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ARRA/MU Stage 2’s Fuzzy Image

June 26, 2012
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Many impications await resolution of imaging in ARRA/MU Stage 2

In February the CMS published the proposed rules for Stage 2 of the ARRA/Meaningful Use act.  The proposed rules include the possible inclusion of imaging, specifically image sharing as a criterion.  The comments period closed in May, and now it will now be up to the government to see if imaging survives as part of Stage 2.  I have heard some rumblings that advocate the removal of imaging, as “the technology is not mature enough.”  I, for one, cannot support this viewpoint.  From my perspective it is less about the technology and more about the application, and the willingness and ability to use it.

In reviewing material on ARRA/MU Stage 2, I came across the following blog ( by David Clunie ( that does a very thorough job of evaluating the imaging references in the proposed criterion.  From David’s blog and other material, I surmise the following issues with respect to the ARRA/MU State 2 criterion with respect to imaging:

  1. Intended Audience

The proposed criterions discuss the potential for image integration with an EHR with the objective of sharing information, but it is not really clear who the intended audience is.  In some respects the proposal seems to be addressing clinician to clinician sharing, but in other respects it seems to address the need to share information with the patient.

Regarding my premise, the ability to share information between clinicians is today routine, and I seem to recall that when considered for Stage 1, part of the argument for not including imaging was exactly that such capability is generally available and routine.  There are a multitude of vendors today that are offering alternative approaches to image sharing, such as replacements for CD’s and the use of edge appliances and the cloud.  Clearly, there is incentive on the part of clinicians to use this capability. 

On the other hand, the capability for electronically sharing image information with the patient is not as robust, and clearly, despite technology advances, there is not yet much incentive for the patient to demand access to their images and to manage them (unless you happen to be someone within the industry such as myself that experiments with the technology, such as storing images on Microsoft’s HealthVault).

  1. The intended use seems to be more about EHR integration and the repository than about the rationale for sharing

Much of the specific discussion relative to imaging is around the EHR integration, and the mechanism for image access, namely a repository in the EHR or a link to the EHR.  I suppose if the intent was to make the EHR the repository for images, integration would be a factor.  In reality, I suspect that more than likely, EHR vendors are looking to imaging and imaging IT companies to do the heavy lifting in terms of the repository, and to rely on a link to the EHR for image display. 

Related to the repository question is the viewer technology.  If EHR vendors are responsible, they will have to be responsible for the viewer technology as well.  Alternatively, if the link approach is employed, the viewer can be from any number of vendors, and can address any number of requirements.  For example, for clinician access it may be essential to have a viewer that can present the native image format, such as DICOM, whereas for a patient view, it does not have to be diagnostic and it could be a simple image viewer.  Similarly, there are emerging “zero footprint” viewers that will enable linking ever more sophisticated image viewing and processing applications to the EHR. 

It does not appear that the basis for sharing is as well defined.  The key sharing implication is that information will need to be shared in native format so that diagnostic quality is preserved.  More on this in the next issue.

  1. There seems to be a preoccupation/perpetuation of the use of DICOM

I have nothing against DICOM, but it seems that perhaps it is a consequence of the state of the industry that the drafters of the proposed criterion dwell on the use of DICOM as the format for sharing data.  Granted the most advanced imaging services such as radiology and cardiology rely on the DICOM format for most of their requirements.  However, this ignores the prospect for imaging areas that are not yet nor may they ever be part of the DICOM standard!  Take for example the case of Dermatology, where the majority of images may be generated from cameras and which are already in an industry standard format such as JPEG or BMP.  In these cases no diagnostic information is lost to deal with them in this format as opposed to DICOM.