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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. 

Unless I am missing something, current capabilities enable an EHR to communicate the diagnostic results, and the EHR to launch an API to a PACS to display the image.  What is missing, and I believe intended to be addressed by ARRA/MU as part of the CEHRT (Certified EHR Technology) is the ability to enable a patient to access, download, and transmit their results.  This opens another can of worms in terms of data ownership in that a primary reason for downloading one’s records would be to control who gets access to them.  But, I believe this is a confusing issue as well!

Just last week I had some dialog with an industry analyst about data ownership and what that might imply for a national health information exchange.  Are there any “hidden agendas” with either the government and/or vendors with respect to how PHI is managed and exchanged?  State managed Health Information Exchanges have recently been in the press with respect to how some are struggling.  In Aunt Minnie’s s ARRA/MU Stage 2 summary, the author states “CMS said it received a number of comments that expressed concern over the cost-prohibitive nature to build out a unique interface for each imaging provider if a health information exchange (HIE) organization did not exist to facilitate imaging exchange.”  This is yet another illustration of the confusion over image accessibility.  If access is for diagnostic (or preservation of diagnostic data), then there are already established methods for image communication (namely the DICOM standard).  There are a number of companies attempting to make a business model out of image exchange, so perhaps these comments came from some disgruntled company that hasn’t yet developed the capability?

And what of image viewing?  As previously stated, there are well-established methods for diagnosticians and clinicians to access images at full resolution.  A patient looking to see their images does not need to download them to do that.  They should be able to launch a simple image viewer to do so.  So again, what is the intent of incorporating image in ARRA/MU?

I would strongly suggest that what the framers of ARRA/MU need to do to properly address imaging is the following:

  1. State clearly the objective for image as part of ARRA/MU – is it for diagnostic purposes, clinical use, or patient use?  Clearly differentiate these in the documentation.
  2. Define specific workflow processes to be addressed as part of ARRA/MU – for example, define the circumstances and process by which a patient would need to secure access, download and transmit capabilities as part of ARRA/MU.
  3. Identify specifically if inclusion of image is part of the EHR or involves other systems (to clear up the issue of how other systems such as PACS and HIE’s are involved).  To date EHR’s have not addressed image storage and access, and it would be redundant to have them do so.

If these simple steps could be taken, it would go a long way toward resolving the confusing ARRA/MU image of imaging!

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