Imaging feels cost pressure from value-based care incentives

Efforts to rein in spending on expensive procedures will place a premium on improving image management and sharing across the enterprise.

With the financial impact from value-based care expected to rise dramatically next year, many health systems, providers and stakeholders are starting to take a hard look at how imaging can contribute to survival under the reimbursement overhaul.

“When you think about the triple aim [improved care, health and cost] of value-based care, improving the patient experience through proper and timely transfer of images improves their experience and gets the patient’s information faster into their doctors’ hands,” says Amy Vreeland, CEO of Imaging Strategies, a consultancy.

But hospitals aren’t necessarily organized when it comes to managing images, Vreeland says. For one thing, hospitals don’t marry the business, clinical and IT expertise needed to succeed when it comes to imaging and value-based care. These departments are siloed, and often don’t understand each other’s roles in the bigger picture of enterprise imaging, she says.

Most providers are focused on DICOM (Digital Imaging and Communications in Medicine) images—those that fall under the international standard for medical images and related information image capture and display. These images include CT scans, MRIs and X-rays—“the images that most lay people are familiar with,” Vreeland says.

But enterprise imaging involves looking at all the varying additional images used by healthcare providers, not just DICOM diagnostic images. These might include the images doctors capture on their mobile devices, which may include photos of injuries incurred from child abuse or domestic violence—to be used for social services purposes. These images need to be stored and labeled properly, but most health systems are not even aware of how important this is, Vreeland says.

To date, in most cases, “no one has ever owned all these images at a corporate strategic level,” Vreeland says. “I think health system leadership may not know the types of HIPAA exposure, redundancy or lack of transparency these images pose. The situation has crept up around them.”

Most radiology images are relatively easy to exchange today, according to David Mendelson, MD, professor of radiology at the Icahn School of Medicine at Mount Sinai Hospital, New York, and senior associate of clinical informatics and vice chair of radiology IT at Mount Sinai Health System. Bandwidth is not an issue—files much larger than those produced by radiology imaging are exchanged routinely by the average American household, he says.

The biggest obstacle is the lack of standardized protocol for sharing images over the Internet.

“This is radiology’s share of the interoperability problem,” Mendelson says, but there is a silver lining. Radiology may be closer to solving interoperability than the rest of the healthcare sector.

Mendelson is principal investigator on a Radiological Society of North America (RSNA) pilot, funded by a grant from the National Institutes of Health. The pilot allows patients to control and personally store their radiology images. So far, the pilot involves 26,000 patients at 11 sites nationwide. Patients can determine who can access their images.

This would be an ideal solution to radiology interoperability, Mendelson says—if patients actually wanted to take on the responsibility of managing their images.

RSNA is working on another alternative that shows even more promise, he says. It’s a validation program that certifies that vendors are using one set of standards for secure image exchange (SIE). “It’s an effort to make them play nice with each other,” he says of vendors, some of which still cling to their proprietary exchange capabilities, much like electronic health record vendors. So far, eight vendors have taken part in the pilot, and some have passed portions of the certification requirements. “There’s a success story building here,” Mendelson says. “Vendors have reached the point that they understand this is what they have to do.”

However, a more basic problem nags at imaging efforts in a value-based care world—not all imaging devices can communicate with each other. That’s why many times, patients must transport their images via CD when they go to another provider.

This impedes workflow, because physicians cannot see the images ahead of the patient’s visit, says Jim Phillips, senior vice president of client services at lifeIMAGE, a medical image exchange vendor. This leads to a potentially frustrating experience for the patient and often results in duplicate testing, both of which directly impact value-based purchasing reimbursement.

LifeIMAGE, founded seven years ago, has found a way to help any picture archiving and communication system read an image sent via the Internet. Phillips describes it as a hybrid solution, in which healthcare providers pull the information off the Internet, where it is then adapted to be read in a uniform way by any image reader. It’s currently being used by more than 130 multisite health systems across the country.

And with the dramatic increase in telehealth services in recent years, integrating telehealth communications with EHRs and enterprise-image viewers is the next frontier for health IT, as value-based care takes hold and providers ramp up efforts to restrain needless expenditures.

To support this, Calgary Scientific provides an alternative to moving images around. Many times, even when patients carry a CD of their images from one place to another, some physicians or hospitals can’t open the CD and convert it into something they can read. Calgary Scientific’s diagnostic medical imaging software, ResolutionMD, allows the images to be stored on the cloud and viewed via a web-link. The viewer can be implemented with any PACS (picture archiving and communication system), says Jonathan Draper, director of product management for healthcare at Calgary Scientific.

The company mainly sells its solution to health systems, according to Draper, who says the solution also makes it easier to consolidate all the archives a health system has—sometimes as many as seven—easing workflow for physicians who have to use different screens with different passwords to access different PACS.

Imaging Strategies’ Vreeland advises healthcare providers to start with an enterprise imaging audit, then develop a strategic plan regarding images. By determining the scope of the problem first, healthcare providers can begin to talk to vendors about how to solve the problems they discover.

An enterprisewide strategic plan is critical to prevent duplication of imaging, and to capture potential lost revenues related to imaging, Vreeland says. Many hospitals offer ultrasounds at the bedside, but they may not be aware that they can bill for these ultrasounds.

Not to be overlooked are the problems—and costs—that could be incurred by HIPAA violations. When doctors give up on the difficulties of image exchange and take a picture of their PACS screen and text it to another doctor, this is a huge risk. There are always ways the patient can be identified—the photo may include a partial image of the individual’s face or a photo that includes the patient’s ID bracelet may be sent along with the diagnostic image. If this information were to be stolen, the hospital could face a major HIPAA violation. “You can’t blame the doctors for trying to get patient care done,” Vreeland says.

For the most part, hospitals are doing an “increasingly good job” at exchanging DICOM images—but the problems lie in making sure the right image is in front of the right clinician at the right time, she says. And proper labeling of images remains a problem.

In addition, the speed of images being exchanged can be a problem to the bottom line, Vreeland says. Delays in getting hold of images can put a kink in efforts to control lengths of stay.

Having the right radiologist with the appropriate skill set available to read images is another enterprise problem. Most smaller community hospitals lack a subspecialty radiologist, such as a pediatrics radiologist, if images from a child need to be studied.

So, for instance, a patient might be transferred to an academic hospital unnecessarily—having subspecialists read images can ensure the proper interpretation of images, resulting in reduced costs related to value-based care for patients who can be supported in lower-acuity hospitals, while ensuring higher-acuity care when needed.

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