Idea in Search of a Business Model: Solving the Image-sharing Dilemma

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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