Roundtable: Evolving Image

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change on healthcare organizations, imaging departments are encountering a turbulent world of challenges and new directions.

Technological advances continue to give radiologists improved abilities to identify patient conditions and support care delivery. But economic forces also are affecting the way imaging professionals, and the executives who manage those departments, approach their jobs.

Consolidation within the healthcare industry is focusing new attention on how to manage images throughout an enterprise. Radiological studies of patients involve larger file sizes, creating storage, file management and exchange issues. And new reimbursement models that incentivize the value of care over the quantity of services represent a quantum shift in how radiological departments have operated for years.

These were among the concerns discussed during a roundtable discussion by Health Data Management and sponsored by Mach7 Technologies.

Moderated by HDM editor Fred Bazzoli, the panel included Louis Lannum, director of enterprise imaging at the Cleveland Clinic; David Marichal, chief technology officer for Radiology & Imaging Specialists of Lakeland, Fla.; Paul Pierre, enterprise imaging architect with DISYS Consulting, Toronto; Amy Radonich, director of enterprise imaging informatics at UC San Diego Health System; Eric Rice, chief technology officer for Mach7 Technologies, Burlington, Vt.; Gorkem Sevinc, managing director for the Johns Hopkins Medicine Technology Innovation Center, Baltimore; and James Whitfill, chief medical officer for Scottsdale (Ariz.) Health Partners and a member of the board of the Society of Imaging Informatics in Medicine.

What follows is an edited version of the roundtable, which was held in conjunction with SIIM's most recent annual meeting.

FRED BAZZOLI: As we look at the current state of imaging informatics, what are some of the biggest challenges, in light of industry consolidation, and the increased use of and dependence on imaging modalities?

GORKEM SEVINC: There's a lot of work being done to modernize healthcare standards, with HL7 and DICOM, but the adoption process takes a long time and is challenging. With the older versions of these standards, it's very challenging to do new integration. We use antiquated technologies. Come on, this is 2015! All my devices can talk to each other, but some of my imaging modalities cannot talk to my PACS unless I do a static IP.

DAVID MARICHAL: As a large radiology group, we have to deal with the various entities that we serve. The governance is very difficult because there are a lot of competing entities that are trying to come together and work together. So how do you bring competitive entities together, and who is going to be in charge of setting some of these standards? Whether they're technology standards or data-sharing standards, it has been difficult to get a consensus with these entities as they come together, even with somebody who has been a partner.

BAZZOLI: Is this just a reflexive reluctance?

MARICHAL: We are working with a hospital that we are getting ready to start a significant joint venture with in outpatient ambulatory imaging. Their CIO is still very hesitant to set up diagnostic imaging exchange, where we can share images across ambulatory services and the hospital. How can you get to the level of true enterprise image sharing if the CIO is worrying about who is going to own the data? We're trying to become more patient-centric; as we work toward a value-based model of care, and as we're trying to take care of populations, we have to be able to share imaging and data into some type of a consolidated patient health record. Everyone needs to come to a consensus on how to do this.

PAUL PIERRE: Security and HIPAA are often thrown up as a barrier, whether it's real or imagined. Once you break through that, then you get to all of the technical issues. Some is just logistical-if I've made several copies of an image because I've shared it with four or five different systems, and now the clinical data needs to be updated, I've lost reference to four of those copies. So now, what's the true, latest piece of that information? We lose the traceability, so how do we effectively update if there's new metadata or new diagnosis?

MARICHAL: It's just kind of peer-to-peer now, specific imaging object change management. But does that really go deep enough to meet our needs?

LOUIS LANNUM: There's a price tag every time you duplicate an image. It's storage for one-there are hospitals that have multiple petabytes of data just stored in these silos, and they keep replicating the images instead of coming up with ways of sharing or viewing those images without duplicating them. If you can do that, you may not have to worry about these other issues. Change something on the one image, share it and reference it.

BAZZOLI: Eliminating image duplication seems like a reasonable way to centralize information, manage it better and get rid of duplication that may cause more harm than good.

LANNUM: But nobody I know today deletes any type of image. They just don't-they keep it forever.

MARICHAL: We tried, and our attorneys told us we couldn't delete them.

PIERRE: We're at the reverse point. Administration wants us to start getting rid of this duplicative stuff, and the clinicians say no.

LANNUM: So we don't delete anything, and we have no problem replicating it. But every time we replicate something, there is a price tag that someone has to pay in your organization. If you go into your organization and take a look at how many images are stored on what media, and how many petabytes you have out there, it's an astounding number.

PIERRE: And when you start to consolidate these previously fragmented enterprises into a single enterprise, and you try to figure it out, that's when it starts getting really messy. Because if I have seven copies of this image shared to seven different parts of my organization, what is the source of truth?

AMY RADONICH: When you get this information from other facilities, yes, we can send it back and forth, but it doesn't make the patients comfortable or the CIOs comfortable because nobody can prove the reliability of the handoff, who's going to take receipt and will always keep it. There seems to be a complete lack of trust. We could save a lot if we had a way of transferring encrypted safe images across the country. There has to be an easier way for us to get the trust of executives to freely exchange this information with each other without a signed and notarized authorization for release.

LANNUM: Do you really have to exchange it? If I already have it in my repository, can't I just let you look at it?

SEVINC: The new DICOM standard would allow you to do that, while keeping the images where they are.

MARICHAL: With DICOM and HL7's FHIR, healthcare is finally catching up with what every other industry is doing. Financial and e-commerce institutions are light years ahead of us in securely transmitting and sharing data.

BAZZOLI: It's appearing that healthcare organizations now believe that it's a competitive disadvantage for vendors that have products that can't share data easily. Won't that be expected of imaging applications as well?

MARICHAL: I think we're going to hit a tipping point with that, and very soon. Interoperability will be mandated, and the government has already said it's going to happen. I'm excited about the ability to actually share data.

PIERRE: Now there's a downside. When you look at the raw data you've got-and some has been gathered over the last 10 or 15 years-and you mine that data and look at its quality, you can find all kinds of horror stories about poor quality. You'd probably say, "Thank goodness I wasn't exposing this outside of the organization. At least I've got a chance to clean it up." You wouldn't dare publish this data to anyone because you'd be embarrassed and you might get sued if somebody knew how out of date it was.

LANNUM: We can be very meticulous about the quality of our images, as radiologists, but we don't seem to care as much about the metadata, and it's just as important because, without the metadata, you can't find the image or the image isn't as relevant for the next person who uses it.

SEVINC: Metadata quality is not only a problem in imaging, but it's really a problem in all of healthcare. So yes, we do have some poor metadata. But at the same time, our diagnosis is based on the pixels, so even if the information associated with the image is bad, I can still do my work one way or the other. All I need to know at this point in time, is the medical record number, a session number that uniquely identifies the images and the image pixel value itself. We've gotten by with that, but now, we can't provide value with that. We need to do a lot better with the quality of the data that is going into the metadata.

LANNUM: As a radiologist or as a producer of images, you'll put up with bad metadata because you can still do your job. You can still look at the pixels and generate a report. But there are 10 other physicians and healthcare providers looking at the same image after you and, without the right metadata, they may not be able to look into the medical record. They may not be able to associate it with the right patient.

BAZZOLI: But isn't that entering a whole different discussion? Because what is radiology's responsibility and what is the enterprise's responsibility?

SEVINC: Radiology does diagnostics, and for us to do diagnostics, we have PACS viewers, so that we have all the tools we need to be able to provide our service. Others in the enterprise may just need to take a quick look at the MRI image and don't need to have all the tools that I have. That's why we are rolling out enterprise image viewers, and these can be web-based viewers. It lets us provide so much more accessibility to our images. So with the enterprise viewer, you can use a small application that points you to your vendor-neutral archive.

BAZZOLI: That sounds like a step forward.

SEVINC: But it raises the question of who manages what. Radiology IT organizations can be small. At Hopkins, we have a 900-person IT department; we have 50 people in radiology IT, which is a lot, but even so radiology IT still shouldn't, in my opinion, be managing a vendor-neutral archive-it should be an enterprise-provided service. But a VNA can be highly unorganized. It's like Dropbox. If you don't organize your Dropbox, it's not going to organize itself.

ERIC RICE: When you think about PACS in the 1990s, everyone rushed to go digital, and there were a lot of proprietary approaches. So we're now living with the hangover from that. I think radiology departments have been able to come up with a lot of efficiencies, but now there's this need to interoperate at a much higher level. So imaging is moving beyond the radiology department and into the enterprise, especially as institutions are spending millions of dollars to implement EMRs. Now, as patients move between organizations for care, we have a whole new set of challenges. As a vendor, I think an enterprise VNA is going to help to consolidate that.

PIERRE: One of the challenges in moving to these new architectures is that you not only take operational control of this data away from radiology, but you need to find a way to say, "I understand that is good enough to do the diagnostics, but it's not good enough for everybody else." Radiology has to get it right, when it does the image acquisition, because it's now part of an enterprise, and because of that, you have to get it right. In these very distributed enterprises, it's a hard message to deliver and execute consistently.

BAZZOLI: That's a tough message to deliver. Who in an integrated system is supposed to enforce that mandate?

SEVINC: It can fall to the CIO, or CFO, or even the CEO.

LANNUM: Look at what's been done with the EMR. It's been implemented and it is an aggregator of structured data from a lot of departments. With an enterprise imaging strategy, you can't let it be driven by a single department. It has to be an enterprise initiative, coming from the CIO with the chairman of radiology supporting it.

BAZZOLI: But does the CIO have the bandwidth to do this? They have a lot of other priorities, so do they see the importance of this?

LANNUM: In a lot of organizations, they're starting to. With the VNA in an enterprise imaging strategy, it's not if you're going to do it, but when you're going to do it. Otherwise, we're missing that whole piece inside of the EMR. Imaging may be done in a variety of settings, but clinicians can't see it in the record.

RICE: We had one customer who said our EMR is like walking into a museum with no art. They see a VNA as being able to bring the images to them.

PIERRE: CIOs have been EMR-focused, and they just didn't worry about imaging-they felt it was expensive, but it's working. But as they tried to include imaging as part of an extensive enterprise where you're starting to redo workflow and reallocate resources, it's harder. As they start to look at imaging as part of the information in your EMR, they're starting to recognize those things, especially as they realize they need to reduce their cost structure or that they need to share information through a regional data sharing network.

JAMES WHITFILL: All of a sudden, our responsibility for imaging is exploding. At the same time, the economics around imaging are about to fundamentally change. Imaging is going to become a cost center in every hospital system in the country because of the move to value-based care. Now, if we get paid a lump sum from treating a population of patients, all of a sudden the revenue model from imaging is going to be completely different.

BAZZOLI: Are you ready to cope with that change and the extent of the impact it will have?

WHITFILL: On the accountable care side, we're just overwhelmed trying to do the basic stuff, and the bottom line is we haven't been able to figure out how to do ACO 101 stuff. There are some smarter people out there who have figured out how they are going to be able to demonstrate some sort of value and outcomes, to show a difference in achieving outcomes or how to do imaging for 30 percent less cost. There could be some big winners, and we have to be able to figure out how to do it.

PIERRE: With these new accountable care approaches, what will be the biggest challenge for the large radiology practice that is partnering with five different institutions?

MARICHAL: We add value to healthcare by the quality of the diagnostic work we do with the images we assess.

SEVINC: You produce a radiology report, which is really just a block of text in medical terminology. You have to answer the question of how do you help the clinician who is caring for a patient understand what is in the report. And getting to the point of access, because you have to have some sort of a strategy where you at least do the long-term storage of the images together. And as patients get access to what's in their charts, they're going to have access to their radiology reports. And more importance is going to be attached to radiologists determining what should be an actionable finding or a critical finding. How do we change what radiologists do with their reporting? That may be very difficult because they're used to dictating and just flying through cases.

MARICHAL: We have to go in the direction that you're talking about to remain relevant, to have relevancy at the point of care. The other option is to just end up being just a "CYA" position that's just sitting there for legal purposes, doing what they have to do to cover somebody else legally. Does that really affect the care of the patient?

WHITFILL: I think it will become our responsibility in radiology to follow up on actionable findings. Radiologists love to discuss with each other how they can be more relevant to care delivery. I think we can do that by following up on our findings; by taking care of the patient; by intervening. Providers say, "Stop worrying about RVU production and help me figure out what's going on."

RADONICH: What do the patients want providers to do? At our institution, patients have access to their record, so once a radiology report is done, we give those images and the report to the patient.

MARICHAL: If we're going to share images, it can go to the level of the patient. I think we need to create human readable reports for our patients so they can understand the recommendations and the highlights. A lot of times, there's really esoteric discussion in these reports. As we get to the point where we talk about sharing a big part of what we produce, which is the report, the image is kind of a byproduct. Patients increasingly want to own that data.

PIERRE: Radiologists are starting to be more attuned or in touch with the patient, but here is where the whole thing starts to break down: Now they're expected to speak to the patient, but their facing a 30 percent cut in pay because organizations want to reduce imaging volume because of new reimbursement incentives. So you're going to do the same amount of work for 30 percent less, and you're going to be asked to, actually, be a GP, too.

SEVINC: There are more educated patients who know what they're asking for. They've gone through this; they've gotten two or three opinions already. They just want an answer about their images. Most of the time, the patient doesn't know that a radiologist is a physician.

MARICHAL: We've had patients say, "Radiologists? Aren't you the people who are sitting there when you're shooting my images?" They don't understand that a radiologist is a diagnostician; the radiologist is the one who is really interpreting and starting the diagnostic process. That perception of the radiologist's role needs to change.

RADONICH: When you get lab results on a chart, they're understandable. You see that results are within normal range, abnormal, high, low, whatever. Wouldn't it be interesting, from a radiology perspective, to see that your report is either normal, follow-up required, or abnormal? Our results are not all that patient-intuitive.

MARICHAL: I'm focusing on the imaging side of the sharing. I'd actually like to see more interactivity so that within the image set, you'd have call-outs or something more human readable, that was directly part of the reporting process. So when a radiologist is mentioning something and annotating or circling or measuring, I'd like to see that embedded right on the image.

LANNUM: That's kind of like what gastroenterologists are doing. They're producing a report that's structured, and they've got clinical findings in it. But they put relevant images on the report. So when you talk to the patient, you show them, "Here is the polyp, there's the polyp." The patient is looking at the image; that's relevant to the patient and, guess what, it's relevant to the referring physician, too.

BAZZOLI: Let's talk about the sharing of images. They're not just coming from radiology solely, correct?

LANNUM: This discussion has been very radiology-centric. Hospitals have been giving physicians cellular phones for communication. When I give you that, I've just given you an acquisition device because you're going to start taking pictures of your patient and send them attached to text messages. We've got to have a strategy to store those images, because they're just as clinically relevant as a radiology image.

PIERRE: You've got to put all these images in a clinical context and present it in a clinically relevant context, along with the EMR. These are hard to share.

LANNUM: There's a problem with a lack of standards. There often is no concept of a DICOM work list. Everything is being hand-typed, everything is being saved on flash drives. There's no comprehensive imaging strategy to identify, to manage, to store and to provide access to all of these images. We can have this in radiology, but we've got to take those best practices across the enterprise and apply them.

MARICHAL: It's a problem because all of these specialties that are now starting to feed into these enterprise archives, we really should have something like a universal or enterprise modality work list type of approach. It should be done through Web services so that any web-enabled device can access images with any device, like an iPad or iPhone.

BAZZOLI: What exactly is the problem with the images coming in from all these handheld devices?

SEVINC: Well, it can be done. What I have seen is that, at some institutions, the JPEG image is put as part of the progress report. Good luck with that.

LANNUM: If you put a JPEG as part of the progress report, and then you get another progress report, and you put in a JPEG with that, you can't compare them side by side. You don't see the longitudinal record. You've got no idea what the previous one looked like, and you're missing the continuity.

SEVINC: There's also other media we have to worry about. What do you do with audio? Who is responsible for storing it? How are videos stored, because DICOM doesn't do videos?

MARICHAL: Well, we have to have the enterprise archive. You have to have it.

PIERRE: This is close to my heart-I do a lot of change consulting, and this is all great stuff, but how do we get better at flowing this kind of transition in an organization when it seems like, in most, you have to talk to each and every physician and make the case to them? It's honestly like house-to-house combat. You've got this autonomy thing going on; they can't seem to adopt anything because everything is such a hard decision.

RADONICH: At our organization, the governance matters. We have really found that the dean of clinical affairs and our chief experience officers have been invaluable to us because they're communicating with the clinicians and doctors consistently. They really have the ear of our CEO and the momentum of the company behind them. They're a very large part of our governance in how we're doing things, and they have said they will take on the communication. I think that's one of the unique positions of being a service line in the medical center rather than being under the CIO in the IT department; we've been able to leverage these people who have the physicians' ear.

PIERRE: Wasn't the CMIO supposed to be that bridge to the physicians?

WHITFILL: Most CMIOs-at least the ones I've come across-are largely focused on EHR adoption. Depending on the organization, they're using the CMIO as a puppet to push forward an unpopular policy. There is a growing number of CMIOs who are seen as equal partners in this process, but I think a lot of times, they've been co-opted, and then what happens is the clinicians say, "I don't trust you."

LANNUM: Is image distribution really part of the EMR?

WHITFILL: Earlier, someone asked if it was the CIO's job to set up governance of imaging. I think everyone here is saying you can't have just one person. You've got your clinicians, and you've got to have your stakeholders. That's the key.

LANNUM: At the end of the day, all of the imaging is the missing component of the EMR. It's not just the radiology. Most organizations today have a nice integration between the EMR and all of the imaging in radiology. But you really need more. What's missing is everything else-a longitudinal record of wound care; a longitudinal record of all of the ultrasounds by OB-GYN. We're missing true multimedia display.

SEVINC: It's not a technological challenge; the data is there. It's just policy.

PIERRE: As consolidation occurs, for radiology, you're part of an enterprise now. You will need to conform to some level of structure in your data management. If I acquire information of any form, I will need to follow these principles and practices. I will only buy technology that enables that. For doctors, you're going to do this-it's not going to be house-to-house combat to get their approval.

MARICHAL: It's because it can bring benefits and enhance patient care. That's what you're talking about because that's the only way to achieve those things. You can no longer have one-off cowboys off just doing their own things in an enterprise.

SEVINC: How many years are we away from really implementing enterprise solutions? It's not the technology that's the challenge-it's the number of years it's going to take for adoption and the number of years for implementation.

LANNUM: Why is healthcare such a late adopter on all these technologies? They're not new.

RADONICH: There is so much legislation governing diagnostic imaging and the IT associated with it.

BAZZOLI: And there is so much institutional inertia.

LANNUM: I think it's got more to do with the institution than anything else.

SEVINC: And security is an issue, but it's used as an excuse many times.

MARICHAL: My organization is a covered entity under HIPAA. If you read the law, there is no signed authorization required for a covered entity as long as it is part of the chain of care for a patient. It's that simple; the law was never written to keep a consultation from occurring, but people have put so many barriers around that when it comes to image sharing, or any sharing. That's just a complete misread.

PIERRE: Maybe it's the cynic in me, but people use HIPAA as the stop point excuse to not change, because they don't want to. It's going to impact their business model.

SEVINC: And talk to chief information security officers and ask them how they feel about the cloud, and the first thing they're going to throw at you is HIPAA. They're going to say, "Wait, what are you doing with my data now? Who is accounting for that data? What happens when there is a breach?" But in the future, what we're going toward is web standards. And Web standards are great because they figured out security much better than we have.

PIERRE: The standards have only solved part of the problem. At some point in time, before this API can speak to that API, you have to figure out the business contract and again, somewhere along the line, there has to be a contact enforcement, some mechanism that says you are part of this chain of care, and that gives you the right to access this particular patient's data.

MARICHAL: From the radiologist's perspective, when we're talking about image sharing, we get confused. It's more than interconnectivity. Radiologists can't necessarily sit down and read a CT that was done, and they want a comparison to the last CT that was done or the last relevant prior...and it was done maybe five miles down the road. Why can't we index things, have it available, know about it, tie it to a master patient index and make it part of a single patient record for that patient? Whether it's a radiologist or any other specialty, they need to know that the record and image is there and have it available at the point of care, every time.

PIERRE: That's solvable now, but have you ever gone through the governance process to get all those organizations around the table to say, "We're going to agree to do all of this, and we're going to empower IT people to make it happen"?

MARICHAL: We've started, twice, trying to bring all of our healthcare entities together to the table to discuss the very fact that we're doing our patients a disservice by not sharing these records and by not sharing these images. Both times, it's been difficult.

LANNUM: We can do better without even moving the data. All we have to do is be aware of it-and we're not aware of it yet.

RICE: There's always this governance and politics between organizations that may compete, and what they share and what they don't share. Ultimately, why can't we get that patient record on a device, on my phone, in my pocket? I can upload, I can download. I may not know the full content of my health record on my phone, but at least I have it.

MARICHAL: It's just very frustrating that we're well into the 21st century and we're still dealing with 20th century problems, particularly when we're talking about a very dynamic change in the healthcare environment where payment models are changing and where we are expected to deliver true quality and value and lower the cost of delivering healthcare. How can we do that if we're not able to share?

BAZZOLI: There's a lot of resistance to this kind of change.

MARICHAL: There's great promise if we can move beyond this. As a specialty, we're coming up with some amazing diagnostic tools. With all the changes in technology and the industry, the nice part is no one will be out of a job for a long time. There's lots of work to be done.

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