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At Indiana University Health, a Push into an Enterprise Imaging Strategy

August 22, 2017
by Mark Hagland
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At Indiana University Health, leaders are pushing ahead on a broad implementation of an enterprise-wide imaging archive

As the leaders of patient care organizations move forward to evolve forward their IT infrastructures, they face a range of choices, challenges, and opportunities. When it comes to the imaging informatics sphere, most patient care organizations are moving to some version of a vendor-neutral archive-based strategy, in order to reorganize imaging informatics for more optimal data and image sharing and storage. VNAs are, over time, replacing outdated structures that have been radiology-centric and based on PACS (picture archiving and communications system) architecture, and putting instead in their place enterprise-wide architectures that encompass all the “-ologies,” as insiders refer to them: cardiology, dermatology, gastroenterology, and so on.

Moving forward on the journey into more advanced imaging informatics is certainly the reality at the 17-hospital, Indianapolis-based Indiana University Health (IU Health), where Kenneth Buckwalter, M.D. and David Hennon are helping to lead a transition towards a more advanced imaging informatics architecture. Dr. Buckwalter, a radiologist who has been practicing nearly 30 years, works at IU Health Physicians, the largest of IU Health’s four physician groups. Together, there are 2,500 physicians in the four groups, with 1,700 of them working within IU Health Physicians. Buckwalter works part-time within system informatics at the health system, on the same team as Hennon, who is IS director for clinical technologies. That division encompasses “pretty much everything except for the EHR,” Hennon notes, referring to the organization’s electronic health record.

Buckwalter and Hennon are leading the broad imaging informatics upgrade, moving through a variety of steps on what everyone acknowledges is a journey over time. Recently, in an internal document summarizing the organization’s overall strategy in this area, Buckwalter and Hennon wrote, “We are uniquely poised to take advantage of our existing VNA infrastructure and catapult our organization forward into the developing realm of Enterprise Imaging [EI]. Sharing images acquired in the current department silos opens up the potential to reduce costs, improve patient care, enhance our educational mission, and create opportunities for unique clinical research.”

What’s more, they wrote in the strategic planning document shared with colleagues this spring, “Building upon the lessons learned from our point-of-care ultrasound pilot will enable us to develop an appropriate governance model which is essential to set institutional priorities and serve as a clearing house for EI projects. If we can catalyze the momentum, we can build upon the enthusiasm of our early physician champions of EI and begin to coordinate activities.”

Recently, Buckwalter and Hennon spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the strategic journey around imaging informatics at IU Health. Below are excerpts from that interview.


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Tell me about the clinical technologies division at IU Health?

David Hennon: Our division manages pretty much everything except for the EHR, including most of the clinical applications except for the EHR.

Kenneth Buckwalter, M.D.: And so that includes PACS, and the enterprise archive. And, in that context, I’ve worked with Dave for nearly 20 years.

Tell me a bit more about the initiative that you’re all involved in, to create an enterprise archive?

Hennon: We had been seeking funding for the infrastructure for an enterprise archive for several years, but had received the funding last year to stand up the software infrastructure to stand up an enterprise archive. And Dr. Buckwalter started our first endeavor to implement point-of-care ultrasound at one of our facilities.

Are you live with the full enterprise archive now?

Hennon: It’s live, but our spread of the technology among the various service lines is just really starting, and we’ve learned a lot of things in our first foray in integrating the systems. Ultimately, we’re making these images accessible and discoverable from within our EHR. We’re also making sure to optimize order-based, encounter-based workflows, so that everything is correctly documented.

What needs did you come into this initiative with, from a strategic standpoint?

Ken Buckwalter, M.D.: That’s a really interesting question. I would say that radiologists are both peripheral and central to enterprise imaging. It’s a bit of a paradox. This is peripheral, in that it represents a part of the infrastructure that we don’t generally roll up our sleeves and mess around with; but it’s also very much central, because, as with cardiology, we have the most experience dealing with issues like security, compliance, data integrity, and process, which are pretty much foreign for the ordering physicians, in terms of the non-radiologists. Folks who do point-of-care ultrasound, for example, are not radiologists.

The other thing that enterprise imaging does for radiology is to provide us access to images outside of radiology, which remains incredibly frustrating to us today, in terms of the silo-ing of images. We have no access to images or reports outside of what we do ourselves. So from a patient care standpoint, this is really important; this is hugely helpful. And from a quality standpoint, for the first time in this institution, there will be some transparency around how other specialties are acquiring and interpreting images. And I’m not saying they’re doing a bad job; I’m saying that for the first time, we’re able to see what they’re doing. So that if we have a CT scan of a bowel, we can correlate our findings with other data and information available. This is like the EHR for medical images. And we’re pretty convinced that this is what has to happen, and that the consolidation and implementation of all the images into this archive will be extremely helpful. What’s more, we’re going to run out of space with our PACS, so this will be extremely helpful. Eventually, all the diagnostic images will be in the enterprise archive.

What’s the timeline of the evolution of this initiative?

Hennon: Part of our challenge is really getting some attention and focus on this on a system level. This reminds me of the development of PACS in the early days—of all the arguments we made for implementing PACS. And at that time, it was all about replacing film. Of course, then as now, it’s about improving medicine, to potentially improve patient care. The problem is that it’s really difficult to put a financial ROI on this, so we’re looking to put additional resources on this.

We finished our pilot in December for point-of-care ultrasound and are getting some information on that. Next, we’re working on retinal screening for diabetics. And we’re working with the vendor that provides that diagnostic technology. That area impacts our star ratings and scores for the quality rating for the hospital—what percentage of diabetic patients do we screen annually? So there is a potential return there.

So you’re about to put the retinal screening images in. When will that happen?

Hennon: We’re working to put them into a test database. So by the end of August or beginning of September, we’ll have the images screen in one location and read by ophthalmologists in another location. We’ve been working on that project for about three months. After that, we’re looking at a video pilot—video laryngoscopy. We’re trying to get our feet wet in a variety of modalities. We’ve already worked on x-rays, putting them into the archive. That wasn’t a big deal, really.

Five years from now, what would you like to say you’ve done? What’s your Nirvana, in terms of the ultimate imaging informatics architecture that you’re working on?

Hennon: The Nirvana is that every image taken in the clinical environment is in the enterprise archive and viewable from the EHR in some logical process. So it will be the EHR of clinical images.

Dr. Buckwalter, I know that you and your fellow practicing radiologists are under intensifying pressure to move faster and better, and to provide ever-better service to referring physicians. Will this ramping up of architecture and capabilities help in all of that?

Buckwalter: Yes, it will, by eliminating process waste. A patient comes in for a biopsy of a nodule. The patient arrives expecting a biopsy; and there may be wasted time, calling the physician and making sure of what the past communications were with the ordering physician. And actually, radiologists won’t necessarily be the prime beneficiaries of all this—it will be all the physicians providing care for the patients. Plus, for a hospital system that has a medical school attached to it, for a learner, this is a fantastic tool for learning. So all of these things are extremely positive and helpful.

What would you like to say to your colleagues who are healthcare IT leaders in patient care organizations across the country, about what you’ve learned so far, and where all of this is headed, at your organization, and across the healthcare system?

Hennon: People think that it’s all about the technology, and in fact, it’s not; it’s about the people and the governance process. PACS is a well-established, mature technology. It’s really about the process around the communications and the image availability. People don’t realize what’s involved—you have to establish workflow for a particular type of imaging across the enterprise. What about order-based and encounter-based workflow, to make sure that processes are occurring as needed, and that you’re doing the right things in terms of documenting for reimbursement? The technology is actually the simple piece. It’s all these other things that are the difficult piece, as you roll out things like this across an organization.

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Study: EMR Interventions Help in Providing High-Value Medical Care

October 19, 2018
by Rajiv Leventhal
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By implementing electronic medical record (EMR)-based interventions, Boston Medical Center was able to reduce unnecessary diagnostic testing while increasing the use of postoperative order sets.

These actions signal two markers of providing high-value medical care, according to hospital officials. Indeed, the data from Boston Medical Center’s efforts demonstrates the impact of deploying multiple interventions simultaneously within the EMR as a way to deliver high-value care, they attest. This study was published in the Joint Commission Journal on Quality and Patient Safety.

The focus on providing high-value medical care was renewed in 2012 with the release of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation that identifies common tests and procedures that may not have clear benefit for patients and should sometimes be avoided. Many institutions have responded to this campaign by developing EMR-based interventions that target individual recommendations.

Boston Medical Center (BMC) specifically focused on five areas in the Choosing Wisely recommendations:  the overutilization of chest x-rays, routine daily labs, red blood cell transfusions, and urinary catheters, and underutilization of pain and pneumonia prevention orders for patients after surgery. To do this, the researchers worked with the hospital’s IT team to incorporate new recommendations into the EMRs that would alert the provider to best practice information. The researchers examined data between July 2014 and December 2016 to look at how the interventions played out clinically.

At six months following BMC’s intervention, which was activated hospital-wide for specific patients using the Epic EMR, the proportion of patients receiving pre-admission chest x-rays showed a significant decrease of 3.1 percent, and the proportion of labs ordered at routine times also decreased 4 percent. Total lab utilization declined with a post-implementation decrease of 1,009 orders per month, the study revealed.

The researchers found no significant difference in the estimated red blood cell transfusion utilization rate or the number of non-ICU urinary catheter days, but the proportion of postoperative patients who received appropriate pain and pneumonia prevention orders showed an absolute increase of 20 percent, according to the researchers.

“The results from our interventions suggest that they alone show promise in improving high-value care, but using only an electronic medical record intervention may not be adequate to achieve optimal outcomes emphasized by Choosing Wisely,” said Nicholas Cordella, M.D., the study’s corresponding author, a fellow in quality improvement and patient safety at BMC, and an assistant professor at Boston University School of Medicine.

Cordella added, ““In order to move the needle on reducing unnecessary healthcare costs, we need to consider multi-pronged approaches in order to engage providers in ways that can truly make a difference in how we deliver exceptional, high-value care to every patient.” He suggested that future efforts aimed at increasing high-value care should consider other elements, such as clinician education, audits and feedback, and peer comparison.

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Industry Groups Urge ONC to Reorient Goals of EHR Reporting Program, Focus on Health IT Safety, Security

October 18, 2018
by Heather Landi, Associate Editor
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Many healthcare industry groups would like to see the Electronic Health Record (EHR) Reporting Program for health IT developers include a strong focus on patient safety-related usability, EHR training, transparency on EHR vendors’ cybersecurity practices as well as cost transparency.

This feedback came in response to a request for information (RFI) issued by the Office of the National Coordinator for Health IT (ONC) in late August seeking public input on reporting criteria under the EHR Reporting Program for health IT developers, as required by the 21st Century Cures Act. The public comment period ended Oct. 17.

ONC issued the RFI on criteria to measure the performance of certified electronic health record technology (CEHRT). The Cures Act requires that health IT developers report information on certified health IT as a condition of certification and maintenance of certification under the ONC Health IT Certification Program.

According to the Cures Act, the EHR Reporting Program should examine several different functions of EHRs and reporting criteria should address the following five categories: security; interoperability; usability and user-centered design; conformance to certification testing; and other categories, as appropriate to measure the performance of certified EHR technology.

In its comments to ONC, the Bethesda, Md.-based American Medical Informatics Association (AMIA) questioned what it views as the “constrained scope” of the EHR Reporting Program to “provide publicly available, comparative information on certified health IT,” to “inform acquisition upgrade, and customization decisions that best support end users’ needs.”


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For years, healthcare institutions have attempted to manage paper documents and electronically captured PDF files. These documents can be electronically stored in various databases like EHRs, ERPs...

Rather, AMIA urged ONC to develop the EHR Reporting Program to measure performance to improve CEHRT security, interoperability, and usability, and not be used simply to provide data for “acquisition decision makers.”

“Especially when viewed alongside the additional provisions in newly developed CEHRT Conditions of Certification, the EHR Reporting Program should be leveraged to bring transparency to how CEHRT performs in production environments with live patient data,” AMIA stated.

“ONC should develop an EHR Reporting Program that more closely approximates a post-implementation surveillance ecosystem, not a government-sponsored ‘consumer reports’,” AMIA wrote in its comments.

Such an ecosystem, AMIA stated, would “illuminate CEHRT performance used in production and would generate product performance data automatically, without users having to submit reporting criteria.”

As proof of concept, AMIA pointed to ONC’s existing nascent surveillance and oversight program for CEHRT that could be leveraged for the EHR Reporting Program. The group also referenced the Food and Drug Administration’s (FDA) Digital Health Software Precertification Program as another example of a federal program that looks to utilize real-world production data.

In addition, AMIA recommends ONC develop interoperability reporting criteria for the EHR Reporting Program by building on previous RFIs meant to “measure interoperability,” including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and ONC’s “Proposed Interoperability Standards Measurement Framework.”

And, the industry group also urged ONC to prioritize an additional measure that demonstrates a capability to provide patients with “a complete copy of their health information from an electronic record in a computable form.” “This focus would align with top-level HHS priorities to improve patient access to their data,” AMIA noted.

AMIA also recommends alignment between the EHR Reporting Program and other aspects of the Cures-mandated Conditions of Certification.

“The EHR Reporting Program is one more vital piece in improving both EHR performance and care quality,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “We have a tremendous opportunity to leverage Cures provisions if we hone our focus on EHR performance in the real world.”

In its comments, the College of Healthcare Information Management Executives (CHIME) advises ONC against establishing any complex rating methodologies for scoring vendors. ONC should also consider establishing benchmarks by which to monitor interoperability progress among vendors, CHIME wrote. The organization noted that patients need better education on the risks of using application programming interfaces (APIs), and ONC should partner with their federal partners and stakeholders on this issue, CHIME said.

Many organizations, including CHIME, would like more information about vendors' ongoing support practices, such as the estimated costs of maintenance and software. The Medical Group Management Association (MGMA) recommended making software pricing structures for upfront and ongoing software, training and maintenance costs part of the Reporting Program, as well as all interoperability “connection” fees. MGMA also urged ONC to consider incorporating into the Reporting Program testing criteria that focused on the effectiveness of the EHR’s integration with practice management system software, and costs associated with it.

The American Health Information Management Association (AHIMA) recommended that comparative information made publicly available under the EHR Reporting Program should also contain reporting criteria that reflects the entire lifecycle of the certified health IT product, including acquisition, implementation, ongoing maintenance, upgrades, additional product and/or application integration, and replacement.

Focus on Patient Safety-Related Usability and EHR Training

In its comments, AMIA also urged ONC to view health IT safety as a measurable byproduct of usable CEHRT deployed in live environments. “To understand CEHRT usability performance in situ, ONC should supplement user-reported measures with measure concepts that reflect the safety of health IT,” AMIA wrote.

MGMA recommended that the Reporting Program report on the ability of the software to identify and address patient safety issues. “Poor usability and inefficient clinician workflow can not only fail to prevent adverse events but can actually contribute to them,” the organization wrote.

In comments it submitted to ONC, Pew Charitable Trusts noted that the establishment of the EHR Reporting Program “has the potential to give health care providers, EHR developers, and other organizations better data to address barriers in the effective, efficient, and safe use of health information technology, and improve systems accordingly.”

“In particular, this program could unearth key details on how clinicians utilize EHRs to meet ONC’s goal of reducing clinician burden while improving patient safety. ONC should ensure that the reporting criteria focused on usability—which refers to the design of systems and how they are used by clinicians—also incorporate safety-related provisions,” Pew wrote in its letter.

Pew recommended reporting criteria focus primarily on testing EHR usability to promote patient safety. To this end, Pew identified four principles to guide usability-related reporting criteria—the adoption of a life-cycle approach to developing usability-related criteria; incorporating quantitative, measurable data; limiting burden on end-users; and ensuring transparent methods that prevent gamesmanship.

Pew also provided ideas for existing sources of information that could be adapted into or utilized as safety-related usability reporting criteria, such as the Leapfrog CPOE tool, safety surveillance data from ONC, the ONC SAFER Guides or a 2016 health IT safety measure report from NQF.

“As ONC implements this program, the agency should ensure that the usability aspects of the program focus on the facets of EHR usability that can contribute to unintended patient harm. To achieve that goal, ONC should consider the aforementioned principles in identifying reporting criteria, and data sources that could become part of the program,” Pew wrote in its comments.

Orem, Utah-based KLAS Research and the Arch Collaborative recommended the EHR Reporting Program include criteria focused on EHR training, as better clinician training is critical to EHR usability and clinician satisfaction, the two groups said. The Arch Collaborative is a KLAS-affiliated initiative comprising 5,000 providers.

The KLAS-Arch comment cited research findings based on responses by more than 50,000 physicians from more than 100 provider organizations around the globe that suggests EHR satisfaction and usability are directly related to the extent and quality of training users have received. The research indicates that organizations that focus on training to support clinician workflows have higher EHR satisfaction than those that don’t. What’s more, the higher the levels of personalization tool use by the clinicians, the higher the EHR satisfaction score, according to KLAS.

“EHRs are not simple enough to be operated efficiently without ample instruction. It is essential that new providers spend enough time learning how to use the EHR, and it is requisite that providers have the option to participate in ongoing training each year,” Taylor Davis, vice president of innovation at KLAS Research, wrote in the letter. “When an EHR training program is well designed, there will be a demand to attend. A trend that has been noted is that success begets success; when providers share how EHR training has improved their efficiency, their peers become more likely to participate. The key is that the providers must have the option to choose what works for them.”

Need for Greater Focus on Security Posture

The Healthcare and Public Health Sector Coordinating Council's cybersecurity working group highlighted, in its comments on the RFI, the need for more transparency on EHR vendors' cybersecurity posture as part of the criteria of the EHR Reporting Program.

“The challenges to our sector are abundant and we believe these attacks pose direct threats to patient safety,” the group wrote in its comments. The group urged ONC to factor into the EHR Reporting Program the growing incidences of cybersecurity attacks on the sector and the need to work collaboratively to address the threats.

The group outlined a number of items that would better inform providers of a vendors’ security practices, such as access to an auditor’s statement regarding the security posture of the vendor and its products, upon provider request, as well as a software security analysis, whether two-factor authentication is in use, information on role-based access controls and how roles are configured, and, with each release and update, the number of patches provided to address security-related issues.

The group also recommended ONC consider developing a more standard way for vendors to report vulnerabilities with health IT upgrades and releases.


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UnitedHealth Group Plans to Unveil Health Record for Members, Providers in 2019

October 17, 2018
by Rajiv Leventhal, Managing Editor
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Health insurer UnitedHealth Group will be unveiling a “fully integrated and fully portable individual health record,” CEO David Wichmann said on the on the company’s third-quarter earnings call yesterday.

Speaking to the insurer’s broader digital health strategy, Wichmann stated on the earnings call that the company’s consumer digital health platform, Rally—which is a website and mobile app—is now serving over 20 million registered users and will leveraged to help develop the health record.

“Rally is synthesizing information and engaging people to better manage their health, helping consumers save money by selecting the highest quality care providers, understanding their out-of-pocket costs up front, and in some markets even scheduling appointments for care. We will soon be releasing at scale a first-of-kind, fully integrated and fully portable individual health record that delivers personalized next-best health actions to people and their caregivers,” Wichmann said on the call.

While many more details are not yet known about the health record, Wichmann did say that by the end of 2019, the insurance giant has the goal of developing individual health records for the 50 million fully benefited members that it serves, as well as for their care providers.

He noted, “We would use the Rally chassis…to provide individuals in a way in which they can comprehend a tool, if you will, not only outlining their individual health record, but also giving them next-best action detail. That's what I mean by when I say it's deeply personalized. It's organized around them, not based upon generic criteria. It also assesses to what extent that they've been, and how they've been served by the health system broadly, and whether or not there's been any gaps in care that have been left behind.”

Giving a little bit more information about the vision UnitedHealth Group has in regard to the health record, Wichmann said, “You might imagine what that could ultimately lead to in terms of a continuing to develop a transaction flow between the physician and us and the consumer and us, as we us being the custodian to try to drive better health outcomes for people, but also ensure that the highest level of quality is adhered to.”

As of now, the platform appears to be more geared toward consumers than providers. Steven Halper, an analyst for financial services company Cantor Fitzgerald, noted in an update that “The Rally EHR should be able to tap into different EHRs that use APIs [application programming interfaces] and other interoperability standards, which are being more-widely adopted. Rally EHR should be viewed as a consumer engagement tool and not as a threat to legacy provider EHR products.”

UnitedHealth Group already has its Optum business line, a health innovation company that provides health services in an array of different ways, including through its growing data analytics capabilities.

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