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An Open Letter to Dr. Blumenthal

August 23, 2009
by Joe Marion
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Dr. Blumenthal:

Thanks to your efforts, considerable progress is being made with respect to defining meaningful use in relation to the American Recovery and Reinvestment Act, with the latest announcement that definitions will be initially available by the end of this year, and will include a 60 day comment period. I am concerned however, at the priority that imaging seems to be given in the preliminary information that has come out on meaningful use, and I would offer these observations for your consideration.

From where I sit, it appears that the healthcare providers I have spoken with are consumed with just addressing their own priorities in order to be positioned to take advantage of ARRA. Certainly, there is the cost and effort to implement an EHR, but more importantly, there is the cost and effort to integrate the EHR into the myriad information systems infrastructure that already exists. What is being missed is imaging, which has the largest impact on systems capacity with respect to infrastructure and EHR's. The providers I have spoken with do not feel an EHR is complete without the ability to display and access medical imaging data.

I am concerned that this may be a “bottoms up” approach, as opposed to a “top down” one. It would be helpful if the process looked at the “end game” and worked backwards, in the context of defining what ultimately is required. One can then dissect what it takes to get there, and what are “meaningful” steps.

Let me cite an example. Many image integration initiatives are focused on single entities with multiple locations, and may already have in place applications that support patient unification. More aggressive Health Information Exchange initiatives that cut across multiple entities need mechanisms for patient unification, a more daunting task, but key to the success of these initiatives if true information exchange is to be achieved. Scaled up to the national level, these so-called “federated” exchanges will absolutely require patient unification. The challenge will be mechanisms that bridge across PACS and RIS applications, for example, to enable federation of information. Such applications become the cornerstone for these initiatives.

The travesty in waiting to address imaging in terms of a priority will be that whatever early initiatives are put in place may not be capable of supporting imaging when 2015 multi-media support rolls around. Another factor in why it should be addressed as part of the initial design is the fact that by the time imaging becomes relevant, there will be many more imaging applications that will make it even more important. Today, diagnostic imaging is the driver, but in a few years, there may be important new imaging applications with greater impact. Areas such as gastroenterology, or dermatology could have a much broader application, particularly with an emphasis on preventative care.

Today, there are many competing alternatives to address managing multiple objects from multiple locations. One such approach that is gaining increasing visibility is that of Cross-Enterprise Document Sharing, or XDS. A number of regional solutions, including Canada and Western Europe, are under way creating XDS based solutions for large regions or even country wide deployments.

XDS is supported by IHE with major contributions from a number of vendors including Acuo Technologies (XDS-I), IBM (XDS), Microsoft (XDS), and others offering the full suite of Actors necessary to create a standards based solution for sharing clinical content. The problem is that until there is some “guidance” in this area, healthcare providers will continue to be confused and uncertain over how to address it.

As one who has lived through the inception and implementation of DICOM, letting nature take its course will never enable the objectives of meaningful use to be achieved in the time frame suggested. This is going to take intervention and an immediate commitment to address what will be necessary to identify a framework that can be embraced as part of meaningful use in order to achieve its objectives with respect to imaging.

I know I speak for many in the industry that believe the time is now to take action. Otherwise, instead of real solutions in 2015, we will still be having the debate. In the early days of networking, there were many competing technologies. Does anyone remember Token Ring? One can argue all day the merits of one approach over the next, but in the end, one won out over the others, and today there is TCP/IP. I could have just as easily used the more recent debate over Blue Ray versus HD DVD. In the end, when an industry comes around to consensus, progress is made.

In conclusion, I would like to propose for your consideration as part of your efforts, the following:

  1. 1. Include in the meaningful use initiative, an effort to include imaging requirements up front in the design of systems initiatives, so that entities can begin to lay the foundation for its inclusion. If the preliminary draft addresses this, there will be ample time for input during the comments period.
  2. 2. Figure out how to steer the industry in a direction with respect to standards so that a solution is consistent in timing with meaningful use objectives. Perhaps a pilot implementation would be one approach to solidifying an industry position.
  3. 3. Seek out more input from the imaging industry. How about an imaging symposium before the conclusion of your draft?

Thank you for the opportunity to speak out. I welcome your comments as well as those in the industry.

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