Building the Fully Loaded HIE: Images on Board
With a health IT stimulus package valued at $19 billion1 in play, one of the least controversial subjects in the health-reform debate is the potential of health information exchanges (HIEs) to lower health care costs while improving efficiency and quality of care. A handful of players in health IT have been developing some form of exchange for a decade or more (supported, in part, by the occasional grant), but images typically have not been included. With this year’s planned disbursement of federal stimulus money to ramp up health IT infrastructure, health-care providers around the country are scrambling to find the best and most economically viable way to connect with one another, and radiology practices with foresight are working toward making imaging part of these efforts. “I think Indiana might be the mecca for HIE,” Chuck Christian says of his home state, reflecting a sense of regional pride shared by many around the country who were attempting to implement local HIEs long before the concept hit the mainstream. “My comments may be biased,” he adds, “but I’ve been involved in this for quite some time. We have five exchanges in Indiana that have been up and running for 10 years.” Christian is CIO of Good Samaritan Hospital in Vincennes. He has been involved with the Indiana Health Information Exchange (IHIE) and others for several years, and is now a board member of the Indiana Health Informatics Corp (IHIC). This group was created by the Indiana state legislature in 2007 to determine how best to provide HIE services for the entire state of Indiana, integrating HIEs such as the nonprofits HealthBridge and the Indiana Network for Patient Care (INPC). imageChuck Christian, CIO Good Samaritan Hospital connects to the latter, which shares information about emergency care. “INPC gives the emergency-department physicians a 24-hour window of access to all the data available on a given patient, so they can log on using a Web browser and see it all: laboratory results, DICOM images (if shared), transcriptions, discharge summaries, and more,” Christian says. “We showed the INPC data to our emergency-department physicians and they wanted them yesterday.” imageTodd Thomas, CIO Christian’s not the only one who’s been involved with HIEs since the 1990s. Austin Radiological Association (ARA), Austin, Texas, got involved with a regional exchange called CriticalConnection® 10 years ago. Todd Thomas, CIO of ARA, says, “We believed in the concept and were interested in participating from the beginning. As an early adopter of PACS, we were very interested in electronic sharing of information and saw this as an opportunity to enhance our services to area physicians’ offices. We provide hosting services, network design, and architecture services.” These informatics specialists have known for years what is, today, still making headlines in the consumer press as a new idea: that HIEs will be key to unlocking new efficiencies in health care. “One of the linchpins of making health care better is HIE,” Christian says. “Thirteen states have been awarded funding to do HIE planning, but we’ve already planned and implemented on a regional basis. We did it on our own, because we knew it was the right thing to do.” Adding Images The Carolinas also appear to be fertile ground for HIE development, spurred in part by the Duke Endowment, which has funded four HIE projects in the region since 2006. These include Data Link, an HIE established four years ago by the Western North Carolina Health Network (WNCHN). The exchange was built on a 16-hospital federation founded more than a decade ago to collaborate on quality-improvement goals and, later, to achieve economies through group purchasing. Today, Data Link provides approximately 1,500 physicians in the region with access to admission/discharge information and to laboratory, microbiology, and radiology reports (as well as other transcribed reports), according to Dana J. Gibson, MPH, CPHIT, CPHQ, vice president, Data Link Services, WNCHN, Asheville. WNCHN hired a software developer in Birmingham, Alabama, to create an application that sits on top of each hospital’s server and communicates with the Data Link server, which periodically queries the hospital information system of each of the 16 member hospitals to retrieve the basic patient information that populates the index. Andrew Wells, MD, a radiologist at Margaret R. Pardee Memorial Hospital, Hendersonville, describes the system as a large electronic card catalog full of patient records that occur across any of the 16 hospitals. imageJames Whitfill, MD, CIO “The application creates the master patient index and the locator tool, which allows any provider with the proper credentials to log in, query a specific patient, and then get the results back from the card catalog saying they have events across two hospitals or six hospitals,” Wells told “At that point, no data are pulled; it’s just that the pointers are identified, so it’s extremely fast to find the events and the history.” He continues, “It’s really important that so far, you haven’t pulled anything out of the host computer system: All you are doing is turning the crank on the card catalog and indexing tool. It’s extremely quick, and it’s not until you say, ‘I want to see this,’ that it actually engages the host repository or host archive to pull it out and then present it. It’s a small question and a small file, and it gets there quickly.” While grant money from the Duke Endowment and the Health Resources and Services Administration (HRSA) paid for software development and infrastructure costs, the 16 hospitals support Data Link, both administratively and financially, by paying a monthly fee and by appointing one staff member to be an administrator within the hospital, assigning access and monitoring use. The next steps will be to add physician-office electronic medical records (EMRs) to Data Link and (significantly for all of the radiology practices that contract with network hospitals) to provide access to diagnostic-quality medical images. According to Wells, “We are in the process of identifying specifications and identifying companies that would like to participate in that development and deployment.” Distributed Reading In Greensboro, North Carolina, Greensboro Radiology has created a network that connects the radiology practice to local hospitals and multispecialty practices. This hub-and-spoke approach might be limited, but it’s a vast improvement over the way that the practice exchanged health information before, Stephen Willis, CIO, explains. “We’ve repositioned ourselves here in the region,” he says. “Around four years ago, we decided it would be nice to expand our footprint, but every time we read for a different facility, it had a separate PACS, billing system, and dictation system. We needed to get it down to one platform that the radiology business controlled.” imageDana J. Gibson, MPH, CPHIT, CPHQ The model established by Greensboro Radiology enables any local practice or hospital to exchange information with the radiology group for a fee that, Willis says, is as close to cost as possible. HL7 orders from connected facilities are pushed to Greensboro Radiology’s PACS, which creates a DICOM worklist to be used at the facility in question. When scans are complete, an HL7 message notifies the radiology practice’s system to expect the images, which are then read by the radiologists. Greensboro Radiology archives the studies on its own PACS, while adding patient data, reports, and images to an archive accessible to any provider treating that patient. “The big win in all of this is really quality of care,” Willis says. “It keeps us from doing another scan when a prior study is already available, so quality goes up and health-care expense goes down. When we bring on small practices, they get quite a lot of benefit from having all these imaging data in the same place.” James T. Whitfill, MD, CIO of Scottsdale Medical Imaging (SMIL) in Arizona, was hoping to attain similar efficiencies when his practice implemented its own hub-and-spoke network. SMIL wanted to connect to referring providers’ EMRs, but HIEs can be hard to get off the ground, especially since, Whitfill notes, “Every party thinks some other party should be paying for it.” imageYaorong GE, PhD Two HIE projects by for-profit groups are still struggling to gain traction in the greater Phoenix region; SMIL is working with them in the hope of getting in on the ground floor with whichever project takes off, but the practice’s short-term business objectives aren’t being met, at this juncture. SMIL’s response has been to connect to its referrers’ EMRs one by one. “In the absence of anyone else having one, we’ve worked to integrate our clinical information systems with about 50 EMRs here in Phoenix,” Whitfill says. “There’s not a cloud out there yet, but we’ve gone ahead and made the spoke connections.” Marlene Smitherman, CEO of for-profit CriticalConnection Inc, Austin, Texas, saw, early on, the importance of engaging radiology providers in HIE initiatives. “Almost from the beginning, ARA has been one of our partners,” she says. “It has such a strong need to link with all the physicians. It’s major in providing financial resources to help make this happen.” In its recently concluded proof-of-concept project, which ran for 2.5 years, CriticalConnection created a physician-centered cluster, connecting a local geriatric care group with all the organizations to which it refers, including Quest Diagnostics® and ARA. “Our team created the technology to connect to physicians using whatever workflow exists in their offices,” Smitherman says. “Then, the link was made to radiology and to laboratory, and we’re getting ready to integrate the hospital data.” CriticalConnection’s IT solutions are proprietary, she says, and include both established vendor technology and new software and technology created in-house. The database is SQL; the front end is Java. “Our system was developed specifically for this project and is unique to it,” Smitherman says. IHIE does not yet handle DICOM images, so Good Samaritan Hospital has held off on exchanging image datasets among facilities. “There are some medicolegal questions that need to be answered before we allow other facilities to start shoving studies into our PACS,” Christian says. “The hospitals want to transfer the datasets via virtual private networks (VPNs) directly into PACS, but I’m uncertain as to whether that’s the best approach. Then, we would need VPN tunnels connecting us to everybody, and we would need to give other facilities access to our PACS, potentially creating licensing issues. We have to think about the ramifications for when patients transfer to other facilities and other modes of care, and HIE is going to be very important to that process. It’s not just moving documents and summaries anymore.” imageJohn Carr, MD Whitfill highlights a critical issue when it comes to HIE development and implementation: money. “There are plenty of public and private HIEs out there, and the reality is that they either have trouble getting started or they run into problems with business models or revenue sources,” he says. “There’s a high barrier to entry into this integration world. Many people look to the payors, but the payors feel that the people who create the information should be responsible for paying for it, and other people think the consumers should be the ones who take on the cost.” imageAndrew Wells, MD IHIE got off the ground thanks, in part, to funding from the Regenstrief Institute, an Indianapolis-based informatics and health-research organization that designed the patient-matching algorithms and security infrastructure. There have been other grant opportunities as well, and the rest of the work has been conducted on a volunteer basis by motivated players. Christian says, “Most of this infrastructure has been created privately, and there hasn’t been any state tax money involved. The IHIC board members volunteer their time to move this work forward.” Similarly, though Greensboro Radiology hopes eventually to see a return on its investment, for the time being, the practice is merely aiming to be “a goodwill leader in the region,” Willis says. “Our vision is for any provider that has a modality in this region to come and use us as its full PACS solution. From a pricing standpoint, we try to get it as close to cost as humanly possible. We’re not really looking at this as a way to pay for our infrastructure. The idea is to lower the cost for that provider so it doesn’t need its own mini-PACS.” Take that concept, expand its scale, and you’ll have some idea of what Smitherman is attempting to achieve with CriticalConnection. Each provider connected by the HIE must pay $250 annually to join the CriticalConnection co-op, an entity separate from (but related to) CriticalConnection Inc. Membership in the co-op comes with privileges that include group purchasing for services that physicians’ offices need, from office supplies to broadband Internet connections; rebates from the vendors pay the cost of operating the HIE. “The revenue model comes first,” Smitherman says. “Nobody has adequate funds to pay for this on their own, so the group purchasing helps to reduce their costs. It’s paying through saving, not spending.” ARA’s involvement in Critical-Connection has been a boon for the exchange. “We’ve been hosting all the data since the beginning,” Thomas says. “Our anticipation is that it will become hugely popular. It’s a different take on the classic model. Eventually, CriticalConnection has to bring on the other major radiology provider in this area, and while that represents referring physicians’ business we may not necessarily capture, our interest in helping get this off the ground will benefit all of us, in the long term.” Whitfill hopes that SMIL’s ability to interface with referring physicians’ EMRs will translate into a competitive advantage in the years to come. “What’s clear is that there’s going to be a gradual raising of the bar in terms of what EMRs need to be able to do, and part of that is being able both to send out orders and to accept inbound results,” he says. Willis concedes that the same advantage might present itself to Greensboro Radiology, although it isn’t the practice’s primary motivation for being a regional leader in exchanging health information. “We could certainly enjoy the benefit of getting more referral business by showing goodwill,” he says. Whitfill adds, “There are financial penalties set to begin for those who aren’t using an EMR that can accept results. You’re going to have decreased reimbursement, and that will be a powerful incentive for everyone.” Meaningful Use As the government increasingly recognizes the importance of health-care connectivity, federal funding has become available for regional HIEs and related health IT projects. Smitherman is hoping to take advantage of this by applying for a grant from the $220 million Beacon Community Program, established late in 2009 as part of the American Recovery and Reinvestment Act (ARRA). These grants are designed to strengthen health IT infrastructure and help build HIEs; Smitherman hopes that a grant will help bring together several local hospital systems. “Once all these entities start working together and stop being afraid of competition, then we can actually get some things done,” she says. “It just takes staying the course and listening. Things are moving even faster now that the current administration is in place. It’s really built a fire under the physicians.” In October 2009, the State of Indiana created Indiana Health Information Technology Inc as the State Designated Entity (SDE), a nonprofit organization put in place to receive federal stimulus funds as part of the Cooperative Agreement Program. “We’re trying to determine where the money would best be spent, where it is most appropriate,” Christian says. “Some will be allocated to connecting hospitals, and some will go to connecting physician offices. I think that’s where the lion’s share of the work is going to be.” There’s bigger federal money to be divvied up among primary-care providers who meet the criteria for meaningful use of EMR technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act provisions of the stimulus package include $19 billion in incentives for providers attempting ramp up their health IT offerings; an initial proposal from HHS on the definition of meaningful use of this technology stresses that it must be used to improve the quality, safety, and efficiency of health care services. Whitfill cautions radiology groups that they are not eligible for stimulus funds. “By the way the law’s designed, there’s really not a way for our physicians to work with us that would be a meaningful use of their electronic records, so we’re not expecting to see any funds,” he says. There’s an upside to SMIL’s investment, though: As more Phoenix-area practices take advantage of the offer, SMIL’s network will extend even more, and its competitive edge will expand. “Our community-relations department lets the referring physicians know that we can set up the interfaces as they’re putting in their EMRs,” he says. “The number of people who have adopted EMRs is really starting to grow.” Gibson also believes that CMS ARRA funds cannot be used to build out Data Link linkages or to create radiology PACS connectivity, and the HIE is not one of the SDEs that will receive HITECH Act funding through the state. “We do have Office of the National Coordinator (ONC) funding secured to build our National Health Information Network gateway, and we already have HRSA funding secured to link unaffiliated physician offices across western North Carolina,” Gibson says. “Going forward, we will be applying for more funding for both of these goals from the ONC Beacon Community Program, which is part of the ARRA provision. We also hope to apply for more funding from HRSA and the Duke Endowment to help us achieve these goals, should we be unable to secure the Beacon Community Program grant.” Greensboro Radiology is also focused on how its referring physicians’ offices can capitalize on stimulus money. “The EMR has never been any hotter than it is now,” Willis says. “There’s not really any money for us in the radiology arena, but for private physician practices and small hospitals, it’s definitely there. We haven’t gone so far as to advertise to them about how they might capture those funds, but we have answered a lot of their questions.” Pushing Forward Greensboro Radiology’s ultimate goal is to create a regional archive of patient data accessible to all providers, including superspecialists nationwide, with patients from the region. “Our referring physicians refer outside this area quite a bit,” Willis says, “and when that happens, image exchange becomes that much more difficult. We’ve been talking with a lot of folks about being a hub and spoke in the same way for Mayo Clinic, Cleveland Clinic, and Wake Forest University Baptist Medical Center. We’re going to solve that problem.” In fact, two faculty members at Wake Forest (Winston-Salem, North Carolina), Yaorong Ge, PhD, assistant professor in the Department of Biomedical Engineering, and John Carr, MD, professor of radiology, have received a grant from the National Institutes of Health to do just that. Their approach to the long-distance exchange of DICOM images pivots on patient-controlled decentralization of medical data, as Carr explains: “The need for sharing images is pretty well defined. Not every image needs to be shared all the time. Generally, the patient knows who his or her care team will be, and can specify whom he or she wants to see the images.” Ge adds, “When the patient says that he or she wants the images to be shared with a physician or hospital, then our infrastructure can send an approval to start sending the relevant images. We want to coordinate sharing only when sharing is needed.” The beauty of this approach, Carr and Ge note, is that it can be overlaid on existing HIEs, treating each as an individual database from which data can be exchanged as necessary. “In our network, regional HIEs become a node,” Ge says. “We envision that our infrastructure will work very well on top of all the regional efforts.” In the meantime, Willis says, there have been discussions within Greensboro Radiology about expanding the project by including more health information and potentially by reaching out to other radiology practices in the region. “We’ve talked quite a lot lately about how we need a better formal definition of our network, capitalizing on the relationships we’ve built through RBMA and by knowing folks around town,” he says. “We’ve been discussing whether we need to take it to the next phase, where we’ve got branding and marketing behind it. It’s a tight balance for us because this isn’t really a profit center yet. We’re just trying to do something that’s good for everyone.” SMIL’s aim is to continue expanding its network, which currently links the practice to around 15% of its total referral base. Whitfill looks for a more broad-based solution in the future, but acknowledges significant obstacles on the road ahead. “It would be wonderful if there was just a single metropolitan, statewide, or even national cloud that linked everyone,” he says. “For now, though, the next challenge is this: How do you have an HIE of image data when the dataset sizes are so large? You can either duplicate the studies everywhere, or you can have some massive central repository of all image data. Right now, we can’t even do a common patient identifier.” Wells sees the addition of images to the Data Link HIE as both a boon for patient care and an opportunity for the potential expansion of his practice’s reach. “A platform that will allow distribution of images, perhaps through an application service provider or other business relationship, would accelerate our service delivery and might provide us with a platform to expand our service area,” he says. “Perhaps within the Data Link federation of hospitals, we will need more radiology services, more cardiology services, or other types of image expertise, and this type of platform could expand that footprint.” In addition to facilitating the ability to shift work within the practice, Wells can imagine an image-enabled HIE offering opportunities to shift work between unrelated (but collegial) practices as well. “If this federated access to images can be built, there is the possibility of work shifting within practices, “ he says, “and, perhaps, if the access to diagnostic original images for dictation would be available as well, of work shifting between practices to provide service to each other over an electronic platform.” For Smitherman, the next step is taking CriticalConnection from the proof-of-concept phase to widespread physician and hospital engagement. “We just started our Central Texas co-op last year, and we’re looking at North and South Texas this year. Then, we’ll start looking outside the state,” she says. “Eventually, we hope to be able to reach out and actually to provide additional dollars for health care for the community, including indigent care and care for the working uninsured. In five years, this co-op could be running a surplus of $50 to $70 million a year. One of our main goals is to keep the physicians’ offices financially viable.” This is no small concern, given ever-declining reimbursement levels and the escalating cost of remaining in business. Christian’s goals are to see Indiana’s five HIEs connected to one another and to see physician practices come on board. From there, he says, the HIEs will be able to redouble their focus on improving patient care, and will ideally be able to begin exchanging DICOM datasets. “We’re still early in the game,” he says. “It can be done, and other people are doing it, but we’re not there yet. There weren’t enough people with PACS initially, but now most people have it, and the ability to exchange data is becoming far more important.” He adds that just as Indiana’s five HIEs will be able to learn from one another as they continue the process of exchanging data among themselves, so will other HIEs nationwide. “There has to be a standard method of information exchange in use,” he says. “We’re creating more of an opportunity for collaboration this way. Each and every HIE has some unique service offerings, and we can all learn a lot from one another.” Until then, an anecdote from Smitherman illustrates the potential of image-enabled HIEs to increase efficiency while lowering costs; it also underscores the breadth of the challenges to come. “We had an ice storm not too long ago,” she says, “and during the storm, the primary-care physician group at the core of our proof-of-concept project got a call from an elderly patient who thought he might be having a stroke. His physician called up the community record from home and saw a brain scan ordered during a visit to the neurologist two weeks ago. He was able to determine that the emergency department was not where the patient belonged.” In the end, the physician was able to persuade the patient that he didn’t need to go to the emergency department, and should instead make an appointment to see the physician after the storm had subsided. “That 15-minute phone conversation probably saved CMS about $35,000, but there’s no compensation for the physician whatsoever. How do we compensate physicians better for what they’re stepping up and doing with this access? In five years, things are going to look pretty different, and we hope that physicians will have some say in how it turns out,” Smitherman says. Cat Vasko is associate editor of Radiology Business Journal and editor of