those images. Now, it’s 11:10, and I’m still waiting in the exam room.”

In a more efficient workflow, physicians could have all images prior to the patient’s arrival. Then, when the patient arrived at 11 am, the physician could immediately consult the images, even showing them to the patient and pointing out areas of concern. “The viewer is basically attached to the cloud,” Tudder says, “and you can pull those images right into the room.”

Tudder points out that in emergency cases, initial images can be sent to the cloud and then downloaded by the trauma center, where clinical planning can occur while the patient is en route.

“Without the cloud, patients arrive with a CD. Sometimes, you can’t get that CD’s files to open properly,” he notes, “so you repeat the study. The cloud prevents this repetition.”

At this point, the disadvantages of using the cloud are minimal—and perhaps nonexistent, Tudder believes.

“I can’t think of a reason to hesitate in implementing a cloud. We can save patients time and keep them from having to be the mule who takes a CD from

www.imagingbiz.com | February/March 2013 | Radiology Business Journal 31

Cloud Computing | Applications in Radiology

location to location. It will save money, in terms of how many times you send images by courier to hospitals or referring physicians. When extrapolated across the country, these relatively small costs will add up,” he says.

Tudder’s hospital has been using what he describes as primarily a community cloud for image management and transfer for the past two years. The project started with two or three hospitals sharing images electronically, and that number ballooned to include more than 180 hospitals in a five-state area. The members share all of the costs.

For Tudder, security has been a major concern, all along. “We vetted a number of options, including creating our own service, and felt it was much more secure to work with a vendor in the industry,” he says. “Working with a vendor also improved the acceptance, by other practices, of the technology—allowing for a more immediate return on investment.”

Prior Studies The future, Tudder says, is likely to feature the ability to search the cloud across multiple entities to improve patient care. This improved search function could help in situations where patients are unaware of the location (or even existence) of prior studies.

Efficiencies such as these are rarely

overlooked by insurance companies, and Tudder expects more companies to support cloud-based incentives. “The cloud will help reduce duplicate exams,” he says. “A lot of states are supporting HIEs, but we can’t have 50 state HIEs that can’t talk to each other. Cloud technology would help make those geographical exchanges easier, both nationally and internationally.”

Philbin agrees that the cloud has the potential to make CDs a thing of the past—replaced by a patient record aggregated across enterprises. “If you have your exam done in an outpatient imaging center, and then, you go to a hospital in a different company, you carry a CD or film,” he says. “The cloud has the potential to eliminate all those physical media and make all your images and prior studies available at other enterprises, even though they weren’t taken there.”

Philbin estimates that within the next five years, the cloud will eliminate 95% of CDs and virtually all film. At that point, physicians will be efficiently accessing prior studies and making better (and quicker) diagnoses.

Rowell believes that the movement toward community-based clouds will start to take hold, but many people are now implementing private clouds. “They will eventually see the value in community,” he says. “As the cloud technology matures and the security aspect improves, it will lessen that hesitation, and people will start adopting it more.”

He continues, “I think, in 2013, you’ll see the adoption rates go up because people will be more comfortable with the security that can be delivered by service providers and the guarantee that service providers can bring to the table. Private clouds will still be the primary version, but the size of the community-cloud group will start to increase.”

The financial and energy sectors are overcoming security issues in the cloud by deploying private clouds instead of working with public cloud-service providers, Rowell says. “They are getting the benefit of the cloud delivery model— its standardization and elasticity—but they are paying a higher price because it is private and dedicated,” he says. “Another way is a hybrid-cloud approach: Users

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keep their most sensitive information private, but when things are ancillary, they will place them into a public cloud, leverage that cost, and get the flexibility of a public cloud.”

Mobile Momentum The mobile revolution virtually ensures that medical images and software will be available on any mobile device, in the future. “Because medical imaging studies are big, the model has always been to move data to the workstation,” Philbin notes. “By moving rendering engines into data centers in the cloud, you need far fewer computing resources on the client’s side. Instead, you’ll have a tablet where physicians can see medical images as easily as they can see the text record.”

Diagnostic interpretation can’t be done on phones (yet), but iPad 3 Retina™ displays (assuming that they are calibrated correctly) are appropriate.

They offer resolution levels high enough for diagnostic use, and FDA-certified apps are available for those devices.

Ultimately, whether the cloud is called private, public, community, or hybrid, Philbin says, the vendor community has used the word cloud so much that a bit of confusion is inevitable. “Today, for a company to do business, it almost must have the word cloud in its name or in the product,” he says. “The product may have nothing to do with what the cloud is, but the company uses the term. We, as a vendor community, still need to come together more and define what the cloud is—and is not—for consumers. After that, we must clearly illustrate its benefits.”

Greg Thompson is a contributing writer for Radiology Business Journal.

Reference 1.

Computer Security Division, Information Technology Laboratory, National Institute of Standards and Technology, US Department of Commerce. Recommended security controls for federal information systems and organizations. http://csrc.nist.gov/ publications/PubsSPs.html#800-53.

Published August 2009. Updated May 1, 2010. Accessed February 5, 2013.

First Person | Imaging Informatics

Commodifiable Me:

A First-person Account of the Virtues of Imaging Informatics Take advantage of informatics to prevent shipwreck on radiologyâ&#x20AC;&#x2122;s rocky shores By Sundeep Nayak, MD

T

he Argonauts (and Odysseus, after them) had to sail past rocky islands housing the enchanting Sirens. Their wonderful songs made sailors hurl themselves overboard and swim toward them, even as they died upon the jagged rocks. After my fifth birthday, however, I accepted that plugging my ears never makes bad news go away for long.

Can I stop myself from being successfully and wholly commodified?

Commodification has pierced our daily workflow: Requests for imaging studies are automated through computerized provider order entry, yet scrutinized at different levels for appropriateness.

Protocols are standardized for problem sets, but customized for specific patients.

Postprocessing offers an array of presentation displays, yet not all displays are used by all radiologists completing final reports.

With standardized reporting, streamlined workflow, and cloud technology, we risk losing value differentials between our work products.

Equivalent work products necessarily imply equivalent work producersâ&#x20AC;&#x201D;and the lowest bidder wins. The injection of informatics into diagnostic imaging implies our willingness to accept a matrix of threats that might ultimately make us expendable. With ubiquitous connectivity, we see empowered consumers taking ownership of their health care, changing the market into one that is both patient centered and patient driven.

The Plain Truth Many imaging clinics and health-care enterprises have successfully integrated data-

intensive and technology-driven informatics into their workflow in the past decade.

Examples include PACS, the electronic medical record (EMR), the RIS, hospital information systems, and telemedicine (including teleradiology) systems.

The ubiquity of teleradiology has accelerated the commodification of the radiological consultantâ&#x20AC;&#x201D;while improving health-care access and expediting patient care. Initially touted as a time-shifting solution for consultant radiologists, teleradiology metamorphosed into a burgeoning market boasting connectivity between specialist providers and specialist consultant radiologists.

Increased competition (with reduced reimbursement and the rise of radiology benefit managers) sparked price wars that led to the rise of predatory teleradiology companies. As consultant radiologists, we need to take concrete steps to correct the total commodification of our role as consultants. This is not an insuperable goal: We need to innovate and to favor process over results, at least initially.

Innovative changes might or might not affect existing market conditions. Many disruptive innovations in informatics are a combination of evolutionary (made in response to customer needs) and radical (unexpected and extreme).

An evolutionary change, for example, would be diagnostic decision support for image interpretation. This requires active engagement of the interpreting consultant radiologist in the EMR. At our facilities, we have embarked on offering further guidance (for studies requested by nonspecialist providers) by recommending surveillance studies at the evidence-based intervals recommended by central bodies.

34 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

An example of a radical change would be the codification and distribution of appropriateness criteria for studies, especially high-ticket exams. This necessarily mandates interspecialty collaboration. We have successfully implemented diagnostic pathways for stroke and for right upper-quadrant disease (with corresponding correction of the use of multiple studies).

Work also is ongoing to reduce the use of studies that employ ionizing radiation in children. This project uses collaboration with providers to choose alternative (or no) tests, along with collaboration with vendors to apply dosereducing strategies.

Ulysses and the Sirens. Tunis, Tunisia: Bardo Museum; 2nd century.

Here to Serve The RSNA has initiated a comprehensive response to the challenge of patient-centered practice by launching the Radiology Cares campaign.1 Its mission is to facilitate our meaningful engagement in the patient experience.

Disruptive informatics: Use Web-based technology to permit patients online access to schedule, cancel, reschedule, and check in for imaging encounters.

Enable patients to receive (on their authenticated smartphones) impressions of final reports—within 24 hours of the appointment—for any study. Continuous enhancement of online offerings keeps the customer base excited.

Tip: Several patients with chronic illness, or otherwise in need of recurring appointments for similar imaging encounters, will be early adopters. They will be particularly adept at passing acquired skills to their peers.

Trap: High touch always trumps high tech. Machines will fail and need service calls, and will always warrant human redundancy. Elderly patients, those with visual impairment, and those who have low familiarity with touchscreen technology will need staff assistance before fully migrating to automation.

Visible Radiology Unless engaged by an interventional

radiologist or breast imager, many patients never see the consultant radiologist. Our need to see the patient behind the image should align with the patient’s need to see the author behind every final imaging report. It is impractical and disruptive (in the negative sense) to inform every patient of preliminary results immediately.

Anti-informatics: In a study conducted at the McWhorter School of Pharmacy,2 patients indicated an overwhelming preference for a pharmacist with a white coat. Appropriate attire is important in creating an image consistent with the public’s perception of health-care personnel, even though it does not correlate with overall satisfaction with care.

www.imagingbiz.com | February/March 2013 | Radiology Business Journal 35

First Person | Imaging Informatics

As a patient, I want simple answers. As a consultant radiologist, it is beyond indefensible to couch my work in hedges, waffles, and more disclaimers than definitive conclusions.

—Sundeep Nayak, MD

Integrate the product and the product offering by amplifying every interaction to a professional, personalized level.

Front-desk staff and technologists should receive ongoing training in discussing radiation safety and procedural details with patients. They represent us, as our agents.

Tip: An uncluttered check-in desk initiates a positive imaging experience.

We strive for our check-in area to be not too sterile, but equal parts welcoming and brand promoting. Consultant radiologists’ smiles beam from large, framed photographs, alongside clear posters informing those waiting in line of the other services that we offer. These posters are regularly rotated. We need to tell everyone what we do; there is an opportunity to do so wherever there is a bored captive audience.

Trap: Overpersonalization of the check-in desk might be off-putting. Staff members should have no food, beverages, or personal belongings visible at the desk.

Farmers’ Market Cost will be the driving force as consumers shuttle between providers to get what they want—at a value adjudged by them as feasible.

Disruptive informatics: Price containment for individual imaging encounters is beyond my pay grade, but improving the quality of my work to align closely with the requirements of both providers and administrators is not. Subspecialty distributed reading is de rigueur. The difference between what we do and our actual capabilities (balanced against more training, superior education, and creative scheduling) will

magnify our commitment to excellence.

Tip: Customized reporting requires effort and ongoing education if it is to engender a high level of customer satisfaction. We conduct regular qualitymanagement conferences to address patients’ and providers’ grievances anonymously: Specific examples can teach us so much, and we suddenly understand something that we’ve understood all along, but in a new way.

Learning is a lifelong process—and it’s what we think we already know that stops us from learning more.

Trap: Hospital administrators assess concrete factors, such as waiting times for specific encounter streams (for example, diagnostic mammography) and report-turnaround times. Consultant radiologists focus on final reports that advance the patient’s position on a clinical spectrum, on early diagnosis of treatable disease states, and on preclinical detection of iatrogenic problems. It is rather challenging to align processes and results.

Repeat Customers Results of the CMS standardized Hospital Consumer Assessment of Healthcare Providers and Systems survey have been publicly reported since 2008 to reflect patients’ perspectives on hospital care. It takes the average respondent about seven minutes to respond to the 27 items in this survey. Medicare is expected to reduce payments to hospitals by nearly $2 billion in the next fiscal year. These withholdings will be redistributed to hospitals with high scores in assessments where satisfaction surveys make up 30% of the total score.

36 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

Disruptive informatics: Follow a fixed percentage of imaging encounters with meaningful single-page surveys with binary response choices. The more complex the survey is, the less it will be worth. Use the results of the survey to generate key performance indicators.

Tip: We employ the Kaiser Member Patient Satisfaction Survey, which returns extremely granular results on an average of 100 surveys per year, per physician.

Two lessons learned from this are the need to treat a patient not only the way that you would want to be treated, but also the way that he or she wants to be treated. Prior to every fluoroscopy-guided procedure, I briefly discuss the small risk of radiation and obtain verbal consent to proceed, thus engaging and involving my patients in obtaining a better-quality product.

At the start of our workday, we huddle with relevant stakeholders to review the schedule, prepare for special-needs cases, and plan bridge coverage or access during scheduled meetings or off-campus travel. Our concierge service quickly directs providers to the most appropriate consultant radiologist.

Trap: Scoring for imaging encounters typically reflects interactions at the front desk and with technologists. We have an interest in keeping our staff members educated, content, and empowered to obtain access to any consultant radiologist. Being accessible via multiple technologies, as needed, is a mixed blessing.

Product-development Cycles The final report is our product, and we are only as good as it appears to be. The report’s utility is compounded by the need to satisfy three users: the provider who requests the study, the services broker (third-party insurance carrier and/or health-care enterprise), and the patient. In addition to satisfying regulatory, billing, legislative, and coding requirements, the product has to be all things to all people.

Disruptive informatics: As a patient, I want simple answers. As a consultant radiologist, it is beyond indefensible to couch my work in hedges, waffles, and more disclaimers than definitive

First Person | Imaging Informatics

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conclusions. While evidence is lacking to support the superiority of structured, itemized reporting over the historical practice of free-form narrative, the former has the advantage of letting the reader instantly find what he or she is looking for (without a struggle). Impressions, in the final report, should be a précis (not a recital of observations) in language that is lucid and readily grasped by the patient.

Tip: Using robust voice-recognition software and reporting templates, we deliver a high-end product with a level of uniformity that aids in the detection of specific problem areas. Impressions (only) are automatically made available to patients using secure access.

Trap: Report generation is not static; today, my reports look nothing like they did three years ago. Reporting templates need curating (at least quarterly) to incorporate ongoing changes in our understanding of disease processes, as well as to address specific itemization changes requested by providers. The quality-management service keeps abreast of the inclusion of Physician Quality Reporting System measures, which are tracked on a monthly basis as part of a larger performance-improvement process.

The Trust Relationship Local data storage (film jackets, CDs, and magnetic optical disks); dedicated workstations; and paper charts have incrementally progressed to cloud technology, with the notion of putting stakeholders first. This enables the consumer to access imaging data from any point. This ethereal location can be securely accessed by multiple stakeholders, including the buyer of services; this has the inadvertent effect of dislodging the provider–consultant trust relationship from the acquisitionto-interpretation segment of the product cycle.

Disruptive informatics: Cloud access allows the integration of value-added services (such as off-site reading, vendorneutral archiving and transfer, and interspecialty consultation within the enterprise) into the core offering. For specialists working from multiple locations, with variable scheduling and availability, this serves as an elegant way to eliminate delays in information transfer.

Tip: Within a closed network such as ours, we can use the cloud to our advantage through interspecialty consultation within the enterprise. When a particularly vexing imaging finding drops me between Scylla and Charybdis, I can always count on my talented coworkers to fish me out of the water.

Trap: With an open network, the importance of trust relationships among end users, consumers, and producers cannot be overemphasized. For example, given a choice between airlines with hard products that are equal in every way (including price), consumers are likely to let the soft products (courtesy, accessibility, on-time service, and followup) drive the decision.

Radiation Overexposure Media attention to skyrocketing volumes for studies using ionizing radiation has percolated into the collective consciousness of our patients, who demand to know more.

38 Radiology Business Journal | February/March 2013 | www.imagingbiz.com Esaote RBJ HalfVert_m.indd 1

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First Person | Imaging Informatics

Fear of radiation poisoning is amplified because radiation is insidious (being colorless, odorless, and tasteless).

Disruptive informatics: In California, it is mandatory to document radiation dose in every final report generated for a study using ionizing radiation. Notwithstanding the controversy pertaining to the choice of dose-monitoring indices, it is time for the unification of exposure indices across different vendors and conditions of calibration, with automatic uplinks to update a record of the cumulative doses incurred.

Tip: Whenever CT technology is used, structured reporting (using templates) force fills fields with documentation of the dose–length product and volumetric CT dose index by default. These data are also screen captured as part of the permanent medical record, in accordance with regulation.

Trap: More systematic work needs to be done by governing agencies.

Much controversy exists as to the meaningful use of dose–length product and volumetric CT dose index, which use phantom estimates and are not truly representative. External calculators must be used to determine actual effective dose per patient. Vendors are actively pursuing automated solutions that not only generate these data, but permit algorithms to autopopulate final reports.

There is a need for a widely accepted, easy-to-use national dose registry similar to the Multidisciplinary European Low Dose Initiative (MELODI), implemented in the European Union in 2010. The

ACR® Dose Index Registry, which lets organizations compare their anonymized dose information (by study type and/or body area) with that of other facilities, is not intended as a patient-specific repository of dose data.

California has mandated dose reporting, but this information is not necessarily available in other states. There is no uniformity, and more legislation is needed. The European Union is not yet ready for universal dose reporting, but MELODI member states are leading the effort. We can’t extrapolate their standards to our patient population, however, because we have been using higher doses for our larger patients, and we also use CT more than many Europeans (who often prefer sonography or MRI) typically do.

Instead of despairing over informatics having disrupted the lives that we lead, we should repurpose informatics to achieve our own targets. This is a domain-specific challenge, and we should equip ourselves with tools that help us master it. When Orpheus heard the songs of the Sirens, he simply used his lyre to make music that was louder and more beautiful; his music drowned out the bewitching songs, and the Argonauts sailed past the craggy isles unharmed. Let the music play.

Sundeep Nayak, MD, is a consultant radiologist practicing nuclear medicine and neuroradiology in Hayward, California, with the Permanente Medical Group, Inc. He oversees radiation safety and imaging quality management in the Greater Southern Alameda area for the Kaiser Foundation Hospital, Inc, in Northern California. The views stated here are those of the author and not necessarily those of the Permanente Medical Group, its parent, its affiliates, or its subsidiaries.

References 1. RSNA. Radiology Cares: the art of patient-centered practice. http://rsna. org/Radiology_Cares.aspx.

Published November 25, 2012. Accessed February 4, 2013.

2. Cretton-Scott E, Johnson L, King S. Pharmacist attire and its impact on patient preference. Pharmacy Practice.

2011;9(2):66-71.

40 Radiology Business Journal | February/March 2013 | www.imagingbiz.com

advertiser index Affiliated Professional Services (800) 841-5200 www.affilprof.net......................................................... 25 eRad (864) 234-7430 www.erad.com............................................................ 11 Esaote (800) 428-4374 www.esaoteusa.com................................................... 38 Fujifilm Medical Systems (800) 431-1850 www.fujimed.com.......................................................... 5 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com.................................................... 2 Integrated Medical Partners (877) 816-1467 www.integratedmp.com.............................................. 19 Intelerad (514) 931-6222 www.intelerad.com...................................................... 44 Intersocietal Accreditation Commission (800) 838-2110 www.intersocietal.org.................................................. 39 LifeIMAGE (617) 244-8511 www.lifeimage.com..................................................... 21 McKesson Enterprise Medical Imaging (800) 661-5885 www.mckesson.com/medicalimaging........................ 13 Merge (877) 446-3743 www.merge.com......................................................... 37 MMP (800) 895-0002 www.cbizmmp.com....................................................... 7 Optimal Radiology Partners (877) 833-2242 www.optimalradiology.com........................................... 3 RamSoft (888) 343-9146 option 2 www.ramsoft.com....................................................... 43 RBMA (888) 224-7262 www.rbma.org............................................................. 41 Sectra (203) 925-0899 www.sectra.com.......................................................... 33 Vital Images (952) 487-9500 www.vitalimages.com................................................. 23 VMG Health (214) 369-4888 www.vmghealth.com..................................................... 9 Zotec Partners (317) 705-5050 www.zotec.com...................................................... 28–29

For Leaders in Medical Imaging Services

The Bigger Picture Behind the Imaging MPPR

By Cat Vasko

T

he fiscal-cliff negotiations have come and gone without the hopedfor repeal of the 2013 Multiple Procedure Payment Reduction (MPPR) for imaging. An enhancement of the MPPR contained in the 2012 Medicare Physician Fee Schedule (MPFS), the 2013 version extends the payment reduction to many second imaging procedures performed— by the same individual or group practice— at the same site, during the same encounter as the first procedure. CMS initially proposed a 50% reduction on the second procedure, but settled on a 25% reduction, in its final MPFS release.

The services to which the reduction applies are listed in an addendum to the MPFS.¹ Harry Purcell, operations manager for Medical Management Professionals (MMP), summarizes, “The addendum is pretty comprehensive and primarily lists advanced imaging procedures, as well as some ultrasound procedures. Any of the professional services listed within the addendum that occur on the same day, for the same patient, are reduced in reimbursement by 25%.”

Continued at www.imagingbiz.com/ imagingbiz_ejournal

Discovering Hidden Data With PACS-embedded Tools

By Cheryl Proval

H

aving a tool kit of advanced visualization tools embedded in the PACS of the Keck Hospital of the University of Southern California (USC) has touched every aspect of the practice of Vinay Duddalwar, MD, FRCR. As abdominalimaging section chief and director of the USC Norris Comprehensive Cancer Center (NCCC) imaging department, Duddalwar reports that there no longer is a problem getting reformatted studies into the PACS. This enables surgeons to view 3D reconstructions on 70-inch screens in the operating room as they work.

Continued at www.imagingbiz.com/ radinformatics

Accountable Radiology: Eliminating Sleepless Nights

Opinion: Measuring for the Future

Cumulative Dose Estimates: More Information Needed

By Cat Vasko

By Bill Pickart

By Cat Vasko

here are performance attributes that we measure well in today’s radiology practice. We are adept at tracking and analyzing clinical productivity, various revenue indicators, and compliance with programs such as meaningful use and the Physician Quality Reporting System. We have the ability to correlate profitability with payor mix, and we can target referral sources based on the volume they generate.

s health-care organizations in California and across the country work to develop the infrastructure necessary to track patients’ cumulative radiation dose, the question remains: How accurate are our methods of predicting cancer risk from medical radiation? Daniel Durand, MD, a radiologist and adjunct faculty member at the Johns Hopkins University School of Medicine, says, “The real question is this: How do we make that information useful?”

F

or 2012, James Reinertsen, MD, CEO of the Reinertsen Group, was invited by the ACR® to deliver the Moreton Lecture at the college’s Annual Meeting and Chapter Leadership Conference in Washington, DC. Reinertsen, a former hospital executive who now educates hospitals and health systems on issues of quality and safety, presented “Possible or Passable? Setting Aims for Accountable Health Care” on April 23.

Continued at www.imagingbiz.com/ medical_imaging_review

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Continued at www.imagingbiz.com/ radanalytic

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Continued at www.imagingbiz.com/ health_it

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