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LIVE from RSNA 2016: Radiology Thought-Leader Eliot Siegel, M.D., on What Value Really Means

November 28, 2016
by Mark Hagland
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Eliot Siegel, M.D. shares his perspectives on the emerging quest for value, at RSNA 2016

If the transition from film-based radiological practice to PACS- (picture archiving and communications system) facilitated practice that started nearly 30 years ago was historic, the radiology world is on the threshold of a far more profound set of changes, Eliot Siegel, M.D. believes. Dr. Siegel made his comments at a media breakfast sponsored by the Amsterdam-based Philips, on Monday at the annual RSNA Conference, sponsored by the Oak Brook, Ill.-based Radiological Society of North America, and being held at Chicago’s gargantuan McCormick Place Convention Center.

Dr. Siegel was one of several speakers at the Philips media breakfast on Monday morning. At that event, Philips executives explained in some detail about their strategic goals for the company, echoing what other vendor executives have said about the present moment in radiology. “We have to be faster, easier to use, and more reliable; we have to change the economics around equipment,” said Rob Cascella, executive vice president and CEO of Philips Diagnosis and Treatment. “So we’re building in things like intelligence, decision support, and predictive analytics. We want to make the clinician more effective. And from an operating perspective, we want to make the group more effective.”

And, following the roundtable discussion involving Philips executives and radiologists, including Dr. Siegel, Yair Briman, the Haifa, Israel-based senior vice president and general manager of Healthcare IT Philips, told Healthcare Informatics Editor-in-Chief Mark Hagland that “We see the opportunity of how much more value we can add to patient care. So the revolution” that’s happening right now, Briman said, “is really in moving from the hardware—though we continue to innovate there as well, for example, around SPECT-CT—but it’s really in the information and in how you manage that information. We need to help radiologists become more effective, especially in their use of time. So being able to provide radiologists at the point of practice with a range of protocols for diagnostic image analysis, all fully automated, will be one of the areas in which we can provide tools”—such as for calculating the volume of tumors—“that will improve not only productivity but also clinical quality.”


Eliot Siegel, M.D.

At the media breakfast, Dr. Siegel, who is the chief of imaging at the VA Maryland Healthcare System, vice chair of radiology at the University of Maryland School of Medicine, an adjunct professor of computer science at the University of Maryland, and of biomedical engineering at the University of Maryland-College Park, noted that “This year marks the twenty-fifth anniversary of when we purchased the world’s first all-digital system. We had the first fully filmless digital imaging hospital system, the PACS. It was really cool just not to lose the films. Back then, that was a really major thing, though we take that granted today. We actually had our department enclosed in an enclosed glass cage, and everyone came in to see the radiologists reading at stations. Twenty-five years later,” he continued, “I’m not sure we’ve achieved all the things we had hoped to. Sure, we have images anytime and anywhere we want to. But we were hoping we could really use the computer and coordinate with the electronic medical record, and really have the radiologist be a consultant.”

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What’s more, Siegel emphasized, “The radiologist’s role is not just to make findings, but to have the judgment. Computers can do some findings, but the radiologist needs to put all those things together. And it’s a complex nexus of information we need—using our judgment, combined with the findings on the image. So what I want from the next generation of systems, is to be able to take advantage of all the amazing things we had hoped for 25 years ago, with a whole new generation of information systems to support us. So I was excited to work with Philips to try to bring this to our healthcare practice.”

Among the issues Dr. Siegel sees as persisting, most are around workflow and clinical decision support of some sort or another. “Some of the challenges I have in my own job,” he said at the media breakfast, “number one, we have many different workstations we need to do my job, I want to consolidate that. I want to be able to combine genomic data and personalize the way I take care of patients, and have that information in front of me, information from the EMR but also from other sources. And I want that information available in real time. As I go to read a study, I want all that clinical information available at that moment. It’s that ‘mission briefing’ concept that was mentioned a few moments ago. And I want to be able to deal with the complexity and volume of information systems right now.”

Among the numerous issues that need to be sorted out for radiologists, Dr. Siegel said, are, reducing the number of workstations necessary for radiologists to do their day-to-day work, and moving forward to leverage technology to optimize radiological practice. “In my academic practice,” he noted, “I have residents and fellows spending hours gathering information, looking at old studies, and talking to the patients. So I have that information. They’ve gathered information about old studies and about the patient’s history. What I want is for my computer system to essentially emulate that team, and bring that information to me. Not everyone is privileged to work in an academic environment and have all those people working for them. I’d like for computer systems to do that, to emulate that—to bring us genomic data, past studies, and EMR-derived information. Over time, we need to be able to work smarter.  And being able to get information in that ‘mission briefing’ form. makes things better. And having all that information on the patient really changes the diagnosis and how I work. Give me the lab information, the patient’s problem list—I want to know if the patient has an underlying condition, for example. And that information can be built up over time, both from the EMR and from additional information added.

In short, Siegel said, “Give me contextual information based on what I already had and knew about the patient. There are a whole bunch of intermediate steps. We haven’t really progressed in 25 years, and I’m super-excited about moving forward and having the train leave the station.”

Shortly after the media breakfast, Dr. Siegel sat down exclusively with Healthcare Informatics to consider the broad-level changes taking place in U.S. healthcare right now, and questions around the kinds of value that radiologists and radiology can bring to patient care. Below are excerpts from that interview.

How do you see radiologists in this emerging healthcare, in which the purchasers and payers of healthcare are demanding more value from providers, and in which such things as additional Medicare physician payment cuts could be looming on the horizon? Rasu Shrestha, M.D., of UPMC, talks regularly about the challenge for radiologists of adding value to patient care.

It’s interesting, because if I go to a cocktail party and say I’m a radiologist, people think I’m the rad tech. And if you watch “House,” everybody does everything. There’s a lot of ambiguity around what the radiologist is, not only in the lay public, but even among physicians, and even among radiologists themselves. And I don’t think that even other clinicians necessarily understand what radiologists do. Sometimes, the assumption is that the radiologist looks at images, and extracts findings, for others to figure out. But I was taught that the radiologist was a consultant. And I’m at the nexus: I get information form the oncologist, the surgeon, the lab. If I’m the oncologist, I think I’m the nexus; the same with the pathologist. But when people talk about radiologists as a commodity, they’re talking about the radiologist as someone who simply extracts findings.

But doing that is a really tiny part of what we do. And when Rasu and others talk about value, the question is, what are we doing to contribute to the overall mission, to maintain health, treat disease, and reduce suffering? And one of the key questions radiologists have been struggling with for years, is, what is the relationship of what I’ve just done in writing a study, to the overall treatment of the patient?

And as we look at where we are in the value chain and how we should be reimbursed in an environment where people are looking at us for value—as you know, I’m vice-chair of radiology at the University of Maryland, and we’re connected by a bridge to the veterans’ hospital. And in the one environment, at the University of Maryland, we’re still in a pay-per-study environment; on the other side, the VA side, we’re in a salaried environment. And the same doctors act extraordinarily differently in the two different environments. For example, at the University of Maryland, my virtual colonoscopy procedure competes with the GI physicians and others, because they do the [regular colonoscopy] studies, whereas at the VA, the enthusiasm is for radiologists to do virtual studies, because of that lack of competition. So there are all sorts of different areas where, depending on the reimbursement model, the same doctors act differently.

Here’s another example: the most sensitive study for infection of any type is PET. But CMS has traditionally not reimbursed for PET for investigating inflammatory processes or infection. So at the University of Maryland, I might do a tagged white cell study [a white blood cell scan] that potentially is more dangerous for the patient, because we’re removing cells and replacing them. But at the VA, I’m able to pick and choose what is the optimal study for the patient. So reimbursement changes things. We kind of cross the bridge and move from one model to the other [those radiologists who practice at both hospitals]. There are advantages of both.

What do your radiologist colleagues say about this strange state of affairs, involving different economic incentives at different facilities at which they practice? Do they say that it’s a crazy situation? That it’s the way the world works? That we could do better as a healthcare system?

You hear all those types of responses. Physicians roll with what they’re presented with. But we have our own practice, we cover private hospitals, we work in the academic facility, and in the Department of Veterans Affairs hospitals. And living in those three environments, you get a chance to see that medicine truly is practiced in different ways, and what’s optimal for the patient could vary.

What should the incentive system be, ideally, in your view?

Clearly, in my mind, the incentive system should reward for value. The system should incent physicians to provide the maximum value for patients. Physicians need to be properly reimbursed. The biggest challenge is that it’s hard to determine what value represents and what quality represents. One example of this is that we currently do conventional chest radiography via regular x-rays. Chest, ankle, abdominal, etc., x-rays are all done with digital radiography. Well, it turns out that I can buy a 16-channel CT scanner from Philips at a price comparable to digital radiography or conventional x-ray. And I can operate that CT at the same dose, and can put my patient into that CT scanner, which costs about the same, and do CT at the same dose, with a similar price, and similar throughput, because I’m not giving the patients contrast—and at the VA, in a value-based environment, I have the ability to make that decision. In another environment, at the University of Maryland, I could not convert digital radiography to CT, because CMS [the federal Centers for Medicare and Medicaid Services, through the Medicare program] would say that that’s not indicated; you should be doing a regular x-ray. And I can say, the scanner costs the same or less, from the same company, with way more information and at the same dose. But the system is not based on value; instead, it’s based on the reimbursement models we have. So I could not do this at U of M on the Philips CT scanner. I’d have to bill for CT, but would get pushback on appropriateness, so in the VA, based on value, I would have more flexibility. There are problems in the VA. But in my own magic wand environment, I would be able to do what’s right for the patient, and include calculations on cost and value. But the payer model is a frustration. That’s why I’m doing it on the VA side.

What should our audience of CIOs, CMIOs, and their fellow healthcare IT leaders understand about all this?

That 2016 brings about a really interesting inflection point in radiology, where we have the capability to reinvent the way we practice. This is why I’m excited about working with Philips. They’ve come to us and said, we’d like you to help reimagine how you consume information from the EMR and other sources, and figure out how to create a consolidated view. So I’m a customer of the CIOs; and  I want their information presented in the context of the workflow and what I’m doing, to better take care of our patients. And the measurements I make on my Philips workstation, I don’t want to just utter words represented on a screen, like a robot, into a radiology report. Because once that happens, unless you type in a patient’s name, know a specific date, call up the report, read the report, there’s nothing that’s helping to consolidate this into a better process. So CIOs need to help transform processes, so that when you’re looking for and collecting information, it’s easier to them to access and use that information. So Philips is helping us reimagine the way we move forward, just like 25 years ago, we transitioned from film to digital. Now the challenge is to work collaboratively with CIOs and everyone else, so we become part of the whole of the integrated process with everyone else in hospitals. And that’s really what we’re trying to do.

And what should CMIOs and other clinical informaticists know, specifically?

The message I would have for CMIOs is that radiologists don’t just interpret findings, but are trained as image specialists. What constitutes image quality? And what level of color fidelity and other quality do I want from systems? What’s the best way to extract information? What’s changing now is that images are now considered to be a part of the electronic medical record, from a legal perspective, etc. It used to be a question as to why one should or shouldn’t save diagnostic images, it was or wasn’t for legal purposes. Truly from a legal and medical perspective, images really are part of the electronic medical record. And I would tell my CMIO colleagues that radiologists have a level of expertise for images in general, not just for radiology, and that we truly want to have our data made more accessible. And we have a lot of needs to be able to consume those sorts of data as well.

And what would you say to those HIE [health information exchange] leaders, who are struggling to incorporate image-sharing into their networks?

I really think healthcare should take a lead from the financial sector, and create true interoperability. Clearly, people need interoperability [to do online banking], and the financial sector needs that. One of the parts of HIPAA [the Health Insurance Portability and Accountability Act of 1996] that people don’t always remember, is the idea of a universal healthcare identifier. We don’t have that in the U.S., and these HIEs have to figure out who the patients are. And that’s a huge challenge for those HIEs. So one of the interesting trends in the future is to what extent will patients have their own PHRs. And also, all my information will all be in one place.

So it will require striking a delicate balance between protecting security and privacy, and supporting optimized patient care. I’m just afraid that the pendulum has swung so far in one direction; if these data silos are so isolated, I’m afraid we won’t learn from the lessons of the past. We’ve come a long way in the last 20 years with privacy and security, and we really ought to be able to incorporate things into healthcare. And I personally would love to see patients take more ownership in their own records and in their own care.

The OpenNotes movement is really helping to accelerate patient engagement.

Yes, and I would love for the EMR and the PHR [personal health record] to be truly image-enabled, too. That would be a great step forward.

 


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EHR-Compatible Pharmacist Care Plan Standard Opens the Door to Cross-Setting Data Exchange

September 14, 2018
by Zabrina Gonzaga, R.N., Industry Voice
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Pharmacists drive information sharing towards quality improvement

Pharmacists work in multiple environments—community, hospital, long term care, clinics, retail stores, etc.—and consult with other providers to coordinate a patient’s care.  They work with patients and caregivers to identify goals of medication therapy and interventions needed, and to evaluate patient outcomes.  Too often, pharmacy data is trapped in a silo and unavailable to other members of the care team, duplicated manually in disparate systems which increases clinical workloads without adding value.

To address these issues, Lantana Consulting Group and Community Care of North Carolina (CCNC) developed an electronic document standard for pharmacist care plans—the HL7 Pharmacist Care Plan (PhCP). The project was launched by a High Impact Pilot (HIP) grant to Lantana from the Office of the National Coordinator for Health Information Technology (ONC).

Before the PhCP, pharmacists shared information through paper care plans or by duplicative entry into external systems of information related to medication reconciliation and drug therapy problems. This documentation was not aligned with the in-house pharmacy management system (PMS). The integration of the PhCP with the pharmacy software systems allows this data to flow into a shared care plan, allowing pharmacists to use their local PMS to move beyond simple product reimbursement and compile information needed for quality assurance, care coordination, and scalable utilization review.

The PhCP standard addresses high risk patients with co-morbidities and chronic conditions who often take multiple medications that require careful monitoring. Care plans are initiated on patients identified as high risk with complex medication regimes identified in a comprehensive medication review. The PhCP is as a standardized, interoperable document that allows pharmacist to capture shared decisions related to patient priorities, health concerns, goals, interventions, and outcomes. The care plan may also contain information related to individual health and social risks, planned interventions, expected outcomes, and referrals to other providers. Since the PhCP is integrated into the PMS or adopted by a software vendor (e.g. care management, chronic management, or web-based documentation system), pharmacist can pull this information into the PhCP without redundant data entry.

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The PhCP allows pharmacists for the first time to share information with support teams and paves the way for them to support value-based payment. The project goals align with the Center for Medicare & Medicaid Services’ (CMS’) value-based programs, which are part of the Meaningful Measure Framework of improved care team collaboration, better health for individuals and populations, and lower costs.

Scott Brewster, Pharm.D., at Brookside Pharmacy in East Tennessee, described the PhCP as a tool that helps them enhance patient care delivery. “From creating coordinated efforts for smoking cessation and medication utilization in heart failure patients, to follow up on recognized drug therapy problems, the eCare plan gives pharmacists a translatable means to show their value and efforts both in patient-centered dispensing and education that can reduce the total cost of care.” (The eCare plan reference by Scott Brewster is the local term used in their adoption of the PhCP).

The pilot phase of the project increased interest in exchanging PhCPs within CCNC’s pharmacy community and among pharmacy management system (PMS) vendors. The number of vendors seeking training on the standard rose from two to 22 during the pilot. Approximately 34,000 unique care plans have been shared with CCNC since the pilot launch.

This precedent-setting pilot design offered two pharmacy care plan specifications: one specification is based on the Care Plan standard in Clinical Document Architecture (CDA); the other standard is a CDA-on-FHIR (Fast Healthcare Interoperability Resources). The latter specification directly transforms information shared using the FHIR standard into CDA. FHIR is straight forward to implement than CDA, so this is an appealing option for facilities not already using CDA. The dual offerings—CDA and CDA-on-FHIR with lossless transforms—provide choice for implementing vendors while allowing consistent utility to CCNC.

What’s on the horizon for the pharmacy community and vendors? With the support of National Community Pharmacists Association (NCPA), the draft standards will go through the HL7 ballot process for eventual publication for widespread implementation and adoption by vendors. This project will make clinical information available to CCNC and provide a new tool for serving patients with long-term needs in the dual Medicare-Medicaid program and Medicaid-only program.  This is a story about a successful Center for Medicare and Medicaid Innovation (CMMI)funded project that started out as a state-wide pilot and is now rolling out nationwide as Community Pharmacy Enhanced Service Network (CPESN)USA. 

The PhCP is based on a CDA Care Plan standard that is part of ONC’s Certified EHR Technology requirements, so it can be readily implemented into EHRs. This makes the pharmacist’s plan an integral part of a patient’s record wherever they receive care. 

Adoption of the PhCP brings pharmacies into the national health information technology (HIT) framework and electronically integrates pharmacists into the care planning team, a necessary precursor to a new payment model and health care reform. In addition, receiving consistently structured and coded pharmacy care plans can augment data analysis by going beyond product reimbursement to making data available for, utilization review, quality assurance and care coordination.

Troy Trygstad, vice president for Pharmacy Provided Partnerships at CCNC, described the strategic choice now available to pharmacists and PMS vendors. “Fundamentally, pharmacy will need to become a services model to survive. Absent that transformation, it will become a kiosk next door to the candy aisle. The reasons vendors are buying into the PhCP standard for the first time ever is that their clients are demanding it for the first time ever."

The move to value-based payment will continue to drive the need for pharmacists, as part of care teams, to provide enhanced care including personal therapy goals and outcomes. Sharing a medication-related plan of care with other care team members is critical to the successful coordination of care for complex patients.

Zabrina Gonzaga, R.N., is principal nurse informaticist and director of health informatics at Lantana Consulting Group and led the design and development of the PhCP standard. 

Email:  zabrina.gonzaga@lantanagroup.com

Twitter: @lantana_group

 


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Health IT Now Pushes for Information Blocking Regulation, Says Administration “Must Uphold its End of the Bargain”

September 13, 2018
by Rajiv Leventhal, Managing Editor
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The executive director of Health IT Now, a coalition of healthcare and technology companies, is again criticizing the Trump administration for not yet publishing any regulation on information blocking, as required by the 21st Century Cures Act legislation.

In an op-ed published recently in STAT, Health IT Now’s Joel White wrote, “More than 600 days after the enactment of the Cures Act, not a single regulation has been issued on information blocking.” White added in frustration, “Health IT Now has met with countless officials in the Trump administration who share our commitment to combat information blocking. But those sentiments must be met with meaningful action.”

The onus to publish the regulation falls on the Office of the National Coordinator for Health IT (ONC), the health IT branch of the federal government that is tasked with carrying out specific duties that are required under the 21st Century Cures Act, which was signed into law in December 2016. Some of the core health IT components of the Cures legislation include encouraging interoperability of electronic health records (EHRs) and patient access to health data, discouraging information blocking, reducing physician documentation burden, as well as creating a reporting system on EHR usability.

The information blocking part of the law has gotten significant attention since many stakeholders believe that true interoperability will not be achieved if vendors and providers act to impede the flow of health data for proprietary reasons.

But ONC has delayed regulation around information blocking a few times already, though during an Aug. 8 episode of the Pulse Check podcast from Politico, National Coordinator for Health IT Donald Rucker, M.D., said that the rule is "deep in the federal clearance process." And even more recently, a bipartisan amendment to the U.S. Senate's Department of Defense and Labor, Health and Human Services, and Education Appropriations Act for Fiscal Year 2019 includes a requirement for the Trump administration to provide Congress with an update, by September 30.

White, in the STAT piece, noted a June Health Affairs column in which Rucker suggested that implementation of the law’s information blocking provisions would occur “over the next few years.” White wrote that this is “a vague timeline that shows little urgency for combating this pressing threat to consumer safety and stumbling block to interoperability.”

Health IT Now is not alone in its belief that the rule should have been published by now, nor is it the first time the group is bringing it up. Last month

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By the end of this year, ONC’s implementation and interpretation of data blocking will also be published and available for comment, as was the case with the TEFCA proposed rule. The TEFCA final rule is also anticipated by the end of 2018.

HOWEVER…there’s still time to prepare for TEFCA and the data blocking regulation, and final rules for both in the coming months will set concrete timelines, and for TEFCA it will be interesting to see how ONC reacts to stakeholder comments, internal and external.

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