The Importance of Making Standards Standard

The health IT holy grail of nationwide interoperability remains top of mind in theory yet miles away in practice. The daunting distance of the road ahead was thrown into sharp relief in early October, when Health Affairs published American Hospital Association (AHA) survey data from 2015 showing that two of three U.S. hospitals can’t locate, retrieve, send and/or meaningfully integrate the electronic medical records (EMRs) of patients who received care at other provider sites (Health Aff (Millwood). 2017 Oct 1;36(10):1820-1827). 

That percentage was a few points better than the previous year, but still well off the hopes and aims of HHS’s Office of the National Coordinator for Health Information Technology (ONC). The ONC contributed to the study and has spent untold hours—and millions of dollars—over the past eight years trying to facilitate, promote or otherwise spur interoperability. 

It’s not only the government that is disappointed. Tweeting a link to the study, cardiologist and bestselling author Eric Topol, MD, called the state of U.S. health data interoperability “pathetic.” He’s got well over 100,000 Twitter followers, which means interoperability may be moving from insider jargon to the national conversation. To patients, of course, the better word might be portability. Or, as Penn Medicine radiologist Saurabh Jha, MD, put it in a retweet of Topol’s take: “Your ATM card works in Outer Mongolia, but your EMR can’t be used in a different hospital across the street.”

The main problem seems to be that too many hospitals are narrowly focused on moving information around just to show they’re keeping up with the program. What they should be concerned with, at least according to the authors of the Health Affairs study, is making sure the moveable data are clinically useful. Radiologists reading imaging exams, for example, shouldn’t have to wade through a patient’s comprehensive record just to dig out the clinical notes, lab tests and prior imaging exams that are relevant to the clinical question at hand. 

So what can the medical imaging industry do to help push U.S. healthcare forward on interoperability? For starters, several experts agree, they could be increasing their awareness of data standards, pushing vendors to supply nonproprietary web-based solutions and pitching in to help get their own houses in order. Many hospitals and health systems still aren’t close to being interoperable even internally. 

No Need to Learn a New Language 

Radiologists and their administrative teammates don’t need to memorize the acronym alphabet soup of data standards in order to know the standards exist and they matter, especially when it comes time to replace a PACS or other radiology-specific IT system that will need to be interoperable. 

That’s the view of Tessa Cook, MD, PhD, chief of 3D and advanced imaging and director of the Center for Translational Imaging Informatics at the Hospital of the University of Pennsylvania in Philadelphia. 

“More and more, we need to have an awareness of HL-7 standards and radiology ontologies,” says Cook, who also serves on the American College of Radiology (ACR) Informatics Commission. “But with the exception of very few radiologists, no one is going to be able to quote FHIR transactions. Nor would they be able to quote you the DI-COM supplement that covers a certain type of imaging data or a certain type of transmission transaction. However, what radiologists do need is just a general knowledge of what role these technologies play in our working lives.”

It also helps to know that the future will be dim for radiology operations using image-archive silos that aren’t enabled to incorporate the Fast Healthcare Interoperability Resources (FHIR) standards of which Cook speaks. As standards go, FHIR is a draft work in progress with can’t-miss prospects for eventual finalization and ubiquity. Radiologists also do well to know of the  existence of REST-compliant web services for moving textual data over the Internet and the same REST (Representational State Transfer) family’s DICOMweb for moving imaging data.  

Armed even lightly with such awareness, radiology department members generally have enough to speak with departmental or hospital IT staffers about user-specific problems and opportunities, Cook says.

“If you’re buying a PACS right now and planning to have it for some time, you need to be thinking about how it will be interoperable and communicate with your other systems,” she says. “It is very important to think about your future state.”

Cook also suggests thinking through radiology’s increasing interactions with image-guidance modalities that integrate with medical devices in interventional suites, not to mention digital-health devices—and any other technologies likely to affect radiology’s ability to achieve full interoperability.  

“A lot has to be taken into account, because so often there’s more than one imaging modality in play at any given time,” she says. Imaging equipment itself may be less of a concern, thanks to firmware upgrades driven by accreditation requirements as well as market forces, she points out. But “a lot of data being transmitted from patient monitoring devices now have to be considered.”

The Power of PACS Interoperability 

Wherever else the technology leads, right now Paul Nagy, PhD, CIIP, advises keeping an eye on interoperability as the single most important feature of your PACS. After all, it’s PACS interoperability—or lack thereof—that will have the single biggest impact on how quickly a radiology group or department is forced to replace big-ticket radiology IT systems, says Nagy, who is an associate professor in the department of radiology and radiological sciences at Johns Hopkins University School of Medicine in Baltimore and serves as chairman of the board for the Society for Imaging Informatics in Medicine. 

“Radiologists’ ability to practice medicine is inherently dependent upon the ability of the PACS to interoperate,” Nagy says. “Ignoring this fact impacts their ability to practice medicine.”

He urges radiologists to recognize the potential interoperability holds for making their work more efficient and effective. “Poor interoperability can drain time for radiologists, forcing them to navigate multiple information systems for information they need to help with their image interpretations,” he says. “It’s not easy to appreciate just how important it is to integrate imaging modalities, speech recognition, diagnostic viewing, arching and the EMR. Now multiply that importance when you integrate within, and between, health systems.” 

Integration is not just a productivity issue but also a patient safety concern, he adds, as trying to manually copy and paste between systems introduces the potential for misidentification of patients. The good news is that the DICOM standard has evolved to embrace Internet standards of interoperability that now allow forward-looking cloud-based PACS, Nagy says. The newer version of the standard, called DICOMWeb, is built around web-based RESTful services. 

“These standards can actually help improve your practice,” Nagy says. “You can have your PACS talking to remotely located DICOM archives,” for example. “And with DICOMweb, you can pull exactly what you’re looking for,” down to the granularity of a single image or region of interests within an image. Relevant prior exams can be linked and mapped to hanging protocols for creating linked work lists—and those are just a couple of ways data standards “can help radiologists do a better job with image interpretation,” Nagy adds.

Sorting Through Standards and Vendors

David Mendelson, MD, vice chair of radiology IT for the Mount Sinai Health System in New York City, seconds the thought that radiologists and radiology administrators needn’t trouble themselves with learning the finer points of data standards. Awareness of their existence and purpose is usually enough to be part of the solution rather than part of the problem, he says, though many would do well to remember that the most enduringly cost-effective software complies with broadly accepted standards. 

As co-chair of Integrating the Healthcare Enterprise (IHE) International as well as RSNA’s representative thereto, Mendelson is partial to that organization’s standards. But he’s open to others as well.

“IHE tries to organize some of the existing standards into workflow documents, so IHE does have its biases,” Mendelson says. “And if ONC took a firm stand on how a standard should be observed, I don’t think I could object to that. The problem is that ONC has leanings toward certain standards and families of standards—but, at least in the world of imaging, they haven’t said, ‘You have to do it this way in order to get paid by CMS.’” 

In other parts of the world, he points out, provider organizations are legally required to use IHE’s XDS and XDS-I interoperability profiles whenever they go to share images, diagnostic reports and related information site-to-site. “And it works,” he adds.

Mendelson also has a word on vendors of PACS and other radiology IT systems. “Relative to imaging interoperability, there are lots of image-exchange solutions out there that stand alone quite well but are proprietary,” Mendelson says. “Once they have you, you have no choice but to stick with them, especially if you’ve built relationships around that proprietary solution.” Let the buyer beware of such tactics, he says. After all, it’s not like honorable vendors aren’t out there for the tapping. That includes EMR vendors, who are finally getting that they have to do their part for interoperability. “The big EMR vendors historically had interoperability built into their products, but it was very hard to search for that data from outside your own enterprise,” Mendelson says. “It was buried in that particular EMR. Today, I think they’re beginning to refine their EMR solutions such that, if there’s information available from a health information exchange or from outside your institution, you don’t have to jump through all kinds of hoops to find it.”

Staying Savvy and Speaking the Lingo

Nagy is excited that some PACS vendors, over the past couple of years, have “exposed a lot of their business logic and let people into their systems” using web-based, open-architecture RESTful interfaces. “The next step is for clinical leaders to understand how important all this is to the success of their practices going forward,” he says. 

To swing the momentum, every radiology practice should consider investing in the imaging-informatics education of at least one radiologist, Nagy adds. He describes a scenario in which a 50-radiologist practice has one radiologist who is indeed fluent in IT. “If that one radiologist devotes half of his or her time to improving the productivity of the group by 10 percent, that practice can realize a 10-times return on its investment,” he says. 

Cook might exemplify the ideal of the “one radiologist” IT expert Nagy has in mind. 

“This is really a phenomenal time to be a radiologist,” she says. “As one of the most technologically invested specialties in medicine, radiology also is extremely adaptable. We radiologists are very good at embracing new technology, making it a part of our workflow and using it to deliver better care—whether that’s more effective care, more efficient care or more patient-centered care.” 

All the major associations serving radiology offer help to assist radiologists along the road to interoperability. Among the must-sees are RSNA’s Image Share network and validation program, ACR’s Connect and copious content at SIIM.org and HIMSS.org. 

All in all, a lot of people, organizations, companies and institutions are working hard to make interoperability happen. Could it be the ONC just needs to adjust its expectations on timeline?