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The World of Imaging: A Changing Landscape for Radiologists—and for Everyone

June 6, 2017
by Mark Hagland
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The entire world of radiology is changing—on the policy, payment, business, clinical, and technological levels—and healthcare IT leaders are in a position to help radiologists transform their practices to meet the requirements of the new healthcare

With the U.S. healthcare system undergoing rapid and transformational change on all levels and across countless dimensions, it would be unrealistic to expect that any medical specialties would somehow remain “exempt” from said change. Indeed, even the most cursory scan of the full spectrum of medical specialties, from primary care specialties like family medicine and internal medicine, to the most procedurally focused ones like orthopedics and oncology, reveals not a single exception to the broad generalization of massive change across specialties.

That said, the various medical specialties are also all changing in their own ways, as federal and state policy and payment changes, broad industry and business trends, clinical practice shifts, and medical-technology and information-technology changes of different types affect them individually and with different emphases and particularity.

Radiology, always one of the most technologically oriented specialties, is caught in a particularly complex and interesting swirl of diverse trends of all sorts—policy/payment, business, clinical-practice, and medical-tech and information-tech trends. And radiologists are caught up in that swirl. On the one hand, they are facing tremendous reimbursement pressure, as the federal, state and private purchasers and payers of healthcare are balking at the high costs of diagnostic imaging procedures and equipment, and are putting the brakes on unrestrained, fee-for-service-based reimbursement for diagnostic imaging procedures.

At the same time, the economics of radiological practice are changing quickly. While the demand for diagnostic imaging services and diagnostic imaging reports continues, that demand remains uneven across different healthcare regions, local markets, and even micro-areas. That fact, and the expense of maintaining radiological practices, have combined with rapidly improving imaging informatics technology and communications technology, to spur the rapid advance of remote radiological practice, literally spanning the globe—with a huge cohort of remote radiologists in India, among clinicians who were trained in the United States and retain state-based medical licenses, while remote-reading from India—but also across the U.S.

And that in turn has led to the rapid consolidation of radiological practices, under a variety of auspices, many of them taking on remote-reading volume from across the U.S., as well as locally to themselves.

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Then of course, there are the changes sweeping imaging informatics itself—with advances in technology and with the consolidation of the healthcare provider space leading to new realities for radiologists. PACS (picture archiving and communications systems) systems are becoming more closely interfaced with electronic health record (EHR) systems, which in turn are erasing the need for standalone RIS (radiology information system) solutions. What’s more, the shift towards vendor-neutral archive (VNA) strategies that unify the storage and sharing of images from across “-ologies” (radiology, cardiology, dermatology, gastroenterology, pathology, and beyond), is pushing PACS into the middle of the enterprise-wide mix. In other words, PACS is no longer an island unto itself. And that, too, is a factor changing radiological practice.

Can I.T. Help Radiologists Become “True Consultants”?

So where does all this leave practicing radiologists? Some, frankly, are finding themselves at least a little bit bewildered, as the volume-based system they’ve been trained to practice in and have been practicing in, shifts noticeably. Others are finding themselves comfortable with change, and moving to adapt to it. Among those is Christopher Deible, M.D., who has been practicing as a clinical radiologist for 12 years, all of those years at the vast, 20-plus-hospital UPMC health system in Pittsburgh. “I actually started in radiology at a unique time,” Deible says. “When we started residency, we were actively converting our imaging from film-based to PACS-based. I still ran up to some of the ICUs to read films. Today, we might go to a unit, or something, but we would look at things on a PACS system. So we’ve definitely accomplished the goal of making images digital, enterprise-wide. The role of the radiologist has definitely diminished to some extent, with a focus on volume—even to the point where clinicians used to come look at images with radiologists, and that kind of disappeared. So the ability to consult now virtually, that’s where we need to go,” he says. “And we still have a lot of challenges in distributing images from one hospital or medical group to another. With regard to reports, there still remains an element of delay in distributing reports with images. And with regard to radiologists becoming consultants, we’re still working on that.”

So how can radiologists become true consultants to referring physicians? And how does IT figure into that frame? “I think it comes in, in two areas,” Deible says. “One is the pre-imaging consult. To some extent, we leave that now to some standard appropriateness software, but a direct personal, telephone or in-person consult might be helpful. A second example—perhaps the ordering physician may need a clarification or an amplification, or even, they’re not sure what to do with a finding—so, pre-exam and post-exam,” he says, there is the opportunity for a more granular type of consultation.

The entire landscape is in fact already changing, says Rasu Shrestha, M.D., chief innovation officer at UPMC, and also a practicing radiologist. “My perspective is that the role of the radiologist is already evolving from a diagnostician simply churning out report after report after report, to that of a physician consultant,” Shrestha says. “And that’s the transition we need in the industry, as we move from volume-based to value-based care delivery. And how do we help radiologists make that leap from being a pure diagnostician to a physician consultant?” he asks.

Rasu Shrestha, M.D.

“Meanwhile,” Shrestha continues, “healthcare is moving towards more of a collaborative care model. We still have hospital-centric, episodic-focused, siloed care, and those elements essentially define the current reality of fee-for-service. As we evolve towards more of a collaborative care model, the focus moves towards collaborative pathways, patient-centric care; and we’re looking at outcomes more than we ever were. And from an IT perspective, we’re looking at interoperability as a driver of care, and looking at standards and standardized interfaces as a de facto enabler of new care models. So we’re moving more into an outcomes-driven reality, and the radiologist plays a really critical role.”

That really is where healthcare IT plays such an important facilitating role in the shifts that are beginning to take place in radiology practice. As Deible puts it, “Availability, reliability, and access are very important elements. When we practiced in more of a departmental, siloed context, as a radiology department, reliability, availability, and access were already important, but not as important as now. Now, they help define what we exist for.” In fact, he says, “In the volume-based environment in which we functioned, two big measures were report turnaround time and volume of studies per hour and day. Now, within a collaborative-care model, it’s not just those two metrics, but a whole range of metrics, including clinical quality metrics, utilization management, and service quality metrics.”

Very importantly, Deible notes, “The things we’re measuring rely heavily on the system being up, and also, access. It’s not just about me as a radiologist having access to the images and studies, but about many things: how do we have access to additional data around a patient that might exist in an EMR or beyond? And then, as we’re looking at things from a care team perspective, access, availability, and reliability become extremely important, because now we’re looking at this in a different context—the radiologist working with the cardiologist or the oncologist in specific contexts, for example, putting a plan around a cancer patient. So the workspace changes. And that happens either directly through the EMR, or the tablet, or the zero-footprint viewers they might have on their desktops.”

New Information Technologies Invade the Practice Space

On top of everything else, some leading-edge technologies, including machine learning and pattern recognition, are beginning to make their way into radiology practice now. Pattern recognition has actually been used in imaging for some time, but, as Bradley Erickson, M.D., Ph.D., professor of radiology and associate chair of research in radiology at the Mayo Clinic in Rochester, Minn., told Healthcare Informatics senior contributing editor David Raths, for the March Top Ten Tech Trends article on value and interoperability in imaging informatics, it has never been extremely successful.

Bradley Erickson, M.D., Ph.D.

But more recently “deep learning” has shown great promise. “My lab and a few others are starting to get pretty good success at applying deep learning to medical images for making traditional diagnoses of a tumor,” he said in that story. “With traditional machine learning, when we would calculate things like intensity and edges, we had 80 to 85 percent accuracy, but with deep learning, we are now getting better than 90 percent accuracy,” Erickson said. Researchers also are starting to be able to figure out genomic properties of tumors with images, he added. “Traditionally, one can understand how an x-ray machine or MRI scanner works,” he told Raths. “With deep learning, it is much harder to understand how or what property of an image you are looking at in order to make a determination.”

For that article, Raths also spoke with Christopher Roth, M.D., Duke University Medical Center’s vice chair of information technology and clinical informatics and director of its imaging informatics strategy, who spoke about the drive towards enterprise strategies. While the shift towards enterprise strategies in imaging informatics has taken some time to pick up speed, Roth believes that that is starting to change now. One reason? The potential inherent in averting redundant testing, and in helping providers get access to the information they need—and not having CDs sitting in closets. “The second driver is information privacy and security, and that gets back to those same CDs sitting in closets or on thumb drives or on mobile devices,” Roth emphasized. “We want to meet our providers at the point of care and fit into their work flows, while still meeting the organization’s macro-level concern about security,” Roth told Raths.

Christopher Roth, M.D.

Tremendous Opportunity for Healthcare I.T. Leaders Going Forward

So, where do CIOs, CMIOs, and other healthcare IT leaders fit into this landscape? They figure into it in a very major way, say industry experts and observers, and those in the trenches. Virtually all CIOs and CMIOs have at least some awareness now of the need to move towards enterprise-wide solutions, including VNAs, even if they might not yet have begun work yet on implementing such strategies in their own organizations.

What’s more, the entire phenomenon of health information exchange (HIE) is beginning to undergo its own transformation with regard to diagnostic images, as HIEs begin to ingest and share those images across communities, regions, states, and even inter-state regions. Initiatives in states like Colorado, Utah, Nebraska, Michigan, and Maine, among others, are breaking past barriers in this regard.

In addition, beyond the development and expansion of the IT infrastructure to improve radiological practice and the medical practice of all physicians is tremendously important, of course—healthcare IT leaders, going forward, can support radiologists in transforming radiological practice, along several important dimensions, as IT will truly be an enabler to radiological practice transformation.

UPMC’s Deible puts it this way: in the next few years, he says, he will be active in “[t]rying to get radiologists more pertinent clinical information as they interpret, so that we end up answering the questions better, and provide better reports—that will be important. And that means that we need greater interoperability. There was a lot of buzz at RSNA [the annual conference of the Radiological Society of North America, held at the end of November and beginning of December last year in Chicago] and elsewhere last year, about providing appropriate and pertinent clinical information at the point of diagnosis. And also having the ability to communicate with other clinicians. Radiologists have gotten away from that collaboration, and moving forward to reintegrate that element into our practice.”

“I would agree with Dr. Deible,” Shrestha says. “If you go back to the basics, it’s really important for us to measure what we want to improve. At the same time, you have to incentivize the measures that matter the most. And if you look at this change in paradigm, we’ve essentially been incentivizing the making of widgets. Now that we’re incentivizing what we want to improve, we need the right systems to incentivize what matters the most. And that includes baseline measures around outcomes, and around cost. How do we make sure we have low cost compared to competitors, and that we’re doing things as efficiently as possible? So we’re looking at scale, across -ologies, etc. And the differentiators that will separate the wheat from the chaff, so to speak: one is around quality. Stronger adherence to evidence-based clinical practices; and the second is service experience. How do we make sure we have high satisfaction around patients and physicians? And how do we translate that experience into value? Including improved outcomes.”

And that means leveraging IT to support new ways to perform clinical peer review. This has long been a contentious area for radiology, as it has been felt by many practicing radiologists to have carried a whiff of punition around it. In fact, says Deible, “We’re dealing with some of this in our department these days. We’ve instituted a number of new ways of reviewing quality. We had a traditional peer review process, based on, we give you a certain number of cases, and you rate them with a score, and everyone compares. But now, the focus is on incentivizing participation in the peer review process. If you submit a certain number of cases, your score improves. So that moves it away from the punitive. And we have a tremendous amount of new information that radiologists are sharing with each other that either didn’t exist before, or just didn’t get back to radiologists from others. So moving the incentive towards participation rather than the focal score, will help. And we can incentivize by bringing new information; because in general, everybody appreciates learning new information that can help them, especially when it doesn’t feel punitive.”

“Today, peer review is more of this thing you do on the side, so that reinforces a sense of the punitive nature of it,” Shrestha says. “With the advances in technological capabilities, peer review should literally sort of fade away into what we’re doing on a day-to-day basis. Clinical and service quality should simply be measured on a day-to-day basis; and if that’s what’s measured, rather than how many studies you performed and then we’ll do a peer review on the side to make sure you’re up to scratch—if that can be changed, it will be better for radiologists. Radiologists always wanted to focus on quality, but the traditional systems like RIS and PACS reinforced a punitive approach. So technology that supports quality is where we need to move.”

In the end, everyone agrees, leadership and facilitation on the part of healthcare IT leaders, especially CIOs and CMIOs, and leaders of imaging informatics, will be a very important element in transforming radiological practice, as the entire U.S. healthcare system undergoes transformation. And the facilitation of practice transformation that they can participate in will in turn reduce some of the stressors that radiologists face as all the policy, payment, business, and medical-technological changes continue to impact them at the same time. Within the next decade, as the entire landscape of radiology practice undergoes profound transformation, the facilitation into healthcare IT change that healthcare IT leaders can help lead, really will make an enormous difference—to radiologists themselves, to their colleagues the referring physicians, to all the other clinicians and the staff people they work with, to the hospitals, medical groups, and health systems in which they are embedded—and ultimately, to their patients and communities. Meanwhile, this train of transformational change has already pulled out of the station, everyone agrees—and it’s time to get on quickly. 


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Where is the Information Blocking Rule? Health IT Now Criticizes Missed Deadline

December 17, 2018
by Heather Landi, Associate Editor
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Industry group Health IT Now, a coalition of healthcare and technology companies, responded today to the Trump Administration's latest missed deadline for publication of a proposed information blocking rule as required under the 21st Century Cures law.

The proposed rule was sent by the Office of the National Coordinator for Health IT (ONC) to the Office of Management and Budget (OMB) on September 17, 2018, setting off a 90-day timeline for the agency to complete its review; a period which was now expired without publication of a proposed rule, according to Health IT Now.

The onus to publish the regulation falls on 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.

“Now, more than two years after 21st Century Cures was enacted, patients and providers are still without an information blocking rule - undermining the intent of the law,” Health IT Now officials stated.

ONC has delayed regulation around information blocking a few times already, previously stating that the rule would be released in April then revising its timeline to September, before finally submitting the rule to OMB on September 17th.  

As previously reported by Healthcare Informatics Managing Editor Rajiv Leventhal, 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.

“It is stunning that, more than two years after 21st Century Cures became law, we are still waiting on regulators to actually do what the law says,” HITN Executive Director Joel White said in a statement issued Monday. “Patients and providers have looked on with disappointment as the administration blows through one missed deadline after another for publicly releasing a proposed information blocking rule. It is time to say 'enough.' By continuing to slow walk these regulations, the administration is adding to uncertainty in the marketplace and is quickly reaching a point whereby it will be in obvious defiance of the spirit of the Cures law.”

White further stated, “Lawmakers who worked doggedly to get this landmark, bipartisan bill across the finish line should be incensed by the way that bureaucratic delays have weakened their signature achievement. This holiday season, the best gift that OMB could give consumers would be an expedited completion of its review and the public release of a robust information blocking rule. In the meantime, we are hopeful that industry stakeholders will not delay interoperability initiatives as a result of the ambiguity created by these continued delays.”

It is not the first time that the Health IT Now executive director has been publicly critical of the Trump administration for not yet publishing any regulation on information blocking. In an op-ed published September 8 in STAT, 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.”

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Intermountain CMIO Stan Huff on the Need for Greater Interoperability: “We’re Killing Too Many People”

December 6, 2018
by Rajiv Leventhal, Managing Editor
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About 250,000 people die per year due to preventable medical errors, and that’s the biggest motivator there is for more advanced interoperability, says one clinical IT leader

Stan Huff, M.D., chief medical informatics officer (CMIO) at the Salt Lake City, Utah-based Intermountain Healthcare for the past 31 years, has long been a top leader in his field. Working on the leadership team for a health system like Intermountain and serving as a co-chair of the HL7 Clinical Information Modeling Initiative (CIMI), while also having been a former member of the ONC Health IT Standards Committee, Huff has a wealth of knowledge coming from both provider- and standards-focused perspectives.

Huff, who represented Intermountain at a White House meeting on interoperability this week, recently chatted with Healthcare Informatics about all things interoperability, including the different types of data exchange that exist today, the greatest barriers, and how potential pending regulations could shake up the landscape. Below are excerpts from that discussion.

When you look at the interoperability landscape today, how bullish are you on where things stand, broadly speaking? Or rather than bullish, are you more concerned?

I don’t know if I am bullish or not, but I think we are making progress—and it’s significant progress. There is an incredible amount of work to be done. I’m not concerned at the progress; I am happy, but mindful of how much work is left to do to really reap the benefits that people are hoping for.

You’re currently a co-chair of the HL7 Clinical Information Modeling Initiative while also having been a member of former the ONC Health IT Standards Committee. How important is it to figure out the issues around standards before things can progress?

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I wish it had a higher priority. Most of the time when people are talking about interoperability now, they are thinking about caring for an individual patient and thinking about sharing information between different systems that have information on that patient. They are usually thinking about EHR [electronic health record]-to-EHR for patient care—they have a very focused idea.

But there are other dimensions. There is interoperability relative to public health, meaning how we share data from an organization to a public health [entity] so that we understand what’s going on with a whole population relative to a particular disease.

There is also research interoperability, so we can share data that’s coming from research activities. And closely related to that is interoperability of clinical trial data and all of the randomized controlled trial data that comes with that.

Then there is interoperability that comes from devices and data coming from devices, which is a whole field onto itself. So you have to be careful when you talk about interoperability. This is one axis of interoperability, in that it has to do with the scope of systems you are communicating with.

The other axis of interoperability has to do with how truly interoperable you are, and there are different levels there as well. One level is the interoperability you get with the HL7 version 2 [standard], where you have a structure and people know how to send messages between systems. And there is a lot of negotiation that happens when you set up an HL7 version 2 interface to say what terminology you are using, and if you send something as two fields or one field. There is a lot that goes on there and that’s helped quite a bit when you talk about HL7 FHIR [Fast Healthcare Interoperability Resources]—it has a more defined structure and has more things specified about terminology use.

And then you can get an even better of interoperability if you are using the Argonaut [Project] profiles. But even at that Argonaut profile level, you aren’t plug-and-play interoperable. There still is ambiguity in the Argonaut definitions that lead to different implementations by different companies and organizations.

The highest level is what I would call “plug-and-play” where this no bilateral negotiation around terminology or anything like that. The standard is explicit enough so that it could be tested for conformance and you can say whether a given system is conformant or not, and the data can be used in the way it was intended. We don’t have any plug-and-play interoperability to speak of right now, and that’s what I’m trying to shoot for.

One of three biggest motivators for me is patient safety. There is really good and convincing data that shows we are killing 250,000 people per year due to preventable medical errors. And that won’t be solved by “zero harm” programs, or by “sort of” interoperable systems. In the end, the “sort of” interoperable systems means that a person still has to look at things and make a judgment. And people are not perfect information processors. So you need a situation where the data is explicit enough where I can write rules that prevent the death or improper treatment of patients.

And we are not at that level yet. How urgent is it? I think it’s incredibly urgent and you can make an argument that it’s more important than lots of other things we’re spending money on that would have less of an impact on patient care. I work in this area, so yes, I am biased.

But I’m persuaded that it’s worth an investment, and to get to where I want to get to will not be easy. This won’t be something where you make one $20 million investment and then it’s done; it will take five or 10 years, and you will make incremental progress over that period of time. Think of it like a military campaign or a crusade, because it’s that type of timeframe and scale where you need planning and infrastructure to really accomplish what we want to do in the end—which is save lives, decrease the cost of care, and reduce the burden of clinicians.

Many folks believe that until the business incentives change, stakeholders will not be incentivized to be open with their systems. Do you agree with this and how much incentive exists today?

There isn’t a whole lot of incentive yet. If the patient care and safety issues were sufficient enough incentives, then this would have been solved a long time ago because those incentives have been there. People know and understand that we’re not caring for patients in the best way possible. And it’s the financial and proprietary considerations that keep us from doing that, ultimately.

We have to be careful [with incentives] though, because there are unexpected consequences. Going back to when I was on the HIT Standards Committee, we thought that we were doing useful and good for U.S. healthcare when we set up the meaningful use measures. And while meaningful use solved the EHR adoption issue, what it taught people was how to manage measures but not manage quality.

People became incredibly good when it came to managing the measures to get paid and to meet the qualifications, but I don’t think anyone would assert that those things improved the quality of care in any measurable way. So I think we didn’t meet the goal that we were shooting for—providing better quality care at a lower cost.

The ONC annual conference took place last week, and there seemed to be significant conversations around pending regulations such as possibly making interoperability a requirement to stay in Medicare and prohibiting information blocking. How does all of this land for you?

I welcome the change; it’s a good as thing you move from meaningful use to promoting interoperability. What I don’t know is if these specific [rules] being proposed are going to accomplish what [we want]. We thought we were doing the right things back when we were doing meaningful use.

At a high level, I would agree that it would be wonderful to require interoperability as a requirement for Medicare participation. But it’s undefined. When talking about the dimensions and these things, there has to be an understood and a useful level for the interoperability that’s required. But I haven’t seen the details to know whether what’s being asked for is both achievable and valuable if it were to be achieved. But I do agree with the [overall] direction.

Intermountain is often at the forefront of health and health IT initiatives such as its sponsorship of the Opioid Community Collaborative. How can these learnings be shared so they can improve the digital healthcare ecosystem?

The thing I try to emphasize to people is that if you look at what we are doing, and you take it in aggregate across the country—the things people are applying decision support to—it’s a tiny part of what we could do. And the reason for that is we don’t have interoperability. You can create a good program at Intermountain, or at Kaiser Permanente, or at Mayo Clinic, but the only place it works well is where it was developed. You cannot move it. If you move it, you have to recreate it. Until you have interoperability, I can’t write a rule that works on top of a Cerner system and also on an Epic system, or for that matter works on two different Cerner implementations. This cannot happen until you have those platforms supplying APIs so I can hook my decision support up to their system without rewriting all of the logic in a different technology platform.

So we are doing good things, and want to continue to do good things, but wouldn’t it be wonderful if what we did, or what the University of Utah is doing with opioids, can be directly moved and used, in the same way people can buy apps for their iPhones in the app store, or any other platform.

The realization is we might be doing 150 things at Intermountain in terms of decision support applications, but there is an opportunity to do 5,000 things, and we will never get to those 5,000 things unless we get to an interoperable platform so that when knowledge is created it can be shared. That’s my real emphasis behind interoperability.

 


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KLAS: EHR Vendors Making Significant Progress with CommonWell, Carequality Connection

December 4, 2018
by Heather Landi, Associate Editor
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While most EHR vendors have connections to the national network, only athenahealth and Epic customers have connected en masse, KLAS reports
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With the establishment of connectivity between CommonWell and Carequality, announced back in August, as well as other interoperability advancements by electronic health record (EHR) vendors, the ability to exchange patient records is within the reach of most acute care or clinic-based provider organizations, regardless of size or financial situation, according to a new report from Orem, Utah-based KLAS Research.

In the report, “Interoperability: Real Progress with Patient Record Sharing Via CommonWell and Carequality,” KLAS researchers note that since the last KLAS report on interoperability, which was published in March 2018, the acute care/ambulatory EHR market has taken critical steps forward in sharing data via national networks. The most notable advancements include the establishment of the CommonWell-Carequality link, Meditech’s initial connection to CommonWell, and notable Carequality adoption among NextGen Healthcare customers, according to KLAS researchers.

Most of the prevalent acute care/ambulatory EHR vendors are connected to the national framework, marking significant progress for interoperability, according to KLAS researchers. The report findings come a few weeks after CommonWell and Carequality announced that the connection to the Carequality framework was “generally available.” Cerner and Greenway Health successfully completed a focused rollout of the connection with a handful of their provider clients, who have been exchanging data daily with Carequality-enabled providers, CommonWell officials said.

In August, CommonWell Health Alliance and Carequality announced initial connectivity, which is the beginning of a broader effort to increase health data exchange nationwide, and builds on an announcement made almost two years ago. In December 2016, CommonWell and Carequality announced connectivity and collaboration efforts with the aim of providing additional health data sharing options for stakeholders. Officials said that the immediate focus of the work between Carequality and CommonWell would be on extending providers’ ability to request and retrieve medical records electronically from other providers. In the past year and a half, teams at both organizations have been working to establish that connectivity.

Now, since the connection went live in July, officials noted that CommonWell-enabled providers have bilaterally exchanged more than 200,000 documents with Carequality-enabled providers locally and nationwide, as reported by Healthcare Informatics in November.

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CommonWell, an alliance formed five years ago, operates a health data sharing network that enables interoperability using a suite of services aiming to simplify cross-vendor nationwide data exchange. Major vendors connecting to CommonWell include athenahealth, Cerner, CPSI, eClinicalWorks, Greenway Health and Meditech.

Meanwhile, Carequality, an initiative of The Sequoia Project that launched about a year later, is a national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks. Vendors using Carequality include athenahealth, Epic, eClinicalWorks and NextGen Healthcare. Nearly all major EHR vendors have aligned with one or both of these options, according to KLAS.

Together, CommonWell members and Carequality participants represent more than 90 percent of the acute EHR market and nearly 60 percent of the ambulatory EHR market. Today, more than 15,000 hospitals, clinics, and other healthcare organizations have been actively deployed under the Carequality framework or CommonWell network, officials attest.

This latest KLAS interoperability follows a report back in March in which KLAS researchers positioned that the CommonWell Health Alliance’s interoperability efforts were hindered by a lack of provider adoption and its interoperability services currently lacked value. However, when CommonWell and Carequality eventually connect, “instant value” will be created for users, KLAS researchers attested in that report.

Currently, Epic is not a member of CommonWell, despite other major EHR vendors pushing them in that direction. Back in 2015, athenahealth CEO Jonathan Bush famously tweeted to Epic’s CEO Judy Faulkner that his company would pay for Epic to join.

Indeed, KLAS reported in March that CommonWell will likely see a significant adoption increase with a solid Carequality connection. “Since its launch five years ago, the tendency to over-market the level of adoption of CommonWell has created apprehension and a lack of trust among potential participants and prompted this report, showing a snapshot of providers’ success,” the researchers said in the March report. KLAS researchers also claimed that when CommonWell connects to Carequality, “the entire Epic base will become available, creating instant value for most areas of the country.”

Following the publication of that report, CommonWell’s Executive Director Jitin Asnaani, in an exclusive interview with Healthcare Informatics, defended his organization’s mission and attested that the network is continuing to grow and prove its worth.

Asnaani also critiqued the KLAS report’s claim that vendors such as athenahealth and Epic give their customers a head start by enabling plug-and-play data sharing via Carequality. Asnaani called this specific critique “totally bogus,” asserting that the quality of data sharing is dependent on the vendors rather than dependent on CommonWell or Carequality.

KLAS Assessment on the Progress of CommonWell-Carequality Connection

In this latest report, KLAS researchers focused specifically on the progress EHR vendors have made in sharing patient records via the standardized (plug-and-play) networks of CommonWell and Carequality.

KLAS researchers assert that this focus is important because the “plug-and-play” option is the “only option” that allows provider organizations “avoid significant costs, delays, and organizational workload.”

KLAS also acknowledged that “virtually all major EMR vendors can successfully share patient records through the traditional point-to-point connections (a costlier approach in terms of time, resources, ongoing maintenance, and money), local HIEs (health information exchanges) and direct exchange (where records are manually sent to other providers).”

Referring to the CommonWell-Carequality connectivity as the “connection heard round the U.S.,” KLAS researchers contend that this connection should be “key in driving value and opening the floodgates so that any provider organization that desires to can exchange patient records with relative ease and little cost.” KLAS plans to measure the impact of this sharing in a 2020 interoperability report.

According to the report, this fall, two CommonWell-connected Cerner organizations tested and validated the ability to connect with Epic sites via Carequality. “Their initial reports are that the connection enables data sharing with critical partners otherwise out of their reach and adds tremendous value to their existing CommonWell exchange. The Epic sites involved indicate that they also are able to see and consume data via the new connection,” KLAS researchers wrote.

In a blog post, KLAS researcher Corey Tate, the author of the latest KLAS report, reiterated the value of the CommonWell-Carequality connection with regard to the availability of Epic data to provider organizations who connect. “Access to the Epic data is exactly what was talked about by the initial sites that tested the CommonWell connection to Carequality. Ironically enough, Epic’s intra-operability, which was initially dismissed, will likely be the catalyst that pulls widespread patient-record sharing forward. “

Currently, all but two of the other major EHR vendors—athenahealth, Cerner, CPSI, eClinicalWorks, Epic, Greenway Health, MEDITECH, NextGen Healthcare, and Virence Health (formerly GE Healthcare)—have customers connecting, according to KLAS. At this point, Allscripts and MedHost have yet to connect to CommonWell or Carequality. However, Allscripts recently announced more solidified plans to have their Carequality connection ready in Q1 2019 and to then roll it out in product updates throughout the year, according to KLAS. MedHost has been aligned with CommonWell since 2014 but has yet to have any live connections, KLAS researchers state.

While all of these vendors have connections to this national network, only athenahealth and Epic customers have connected en masse, according to Tate, in his blog post. “Each vendor has more than 90 percent of their customers connected. Cerner is next at around 35 percent. Many other vendors’ customer bases are just getting started,” Tate wrote.

“Epic and athenahealth have near complete uptake among their customers, allowing them to work on the next steps for interoperability, such as fine-tuning usability and increasing value for clinicians,” KLAs researchers wrote in the latest report. The researchers noted that plug-and-play sharing is “virtually invisible and automatic” for athenahealth and Epic customers, and “both vendors remove the big obstacles” to providers’ success.

KLAS researchers also highlight Epic’s and athenahealth’s approach to facilitating participation, via an opt-out approach, and removing governance barriers, via predetermined handling of outside data. The researchers contend that this indicates that “regardless of customer size, vendors can facilitate widespread adoption if they choose.”

NextGen Healthcare and eClinicalWorks show the most notable progress in connecting to the national framework, according to KLAS. Since NextGen Healthcare made their bidirectional connection available in Q1 2018, customers have rapidly taken up connections to Carequality. “With 80 customers connected, there is still much room for additional uptake—though NextGen has removed both financial and technical barriers to make this a reality. eClinicalWorks customers have also rapidly taken up connections, with nearly triple the number participating today (~2,500) compared to March 2018,” according to the report.

Meditech also made their first connection to CommonWell, and CPSI has made notable progress this year as well, KLAS reports. Cerner continues to actively push for customer participation and has added 35 hospital customers.

“Virence Health (GE Healthcare) has been slower to get out of the gate despite good feedback from early adopters,” the KLAS researchers wrote. “Greenway Health also doesn’t have much momentum, and overall, interviewed Greenway organizations are the least excited about their CommonWell connection.”

KLAS researchers also note that with CommonWell and Carequality linked, the biggest technical obstacle to widespread patient-record sharing has been removed, and the biggest remaining obstacle is local community adoption. “The healthcare industry is rapidly approaching the point where an organization using any of the major acute care/ambulatory EMRs should be able to easily connect to other provider organizations with minimal cost and effort,” KLAS researchers state. “Many vendors have eliminated obstacles on the path to data exchange—all but Virence offer connections to customers at no cost, and all but Cerner have made this plug and play by removing technical barriers.”

“Today, the biggest barriers preventing widespread participation are governance and the need for organizations to decide to participate. Even Epic and athenahealth customers report diminished value from their connection when local exchange partners opt not to connect to the national networks,” KLAS researchers wrote in the report. KLAs also believes that until other vendors take an opt-out approach, provider organization leaders will need to be proactive in promoting local connections to the networks to ensure high value from the connection.


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