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ARRA/MU: Confusing Imaging Image!

August 29, 2012
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Final Stage 2 ruling is confusing when it comes to Imaging.

I have been reading several posts attempting to interpret the impact of the final ruling for ARRA/MU Stage 2, and the absence of imaging.  As best I can conclude, the “image” of imaging is one of total confusion!

In my view, one needs to keep the proper perspective when it comes to consideration of image and ARRA/MU.  Part of the rationale for why imaging was not part of the Stage 1 criteria was that imaging was already well established, and therefore, it was currently accessible and didn’t need to be encompassed in ARRA/MU.  Many facilities have already worked out protocols for image access by means of their Picture Archiving and Communications (PACS) applications. 

Current mechanisms involve DICOM transfer between systems using such protocols as DICOM Query/Retrieve.  Or, the more mundane approach is to copy studies to a CD/DVD and transport the media.  These approaches may not be elegant, or integrated with the rest of the patient record, but they work.

So, I was surprised to see imaging included in the proposed rules for Stage 2.  Digging into the language though revealed a whole different aspect of imaging’s inclusion in Stage 2 – namely patient accessibility.  This is consistent with ARRA/MU’s emphasis is on patient results accessibility, including the patient.  The language and the comments all paid considerable attention to downloading images at full resolution, and having a viewer (such as DICOM) to display them.

What is confusing to me is what ARRA/MU is attempting to address relative to imaging.  There does not seem to be any consideration of clarification of the old adage, the Who, What, When, Where, How and Why!  The ability to share information between clinicians is one thing.  The ability of the patient to access and download images is entirely another.  To clarify:

Who:  Does ARRA/MU speak to the clinician, the patient or both?

What: Are we attempting to address “diagnostic” or “clinical” image access? Or both?

When: At what point in the diagnostic/treatment process is access to images required? During Diagnosis? Treatment? Afterward?

Where: Are we speaking to EP’s, ACO’s, and/or the patient in terms of where this information is accessed?

How: Is the need simply accessibility or control over the image?

Why: What is the reason for image access? 

I would ask that in the ARRA/MU process, did anyone sit down and attempt to address requirements from a clinical process basis?  I would further speculate that there are probably many in the industry who are interpreting this differently because of a lack of definition.  The result is what we see in terms of the comments relative to why download and transmission of images was left out of Stage 2.

David Clune’s August 24, 2012 posting is a good example.  Dr. Clune makes some excellent points with respect to some of the comments regarding the need for DICOM or non-DICOM access.  But again, I am struck with the lack of any clear understanding of what we are trying to accomplish.  For example, Dr. Clune points out that “Lost in the analysis of the comments seem to be two fundamentally important factors…,” and then goes on to describe that “If that third party is …. any one of a multitude of specialists with imaging expertise, your damn right they need diagnostic quality images.”  In addition, he states with respect to the EHR, ” what these systems are called and who sells them is irrelevant; PACS can contain functions of "Certified EHR Technology" too!”

Did the framers of ARRA/MU mean to address image sharing and accessibility between clinicians?  I thought that’s what PACS and all of the associated technologies were for!  On the other hand, why does a patient need to “download” or otherwise “transmit” images?  And, what does this have to do with the “quality” objective of ARRA/MU? 

In a summary of Stage 2 in the online Healthcare IT News, Farzad Mostashari, MD, national coordinator for health IT is quoted as saying that “The big push in the Stage 2 rules is to move beyond data collection to improving care.”  A summary by Healthcare-Informatics addresses concerns by Charles E. Christian, CIO of Good Samaritan Hospital, Vincennes, Ind. who, “sees an issue with access by the patient, who see their primary care physician and also use care from another setting such as the community health or outpatient diagnostic services can use more than one portal, “and we don’t want to do that.”

Clearly, both see the emphasis of ARRA/MU as improving patient care and emphasizing the patient by means of interaction with an EHR.  Not even the ARRA/MU framers suggest that imaging has to be part of the EHR, and address the capability of a linkage between a PACS and an EHR.