Most readers will agree that there are tremendous improvements to be attained through the sharing of healthcare information across organizational boundaries. The benefits include having more complete and accurate information at the point-of-care, more informed and timely clinical decisions, fewer medical errors, and a reduction in redundant healthcare services.
Despite all of the apparent benefits, governance, political, technical, and business issues have precluded most regional health information organizations (RHIOs) from achieving their goals to date.
Cambridge, Mass.-based Forrester Research recently studied the more than 100 RHIOs that have formed over the past several years and found that only seven had achieved the mission of successfully moving patient data across a broad set of competing provider institutions. While the reasons for the under 10 percent success rate are numerous, we believe that the prioritization of which types of health information to exchange can play a large part in the success or failure of health information exchange (HIE) efforts.
Where to start with HIE?
Conventional wisdom suggests that medication history and laboratory results sharing should top the list — and this is where many RHIOs have begun. There is just so much money being spent on prescription drugs, and there are so many lab tests that get ordered, there just must be inordinate amounts of money that can be saved and health outcomes that can be improved, the thinking goes.
But as John Kenneth Galbraith (the economist who coined the term conventional wisdom) explains, "The conventional view serves to protect us from the painful job of thinking." Sharing lab and medication information is unquestionably important for the effective and efficient delivery of quality healthcare. Though usually farther down on the priority list, it turns out that the hard dollar savings available by sharing diagnostic imaging information are greater than those from lab and medication information. Furthermore, the benefits from exchanging radiology studies are actually more readily achievable today.
Focus on "hard" savings
Based on data from the Center for Information Technology Leadership referenced in the table below, the potential financial savings from sharing all types of health information is enormous. When evaluating these savings, it is important to distinguish between "hard" and "soft" benefits. Hard savings are those that can be monetized and can reasonably be expected. Soft benefits include those that have non-monetary value or require substantial organizational or process changes and are therefore less likely to be readily achieved.
The hard savings from the exchange of health information are in the elimination of redundant procedures or testing as a result of having access to those existing clinical results. Breaking down the savings from HIE that way, the table shows how sharing, diagnostic imaging (radiology) information offers 64 percent greater hard dollar savings versus laboratory and pharmacy combined.
In addition to greater hard cost savings, the factors making the savings from interoperability for imaging data more readily attainable include:
Diagnostic imaging information is already predominantly stored digitally today. Device manufacturers have universally implemented the DICOM standard for years. Other forms of medical information sharing are dependent on the adoption of electronic medical records (EMRs) as well the development of interoperability standards to share information between users of various EMR systems.
Radiology services are usually delivered by hospitals or local imaging chains in which no one player is dominant. This contrasts to other areas in which there are large players with substantial influence that might have financial or political disincentives to make information readily accessible to competing institutions.
There is substantial motivation for all parties to eliminate redundant imaging. At $100 billion in annual spending across the United States, diagnostic imaging is now the second largest — and fastest growing — spend item for healthcare payers. As a response to this explosive growth, payers are increasingly deploying draconian radiology-utilization-management techniques (such as preauthorization) that call the physician's medical judgment into question and can also be perceived as limiting patient access to the best care. The elimination of redundant imaging is a much more benign form of radiology-utilization management that reduces unnecessary cost for payers, while providing benefits to both the provider and the patient.
In addition to the benefits that are both larger and easier to attain compared to other types of medical information, the exchange of diagnostic imaging provides tangible benefits for all key healthcare stakeholders.
Providers — Immediate access to prior studies both speeds and improves quality of care. For clinicians, access to a prior study enables an on-the-spot diagnosis and treatment plan. For radiologists, access to prior studies has significant impact on accuracy of diagnosis. While the standard of care for radiology requires access to priors, that access is typically limited to those procedures that were performed in house. Research at the University of Pennsylvania, Philadelphia, found that radiologists utilized prior studies in 39 percent of procedures, but were unable to access relevant priors in 19 percent of cases due to their location beyond the borders of their own institution. Providing radiologists with a single point of easy access to comparison studies could increase the rate of comparison study inclusion by almost 50 percent. Additionally, by participating in an imaging exchange, providers may be able to avoid preauthorization and other burdensome managed-care approaches to radiology-utilization management.
Payers — In implementing a diagnostic imaging exchange, healthcare payers are able to mange their utilization of radiology services without the provider and member friction caused by managed-care approaches such as preauthorization. Instead of being viewed as restricting care, payers that support diagnostic imaging exchanges are championing higher quality care while eliminating waste.
Patients — A redundant imaging exam requires that the procedure be ordered, scheduled and performed — introducing a delay and hassle factor into the care of the patient, not to mention the additional radiation exposure, risks and discomfort associated with the exam. For patients, access to a diagnostic imaging exchange speeds and increases the quality of care, while empowering their physicians to stay in control of medical decisions.
Over 100 RHIOs have been formed, yet fewer than 10 percent are sharing patient information today, despite the compelling benefits that are apparent to everyone. One RHIO effort, the Philadelphia Health Information Exchange (PHIE), started with diagnostic imaging and has been able to quickly ramp up to contain over 200 million images from about 300,000 patients. PHIE has been able to demonstrate success because of a strategic choice to begin with diagnostic imaging, a category that offers a compelling business case to all stakeholders, primarily involves exchanging information that is already stored digitally, and is a category of increases importance to payers, providers, and patients alike.
Once a diagnostic imaging exchange is deployed, the technology platform can be leveraged to support other healthcare information data so that the full potential of HIE can be achieved.
David Kates is COO for Hx Technologies, Philadelphia, and co-chair of CCHIT.