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Imaging Out In Front of Meaningful Use!

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I finally took time today to peruse the Meaningful Use Final Rule document (Federal Register / Vol. 75, No. 144 / Wednesday, July 28, 2010 / Rules and Regulations) – note I said “peruse” as I couldn’t possibly read and digest all 276 pages of it!

The Government View

I understand from the document that the Meaningful Use criteria have now been broken down to three “Stages” and the only defined stage at this point is Stage 1. The document states the goal for Stage 2 as (to) “expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests, genetic tests, genomic tests and other such data needed to diagnose and treat disease).

Note that I have bold faced potential imaging services listed as examples. So, in effect, Meaningful Use is now contemplating the inclusion of electronic imaging in Stage 2. This seems to be an improvement over the initial guidelines that had imaging at the tail end of MU.

The Reality

I would subscribe that imaging is way out in front of MU in terms of the ability to apply it today. Take the case of Radiology PACS (Picture Archiving and Communications System). In the United States, Radiology PACS is relatively well-saturated in all but the smallest of facilities. Most current-day PACS offer some form of web services that enable external users such as physicians to remotely access their patient’s exams. Hence, the general practitioner that referred their patient to the hospital for a CT to rule out a tumor can access the images from their office, and potentially even share them with the patient.

Alternatively, the patient may have received a CD with their study on it if the physician had requested the patient bring a copy of the study with them on their next visit. The CD has a built-in viewer, so the physician does not require anything more sophisticated than a PC to view the study.

Recently, several companies have introduced technology to improve accessibility while eliminating the CD. Such systems can import the CD to a server and make it available electronically, as well as import the study directly from the imaging equipment or PACS and eliminate the CD altogether.

Most current PACS also support API’s (Application Programming Interface) that enable an EMR (Electronic Medical Record) to link a URL and launch an image viewer for EMR studies that include imaging. If a physician can access the EMR, they most likely can see selective images for their patient.

I have recently been playing around with Goggle’s Health record. I have successfully imported DICOM images to the cloud using their import tool, thus establishing the prospect that a facility could directly link their imaging records to such patient health record sites, and thereby enable the patient to have a copy of their imaging studies.

Most of the Stage 1 measures to meet the objectives provide for some percentage of patient records electronically communicated. I would make the argument that imaging is more than capable of doing this already. The question is the value in doing so. While it is clear that the priority and greater value is in delivery of diagnostic results, such as the pathology or radiology report, there are many instances where the image is of value in addition to the report. EMR accessibility will bear this out, given the relative ease in interfacing PACS to the EMR. I further wonder about the value of the ability of the EMR to capture the percentage of time the image was accessed from the EMR when the report was viewed. Perhaps this could be a powerful justification for inclusion of imaging in MU if this information were captured and published.

Given the advanced state of electronic image accessibility, shouldn’t it be possible to make the case for inclusion in Stage 1 of MU and improve the likelihood of compliance and funding? Anyone care to comment? Perhaps it’s time for me to draft another open letter to Dr. Blumenthal?!

I would subscribe that imaging is way out in front of MU in terms of the ability to apply it today. Take the case of Radiology PACS (Picture Archiving and Communications System). In the United States, Radiology PACS is relatively well-saturated in all but the smallest of facilities. Most current-day PACS offer some form of web services that enable external users such as physicians to remotely access their patient’s exams. Hence, the general practitioner that referred their patient to the hospital for a CT to rule out a tumor can access the images from their office, and potentially even share them with the patient.
The case for adding imaging to Stage 1

Comments

The real point with the MU staging issue:

I think you are right that imaging and archiving are fairly well advanced in most institutions. But product maturity is not the sole driving criterion for public policy. Yes, the technology is sufficiently mature. However, in my book there are 2 more important drivers that argue imaging is not a good candidate for an MU incentive requirements.

First, the blog implies pretty clearly that the value of imaging is through moving the image from one provider to another that means HIE and the HIE mechanisms (including the technology, the infrastructure and the patient privacy issues) are definitely not mature and not ready for prime time. Without the readiness of an HIE infrastructure and established patient consent policy, mandate of imaging would not result in the movement of images as you envision and thus his proposed mandate would add no value.

Second, my impression of PACs etc. is that there is already very good adoption in the marketplace. So what would inclusion of a mandate accomplish above and beyond what is happening 'naturally?'

Joel:

Yes, I meant Stage 2. Thanks for th catch!

Insightful Anonymous:

Yes, concur HIE mechanisms are not mature. However, I see a lot of activity outside of HIE's for imaging that do work. My conversations suggest that interest is in how to tap these resources in support of HIE's - i.e. don't embed images in HIE, provide a link to image repositories to provide access.

My issue with imaging is its "value" to MU. I think it is well established that besides the report, having access to the image is meaningful to the clinician, and perhaps more widely used than other potential initiatives suggested as part of Stage 1 MU.

Joe, Nice post. Your points regarding the value of imaging and image exchange are valid, on point, have been relatively silent in the discussion follow the Stage One Final Rule.

I am troubled by your statement, " ... shouldn't it be possible to make the case for inclusion in Stage 1 [one] of MU ... " I'm going to assume that it was a typo on your part and that you meant Stage 2 [two].

For those readers who aren't aware, good manufacturing process for software (both development lifecycle on vendors part, and implementation and regression testing by provider organizations) demands time frames that preclude revision of Stage 1 requirements. Here's a nice discussion from the HIMSS Electronic Health Record (EHR) Association: (http://www.himssehra.org/docs/20100312_EHR_AssociationNPRMResponse.pdf)

Here is a relevant excerpt (bottom of page 4, bolding and [brackets] mine):


Not only are the timeframes too short, but the content has changed significantly each time information becomes available at various points in the process. A multi‐stage glide‐path is needed to allow for vendors and providers to plan for and implement requirements.    Previous to ARRA/HITECH, there was a road‐mapping process in place based on the federally‐ recognized organizations, CCHIT and HITSP. There was 18‐months advance notice given on the intent to certify a specific function, using already clearly‐defined and federally‐ recognized specifications for interoperability (from HITSP).


and


The 18‐month lead‐time (as discussed above) would require an NPRM for Stage 2 [two] by November 2010. However, this timeframe might not allow for adequate understanding and experience on Stage 1, which should directly contribute to the requirements for Stage 2.    Allowing for adequate lead‐time for vendors and providers, while enabling feedback from the current stage, should have a positive influence on the desired result to increase EHR adoption. We suggest that CMS use a focused early assessment of Stage 1 experience, along with comments received on the NPRM, to make needed adjustments.    We recommend that the NPRM for Stage 2 be available by the end of 2010 and the final rule by April 2011 at the latest. We also recommend that the NPRM for Stage 3 be available by the end of 2012 and the final rule by April 2013 at the latest.


No rational party would want the entire country running on beta software. Elimination of 18 month lead times, even for simple, new requirements is essential, if only because the combinatorial issues inherent in the Core and Menu set requirements.  This was one of the key, recurring elements of feedback that seemed to influence the Final Rule for Stage One.

Like you, I welcome comments and clarifying perspectives on your important post.