The deftness of data movement between sites creates a deception that it’s easy; it’s not. Leaving aside technical problems with integration, servers, and storage, the more central problem might be this: Who pays the bill to set image exchange in motion? In the case of image exchange, especially as part of an electronic health record (EHR) network, who pays hasn’t been determined. The day when entering an identifier and a clearance code will let a physician in Utah see prior studies for a New York patient on vacation hasn’t arrived. For now, the best many patients can do is to carry CDs of prior images with them. The opportunity is tantalizing: The data are there to be transferred. Perhaps trillions of image datasets are stored digitally—somewhere. The rationale is there as well: In the interest of efficiency, to curtail unnecessary imaging, to limit radiation exposure, or (especially) to stop unnecessary patient transfers, hospitals, specialists, insurers, and patients all want image transmission made quick and easy. The flow of imaging data is held back, though—stopped at the crossing by financial inaction. Who will pay to open the switches? Nonetheless, HIEs are popping up everywhere, and planners want image exchange to be part of them. All 50 states have some sort of HIE activity underway. There is even an unspoken competition among states to be first with a comprehensive HIE that includes medical images. Maine, for instance, is claiming the first-with-images title. James F. Leonard, deputy director of MaineCare (the state’s Medicaid program) and director of Maine’s health IT program, says, “Maine has, for a long period of time, been a leader of innovation, when it comes to measurement and information about health care. The providers in Maine are always looking for ways to improve, and for them, an HIE is another tool.” HealthInfoNet Maine organized what has become a robust, statewide HIE in 2005, when it put in place a private, nonprofit entity—HealthInfoNet—to oversee formation of an HIE. By 2008, HealthInfoNet had the HIE up and running. In 2010, Maine received a $6.6 million federal grant to build capacity in the exchange, and Leonard predicts 100% provider participation by 2014. As a private entity, HealthInfoNet is able to contract with health-care providers to pay for the HIE’s services. Many of Maine’s large providers have been glad to pay for access to the HIE. Shaun T. Alfreds is COO of HealthInfoNet; he says that 36 of Maine’s 38 hospitals are under contract with HealthInfoNet, although four of those are not yet connected to it. The hospitals pay an average of about $1,000 per bed, per year. Ambulatory clinics can join, too, and their rates are approximately $300 to $600 per provider, Alfreds adds. HealthInfoNet also collects separate fees for data and IT support. He says, “We offer services that are a perceived value: transitions of care, notifications, and other tools in client management.” The fees that HealthInfoNet collects offset about 60% of its operating costs, leaving the rest to be made up elsewhere. This is one of HealthInfoNet’s challenges; in addition to having a federal grant, it also receives funding through private charitable foundations. Imaging Pilot Until now, Maine’s HIE has contained radiology reports only, but that is about to change, with the launch of what is believed to be the nation’s first statewide image archive. HealthInfoNet hopes that the image archive will become a service that it can sell to providers to make up some of the 40% of funding missing from its sustainability projections, Alfreds says. As director of IT at HealthInfoNet, Todd Rogow is responsible for the technical rollout of the image archive. He reports that about half the state’s hospitals are participating in the pilot program. The image exchange will use a centralized archive, but each hospital also will maintain seven years’ local storage for site-generated images. Hospitals will be able to access images through local PACS and through the HIE image archive. The redundancy is in place so that the local sites will come to trust the HIE imaging network. They will see that it’s as reliable as local access, Rogow adds. Trust building has been a vital element in getting the HIE itself up and running. “You build the trust model and the business model,” Alfreds says. “That’s what justifies the collection of data on behalf of the patients. That’s a hard process, but it got us to where we are today.” The imaging pilot will be done without cost to participants, but once the network has been implemented statewide, HealthInfoNet intends to charge for the service. “After we go live, hospitals will pay per image stored on the archive (a one-time payment),” Alfreds says. “They will get access through the HIE, and that will be seamless, with their PACS integrated on the back end.” The actual collection and storage of images probably will start in spring 2013. “We are right in the middle of the integration work and installing the hardware,” Rogow explains. “We also are putting the local storage on-site and getting everything set up in our data centers. As we get toward May, we’ll bring in the images and start the validation and final testing.” The image archive will be stored in the cloud through a commercial vendor, with disaster recovery storage at two other US sites. Maine’s strategy in building an HIE has been to rely on private vendors to provide the necessities, from equipment to integration. It has a vendor to manage a common health registry that has established a master person index to ensure that patient records are correctly matched, for example. Other vendors will provide an integration engine for the HIE and EHR, terminology content and mapping, hardware and software services, cloud-based business services, a secure cloud platform, and a electronic prescribing network. HealthInfoNet sees itself as a neutral third party between vendors and providers, and that’s why it has opted for a buy-versus-build strategy. Maine is not currently attempting to integrate its HIE with those of other states. Alfreds says, “We’re further along than the other states. We have 1.1 million residents in our repository, out of a state population of 1.3 million. We are leading the curve in data collection and in a centralized model. There’s not much to connect to in other states, at this point.” Mount Sinai Medical Center David S. Mendelson, MD, FACR, is director of radiology information systems and senior associate for clinical informatics at Mount Sinai Medical Center (New York, New York). He also is cochair of Integrating the Healthcare Enterprise (IHE) International, a collection of hundreds of health-care organizations that have designed and are advocating the use of industry-wide integration profiles (including standards and workflow) in several domains. One of the essential profiles for image sharing is IHE’s Cross-enterprise Document Sharing for Imaging (XDS-I), which allows image and radiology-report sharing through a common registry (such as an HIE). The beauty of the IHE profiles, Mendelson says, is that they available to any health-care entity or commercial vendor. They are not vendor-specific or proprietary. “Whether it’s one or multiple vendors, all of these networks should be able to talk to each other and use the XDS-I exchange mechanism,” Mendelson says. “All you have to do is authenticate that you have the right exchange. The notion is a common platform, using common standards and common authentication—and then, you have to make sure everything is moved securely.” If all vendors make their products compliant with IHE profiles like XDS-I, the door will open for HIEs to transport data among themselves, and the foundation will be in place for what could become a national HIE, Mendelson says. Patient Control As HIE activity ramps up, who will control all of the shifting data? One way to minimize privacy intrusions would be for patients to control access to their own electronic personal health records (PHRs). Along with several other hospitals, Mount Sinai Medical Center is participating in a pilot study, funded by the NIBIB, that will investigate whether patients can act as their own gatekeepers for an image-sharing network. The study is being conducted through the RSNA, using its IHE-compliant Image Share network. Mendelson says that the study was funded with one underlying motive—to dispense with giving patients their images on CDs. At Mount Sinai Medical Center, Mendelson estimates, 5% of arriving CDs turn out to be unreadable. In addition, CDs can be damaged, or the person who prepares the disc can get the patient’s identification wrong. The facilities receiving the CDs have to store them, creating another headache. The RSNA study is designed move the image data of 2,000 patients into the cloud, where they will be stored in electronic PHRs offered by two vendors; patients alone will control access. To date, Mount Sinai Medical Center has enrolled 419 of its patients in the study. The patients must have Internet access and must be savvy enough, for instance, to make a purchase online. For now, the study is paying for the PHRs, but at some point, paying for the PHR could become the responsibility of the patient. This is one option for funding image sharing, Mendelson says. He estimates that patients might pay $5 to hold an image set for a couple of years or $25 to hold it permanently. Mendelson says that it’s too soon to determine how effective it will be to have patients managing their own images as part of an imaging network. The four other hospitals participating in the project are in the work’s early stages, too. Anecdotally, Mendelson says, patients have said either that Web storage is long overdue or that it’s too complex (depending on their own skills). “People who have cancer and go from office to office to get treatment—people who have a real problem moving images—tend to like this,” he says. Pay Per Click While patient-funded PHRs would offset some of the cost of operating an image-sharing network, Mendelson acknowledges that a business plan for sustaining that network has not yet been devised. “In another model, the radiology office pays on a per-transaction basis when it sends images out to the PHR or an HIE,” he says. “The real cost of putting an exam on CD is $10 plus. It might be cheaper if you use the Internet, but my numbers aren’t rigid. I think the real cost to the radiologist’s office is lower than the cost of making and shipping CDs.” Mendelson says that another sustainability option for image sharing is to convince insurance companies to pay all or part of the cost of an image exchange. So far, that does not appear to have happened—but if unnecessary imaging is curtailed, if patients receive better treatment when images are quickly available, and if there is less radiation exposure, payors will be saving money. “Any way we can get these exams distributed will prevent unnecessary redundancy,” Mendelson says. Reducing redundancy, however, entails reducing volume, which makes some institutions or providers hesitant to join a network, Mendelson says. “The professional organizations are clearly articulating the message that we must do the right thing,” Mendelson explains. “Sharing images in the appropriate fashion is the right thing. At Mount Sinai Medical Center, by doing this, we do lose some imaging, but we have to take a leadership role.” Mendelson adds that health planners are looking at the feasibility of a national HIE, including a national image-sharing network. He’s optimistic that common, open-source standards and a common infrastructure platform, such as that offered through the IHE project, can bring about a national network. “I hope that in two to four years, there will be a way of hopping on this network,” he says. Canadian Guide Can Canada’s national health system offer a guide to developing image-sharing networks in the United States—including a national network? Eugene Igras is founder and president of IRIS Systems, a health-care IT and information-management company. In 2002, Igras says, the Canadian government formed Canada Health Infoway, an entity to catalyze health-care information transfer through the adoption of EHRs, along with relevant standards and communications technologies. IRIS Systems has worked on several Canada Health Infoway projects, including the construction of EHR and diagnostic-imaging repositories, as well as a telehealth project that extended telemedicine to remote areas of Northern Canada. “We have linkages that connect the registries and the depositories within each province or region,” Igras says, “but a cross-province, trans-Canadian image-sharing network has not happened yet.” EHRs, in the Canadian context, are secure, private lifetime records that encompass a patient’s health history and the care that he or she has received. They are stored in repositories and registries that comply with the national Electronic Health Record Solution Blueprint.¹ Diagnostic images, reports, and other information from imaging equipment, RIS, and PACS are integrated with other components of a person’s health record, stored in the repositories, and shared among authorized care providers via uniform, secure access mechanisms provided by the EHR solution. Although the EHRs currently in use are built to share information within each jurisdiction, information sharing between areas can be achieved through the implementation of the EHR Locator, a service that makes the discovery of specific EHR solutions possible across a network of EHR systems. Canada’s EHR solutions are evolving, Igras reports. Some regions are working on expanding their capabilities beyond information sharing to include collaboration, business-intelligence, and knowledge-management tools. There also is growing pressure to provide access to the public, so that individuals can actively participate in information exchange with their care providers. In the public sector, the integration of health information is complex enough. Igras notes, however, that Canada also has a sector of privately owned clinics and radiology practices that have to be integrated as well. This task has its own set of challenges, including a clear definition of which components of the medical record can actually be shared. In addition, funding for health IT in the private sector can be challenging. Because the US health-care system is bigger and more fragmented than Canada’s system, sound planning (see sidebar) would be critical to the development of a national image-sharing network in the United States, Igras says. Uncertainty in Alabama Alabama (like Maine) is among the first states to have a statewide HIE underway. It is attempting to add image-exchange capabilities—if funding develops to sustain them. In Alabama, the question of who pays to transport images over a network has come front and center. In 2009, the University of Alabama at Birmingham (UAB) received a grant from the NIBIB of roughly $2 million to establish an image exchange among several Central Alabama hospitals—with the UAB Medical Center (UABMC) serving as the hub. That grant has now expired, and the Central Alabama Health Image Exchange (CAHIE) is only partially completed. In seeking the NIBIB grant, UAB administrators had stressed the efficiency of an image exchange, but with particular emphasis on cutting down on the unnecessary transfer of patients. Too many patients were being sent to UABMC from outlying hospitals when images on hand at those hospitals would have prevented transfer—if UABMC radiologists had been able to see them. They weren’t able to see them because no electronic image exchange was in place. The unnecessary transfers were wasting money and time and were especially unnerving to patients. Don Lilly, vice president for clinical development for the UAB Health System, says, “The transfer of those patients can be overwhelming.” He adds that since the NIBIB funding expired (near the end of 2012), CAHIE has been seeking financial sustainability through other means. “We are searching for additional grant funding to expand, or we will have to make do with our own funding, or with funding done jointly with the outlying hospitals,” he says. “We are trying a couple of different paths to get this widespread. We are, from a UAB standpoint, approaching our strategic hospitals, where the patient flow is pretty high.” Those hospitals are already connected to the CAHIE pilot network, which is in operation, and have paid fees to participate, but whether those will be enough to sustain the image exchange, over the long term, remains to be seen. “If we’re going to expand, then we’ve got to figure out a way to keep it funded,” Lilly says. “We don’t have all those answers yet.” State Help Lilly reports that one potential avenue of collaboration might be the state’s budding HIE, One Health Record, which has shown interest in using CAHIE. Intervendor integration issues are being analyzed. Another means of funding might be the contributions/fees paid by insurers and large, self-insured employers, which would save money if there is less redundant imaging. Lilly would like to see more interest from payors and large employers that could fund image exchange. “They’re not closed minded; we just haven’t had success in coming up with a pilot structure they feel good about,” he says. “We’re a few months away from giving the insurance companies what they want in proof of concept.” Joan C. Hicks, MSHI, RHIA, is CIO for the UAB Health System. Her department is providing the IT expertise needed to get the outside hospitals connected to CAHIE. To date, Hicks says, two outlying hospitals with sizable transfer rates have been connected to CAHIE. Two more are in the pipeline to be connected. For now, CAHIE is handling only images, not radiology reports. Like Lilly, Hicks is deeply concerned about CAHIE’s financial sustainability. She says that through the use of the CAHIE image network (in addition to the expertise and advice provided by UAB physicians), UABMC has been able to avoid a few transfers from referring organizations. “We all agree it is the right thing for patients,” she says, “but right now, it’s the organizations that are participating that are sustaining CAHIE.” Currently, the costs of maintaining the network are not reimbursable, she says. “Financial support of CAHIE is our most pressing challenge,” Hicks says. “UAB and the organizations using CAHIE are funding the project.” One of the key objectives of CAHIE is to support the determination of whether a transfer is clinically necessary, perhaps saving payors significant amounts of money. “The current model and the objective are misaligned,” she notes. One Health Record Gary D. Parker, MBA, JD, is director of health IT for One Health Record, Alabama’s HIE. One Health Record is being run through Alabama’s Medicaid agency and is in the early stages of implementation. “We’re still connecting hospitals for our pilot,” Parker says. “We’ve got one, and in three months, we’ll have four. UABMC will be one of them.” Unlike CAHIE, One Health Record has funding: a $10.6 million grant from the Office of the National Coordinator for Health IT, Parker says, adding that Alabama is one of only a few states to have an HIE that is federally certified. Parker wants CAHIE to be included. “CAHIE is just a natural partner for us, and we want those images on our exchange as well,” he says. The problem is getting them there. The ball is in CAHIE’s court, Parker says, because its infrastructure vendor has to figure out how to interface with systems from One Health Record’s vendor. “What do they need to do? If they can’t do it, what can we do to help them get there?” he asks. He reports that the vendors have been talking, but haven’t yet arrived at a solution. He remains optimistic, however. He says, “We’ve got to get connected and then see what happens. We’ll probably connect in late spring.” Parker says that radiology reports, as part of the continuity-of-care documents required for federal funding, are already contained in One Health Record. Funding for One Health Record (after its grant expires) is yet to be determined. “I guess it’s kind of like cable television,” he explains. “Do you only want continuity-of-care documents? If you want images, add a few dollars per month for those services, and we provide services for those who wish to access them. Maybe there will be a regional demand in Birmingham.” Parker says that he’s optimistic that insurance companies will eventually step forward to shoulder some of the cost of HIEs and image exchange. “Blue Cross has committed to this, but it hasn’t given us money. It does have a representative on our commission,” he says. “It is aware of the challenges. I think it will be a viable partner, at some point.” In the meantime, CAHIE administrators are hoping that the network will survive. The funding question could break either way. As Hicks says, agencies could provide further incentives for information and imaging networks. On the other hand, they could begin to impose penalties for not having such networks in place.
George Wiley is a contributing writer for Radiology Business Journal.