Everyone in healthcare these days is talking about the new connected healthcare—a U.S. healthcare system that will seamlessly connect patients to clinicians, clinicians to other clinicians, all kinds of patient care organizations to each other, and the payers and purchasers of healthcare to everyone else. Yet even as health information exchange (HIE), patient engagement, and coordination of the transitions of care move forward, what to do about diagnostic images remains for most healthcare leaders something of a conundrum. And as much as we in healthcare are awash in diagnostic images of all kinds—not only from radiology and cardiology, but also from pathology, gastroenterology, dermatology, pediatrics, and other medical specialties—how to create an information superhighway for images as well as documents, remains an unresolved challenge.
Still, at some of the most advanced integrated health systems, leaders are moving towards some level of clarity. One of the most advanced with regard to imaging informatics is the 20-plus University of Pittsburgh Medical Center (UPMC) health system in western Pennsylvania. There, leaders are focusing on how to make images move seamlessly, with a patient-centered focus. Rasu Shrestha, M.D., the organization’s vice president of medical information technology and its medical director for interoperability and imaging informatics, puts it this way: “If you look at the healthcare landscape at large, we essentially have three buckets of data: you have structured information, unstructured data, and then imaging data. And up ‘til now, you’ve had all these EMR deployments involving structured data; and interoperability efforts; and then natural language processing initiatives. And historically, PACS [picture archiving and communications systems] has been a very separate area, though of course, cardiology, gastroenterology, and other –ologies are becoming involved.”
Given all that, Shrestha says, “Going forward, I think it’s going to be more of an enterprise play. And we need to get a fuller picture of what’s going on with the patient. So that story of connecting the dots will need to continue to grow, and will need to embrace imaging in a big way.” Importantly, says Chris Deible, medical director of radiology informatics at UPMC Presbyterian, the system’s flagship facility, “I largely agree that we’re definitely going to have to bring things together in a patient-centered way.” Indeed, in that regard, Deible says, moving forward on health information exchange, when it comes to images, means this: “I think that globally, a lot of aspects of HIE will be governed by local policy and hospital interactions, so part of this comes from everybody realizing what they have to benefit from it.”
Similarly serious discussions are taking place at the eastern end of the state, among the folks at Penn Medicine, the four-hospital integrated health system based in Philadelphia, where a whopping 7.2 million diagnostic imaging studies are done annually in radiology and cardiology. There, Jim Beinlich, the system’s associate chief information officer of entity services, has been helping to lead transformative work, via the convening of a Medical Imaging Steering Committee, which came into existence last summer, and which has been overseeing the selection and implementation of a vendor-neutral archive (VNA), and other capabilities (as of press time, VNA vendor selection was set to take place by around April. The goal at Penn Medicine, he notes, is to seamlessly integrate the VNA with the organization’s electronic health record (EHR), its patient portal, and its provider portal, as well as its HIE capabilities that are connecting Penn to other patient care organizations. The goal is an ambitious one, and will take some time to execute, he notes.
Community-wide views, and beyond
It’s important to note that most U.S. communities are still not live with regular image-sharing even as most health information exchanges have been live with data-sharing for several years now. The governance, process, and technological issues are all factors, say HIE leaders. For example, Daniel Chavez, executive director of San Diego Health Connect, is currently leading preparations for a go-live of image-sharing at SDHC, whose activity spans 19 hospitals, 125 clinics, 9,000 physicians, and 3 million lives across the far southwest corner of the state of California. SDHC has been live with patient records exchange for over a year, but Chavez notes that it will have taken two years of preparation to go live with images, because of the complexity, and thus, the HIE will not be live with image-sharing until sometime next year.
“It takes time to ramp up properly to image-sharing,” Chavez says bluntly. It’s a function of our own resources, and the resources of our participants. We have to prioritize, the priority was to bring up the virtual record first. But it’s a board-approved project to share images, but they want to make sure the images can ride on the same network, and the challenges have been around the anticipated speed of the network, and around patient identification. The images are going to ride on the same rails. These are large data content files, and the speed and the performance have to be there. And, too, each of the participants has a small investment; they need to set up a staging server so we’re not hitting up their native PACS. The system rides outboard, so that exchange doesn’t impact production radiology functions.”
And all of these issues also inevitably lead to a policy-level discussion of the place of the diagnostic image in the new, connected, transparent, accountable healthcare. Russell P. Branzell, a former CIO and the president and CEO of the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), asks, “Who really owns the image? If you look at most people who move through a continuum of care, they have image management in multiple locations—cardiology, radiology, pathology, whatever the case may be, and even old hard film converted to digital images. And I think that what will occur is, there’s going to be this ubiquitous aggregation of images. But it may well be not organization-specific, but rather, patient-specific, and how they gather and garner those images across that.”
Importantly, Branzell says, “There’s still the holy grail that’s missing here, which is appropriate patient-matching and identification. Kudos to ONC [the Office of the National Coordinator for Health IT] for starting the dialogue and the discussion, but in some cases, there should be fairly clear ability to do this, through electronic authorization. I recently tried to get my daughter’s images from Colorado, and they wanted to send me a form via fax,” he notes (Branzell and his family recently moved from Colorado to Georgia). “And I said, I don’t own a fax machine: it’s 2014! And this was my own former organization, which was balking at creating an electronic pathway to send me images for my family.”
In the end, Branzell says, “It’s time to look for new technology and create innovative solutions. And I think we’re not far from that but it’s like fee-for-service healthcare—we’ve still got a lot of people addicted to the current technology. But you see a few people every now and then who are really pushing the envelope.” And clearly, with just the right new technological innovations, as well as process innovations, and collaborations across entire communities, the future of image-sharing is wide-open—and ready for transformational change.