Wednesday, December 1, 2010

Chicago News

For me, the Radiological Society of North America (RSNA) annual conference begins at the airport in Dallas. I always run into a group of folks from our industry catching Chicago-bound flights to attend the same meeting as me. Some people complain about RSNA, but I love it. It's great to catch up on who is doing what and where they're doing it, as well as reconnecting with old friends and making new ones. 

Our industry is a relatively small one, with only about 700 or so companies exhibiting at RSNA each year. It's always interesting to me who is working for whom, as people tend to move around among different vendors every few years or so. I'm probably somewhat of an exception, having only worked for two firms (Philips Healthcare and Carestream-back when it was still owned by Eastman Kodak) prior to starting OTech. 

Another thing I find fascinating about RSNA is the use of the latest buzz words at the meeting. For example, what exactly does cloud storage mean? What are the requirements? What are the advantages? For medical imaging, what sense does it make to have a cloud storage solution that archives images in a non-DICOM format? Or to offer a solution that does not have any real life-cycle management? 

Another of the favorite buzz words being bandied about is dose reporting. Please explain what sense is there in designing a CT system with a dose report that consists of a screen-saved DICOM image? Unless, of course, you're looking forward to buying sophisticated optical character recognition software and paying someone to validate its output for every image/exam/study in order to put patient dose information into a shareable, electronic format. 

My current favorite is Vendor Neutral Archive. Unfortunately, most of the offerings that use this label are not capable of archiving MPEG's, documents, or the new CDA and CCR longitudinal records. 

I long ago learned to document my requirements, check out a product's specifications, and see if it met my needs. Buzz words are great for catching your attention, but that's about all they're useful for accomplishing. 

And never use buzz words in an RFP. If you ask for a vendor neutral archive, or dose reporting, or cloud storage—you're going to get a Yes. Specify precisely how you want to use these devices, with exact requirements, and extensive technical detail. For example, storing dose reports should be done using DICOM Structured Reports, according to the most current radiation exposure monitoring profile. 

Sifting through the hype, peering through the smoke, and looking behind the mirrors is part of the fun of attending the RSNA meeting. Make sure that when it comes time to add a new system or piece of equipment to your practice, you don't get buzz sawed by buzz words. 

Meaningful Use or Mis-Use for Radiology?

If you scan all the marketing materials, press releases, and announcements of healthcare device and IT companies, the term Meaningful Use (MU) would be one of the most used (followed closely by cloud storage, vendor neutral archive, and dose reduction). For obvious reasons, healthcare providers are rushing to implement Electronic Health Records (EHR) that comply with MU requirements in order way to receive a share of the multibillion dollar subsidy for these products from the American Recovery and Reinvestment Act. If they don't have a system in place, procedure reimbursement will be cut—so there's a strong incentive to implement an EHR.

As would be expected, creative marketing for these products has kicked into high gear, stretching the meaning of MU. Radiology, in particular, is difficult to define in terms of MU, at least in a first pass at the recent Phase 1 Rule on Medicare and Medicare EHR incentive payments. 

What is the impact of MU on radiology? As a start, the word radiology appears only once in the entire Phase 1 Rule description, which doesn't give diagnostic imaging much to go on. The emphasis is on medication interactions, errors, and public health. Even the Phase 1 Rule requirement for Computerized Physician Order Entry (CPOE) does not include radiology tests. 

What is puzzling is that radiology has led the way in the development and implementation of IT in healthcare. Digital imaging, PACS, voice recognition-based reporting have been mainstream technologies for radiology the past decade. As film has been phased out, so have errors due to missing, lost, or misplaced images. Turnaround times for reports have been slashed from a day or longer to less than an hour at many facilities. And teleradiology has permitted the expertise of specialty radiologists to be available in remote areas, and allowed all-day, every-day coverage at any facility. 

This is not to say that there is not still work to be done. The integration among radiology, cardiology and other ologies is still in its infancy. Most radiology images are distributed via somewhat cumbersome API's in EMR’s. The implementation of images of for anyone everywhere at any time is still a challenge. 

IHE has addressed integration by offering a set of standards that makes this available, and its 2010 Connectathon has shown that vendor implementation is feasible. Unfortunately, vendors typically don’t choose to voluntarily implement standards; they tend to be biased toward using proprietary solutions that lock users into their architecture and products. And this is where the Phase 1 Rule for MU could have drawn a line in the sand by mentioning some of these efforts. 

The Medical Imaging and Technology Alliance (MITA), a lobbying organization for diagnostic imaging, attempted to bring this to the attention of the Dr. Blumenthal, the Director of the Office of the National Coordinator for Healthcare Information Technology (ONC) earlier this year--without any noticeable impact on the Phase 1 Rule. 

So, where and how does the MU regulation address radiology? First, it shows up in the requirement to use a CPOE; however, for radiology this is probably not to be expected until the Phase 2 Rule. Second, drug-to-drug and drug-allergy checks are required, which impacts the modalities that use contrast agents. 

DICOM has defined the capability for substance administration at a modality that allows queries for verification of the supplies to be used. There is an impact on the recording of certain demographic information, such as race and ethnicity, which might impact the data that will be sent to remote readers. Problem lists and diagnosis have to be encoded. 

Also, patients will have to be provided with a copy of their health information, which is a somewhat regular practice as many patients currently are requesting a copy of their images on portable media. Eventually, this data will be automatically uploaded to their Personal Health Record (PHR). There are also privacy and security requirements to protect electronic health information, which is already addressed in radiology via the widespread implementation of audit trails in PACS. 

It will be interesting to see what the Phase 2 and 3 MU ruling will say; hopefully radiology will be addressed in greater detail--in particular the requirement for interconnectivity standards, which are needed to make EHR’s that include imaging a success.