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ARRA/MU Stage 3: Imaging Implications

October 14, 2015
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With the recent publicity surrounding the publishing of the ARRA/MU Stage 3 rules, I decided it was time to weigh in with respect to the impact on imaging.  I think there are some interesting prospects for meeting Stage 3 objectives in terms of imaging content and technology. 

Objectives 5 (Patient Electronic Access), 6 (Coordination of Care through Patient Engagement, and 7 (Health Information Exchanges, or HIE) all have potential impact.  One aspect of the Stage 3 rulings involves the introduction of the concept of API’s (Application Programming Interfaces) in conjunction with CEHRT (Certified Electronic Health Record Technology).  All reference patient involvement with respect to the “viewing, download, transmission, and access” to patient information.  As defined in previous stages, patient information can include image content. 

A key aspect of the Stage 3 ruling is the timeframe for accessibility by the patient.  The ruling addresses patient access within 24 hours of availability to the EP (Eligible Physician).  I know from personal experience with my provider, this will be a challenge!  Currently, lab tests are available in this time frame, but radiology results take substantially longer, as they are printed and scanned into the EHR (Electronic Health Record).  It can take weeks before they appear to me in my patient portal! 

Clearly, this would need to change to comply with Stage 3.  And, this is only the report!  At present, there is no ability to access images associated with the report – short of requesting a CD at the time of the exam – something a less-savvy patient is not likely to do.

In terms of the implementation of API’s, I have been contemplating how one might do this for images.  The primary concern is with the question of diagnostic quality.  Clearly, one approach to this would be to provide access to the full DICOM (Digital Imaging and Communications standard) data set, but this would be overkill for simple patient access.  The use of DICOM would be useful in terms of referral (another objective of Stage 3).  It is unlikely that providers will want to support multiple mechanisms for access. 

One option might be to employ the use of API’s as it pertains to streaming technology.  In the case of most imaging applications, the data set is communicated to a device that then has a viewer technology for interpreting the data set and displaying the images.  In the case of DICOM data, this means moving the DICOM data set to a device that has a DICOM-compatible viewer.  In the case of simple viewing technology, this might be in the form of JPEG data and a simple viewer. 

With streaming technology, the data is not transmitted.  All of the “rendering” is done on the server side and the viewing is simply a means of remotely presenting the results, usually via web-based technology.  This would mean that through an API link, a patient might access their records by means of an EHR, and have the EHR through an API launch a streaming capability that enables them to view the images from a web browser without having to move the data.  Likewise, the patient could easily authorize access by other healthcare providers, either on a non-diagnostic or diagnostic level. 

It seems to me this might be a simple way to enable patient and 3rd party access without having to worry about physically moving the data - a win-win for all.

The ruling makes reference to the ability to download data via API’s to 3rd party applications.  I initially experimented with Google’s Google Health, which for reasons unbeknown to me they dropped.  I have also experimented with Microsoft’s HealthVault, and I continue to make use of it for storing my medical records. 

A key issue with HealthVault has been getting data into it.  The advent of API’s in conjunction with an EHR should enable a simpler and broader means for importing data into such an application.  Perhaps Stage 3 is just what the doctor ordered in terms of promoting broader use of 3rd party applications such as Microsoft HealthVault. 

The key to achieving many of the objective thresholds set forth in Stage 3 will be broader patient acceptance of electronic access.  I know in my case, I comment at every encounter about the number of trees my provider is killing, as I always get a printed encounter summary which is usually multiple pages of redundant content (single-sided printing to boot)!  At least on the front end I get email reminders for appointments, so perhaps it is just a matter of time before they will offer me the option of getting an emailed encounter summary.

Again, I represent probably a smaller population of informed consumers.  How can providers build demand for greater electronic access?  One thought I have entails another aspect of the ruling dealing with “authorized patient representatives.”  Perhaps there is a potential market for patient representatives that can act as the go-betweens and educators for the less informed.  Clearly there are legal implications, but what if a clinically-educated entity could be authorized to receive and review patient results and assist the patient with further actions?  Could this be a legitimate means for extending the application of electronic patient accessibility? 

I guess only time will tell.  Instead of the “glass half empty” perspective of why Stage 3 is not ready to implement, perhaps one should take the “glass half full” perspective and view it as an opportunity to innovate.