Tracing the movement to make electronic health records easier to share through health information exchanges — and finding the ways radiologists stand to benefit.
Mrs. Martin calls her primary care physician complaining of mild chest pains. Her physician refers her to an outpatient imaging facility near her home in Maryland, where she undergoes a CT exam.
Weeks later, she is admitted, unconscious, to an emergency department, which is unaffiliated with the outpatient center or her primary care physician’s office. Because the doctors can’t ask her if she has had any recent imaging, and because they do not have access to her medical history, they end up repeating the exam at an additional cost to Mrs. Martin (since the insurance company will likely not reimburse for repeat imaging). In addition, the repeat imaging wastes valuable time in an emergency and likely doubles her radiation exposure.
Mrs. Martin’s situation could have been avoided if the emergency department had access to her prior scan. However, her medical history is stored in multiple electronic health records (EHRs), each managed by a different vendor. In the U.S. today, a variety of platforms have flooded the marketplace, each with its own protocols and customizable set-ups, making it hard for a provider using one vendor’s EHR system in a hospital setting, for example, to send images and reports electronically to another provider using a different vendor’s EHR system. As a result, sharing EHRs has been akin to trying to text an image to a landline.
Although the ability to transfer reports and images nationwide remains elusive, there is a movement afoot in the U.S. to solve EHR incompatibility problems on a state and regional level. Health information exchanges (HIEs) are networks that allow radiologists to send and receive reports and, often, images through a third-party technology provider. These networks supply radiologists with a more complete picture of the patient, allowing individuals to receive quality care no matter where they seek it and enhancing the radiologist’s value to the patient.
Information at Your Fingertips
In addition to helping standardize EHR networks geographically, HIEs also seek to solve issues surrounding technical and motivational issues. Health systems often do not want outside entities to access their patients’ records for fear of making it too easy for their patients to seek care elsewhere, thereby losing the health system money. Organizations that agree to join an HIE understand that they benefit from the exchange of clinical information, and seek not to control the patient population by throwing up barriers but instead try to attract patients by offering the best services and lowest costs possible.
According to the Healthcare Information and Management Systems Society, “HIEs are formed by a group of stakeholders from a specific area or region to facilitate the electronic exchange of health-related information for the purpose of improving health care for a defined population.”1 The exchange technology is provided either by an independent private company, a government agency, or a private company contracting with a government agency. This entity establishes agreements with health care providers in a specific geographic area who agree to use the HIE to improve patient health.
Mark D. Mangano, MD, second year radiology resident at Massachusetts General Hospital in Boston, whose institution participates in the Mass HIway HIE, acknowledges that HIEs do indeed improve patient care. “From a radiology perspective, the most meaningful benefits of the HIE are avoiding duplication of imaging studies, accessing prior imaging studies for comparison, and obtaining key clinical information to aid in imaging interpretation,” states Mangano.
Even though every HIE configuration is different, many features are common across platforms. Chief among these offerings is the ability to integrate the software directly into existing structures. Many HIE administrators, for instance, can build exchange functionality directly into a radiologist’s PACS, ensuring ease of use.
However, when James V. Rawson, MD, FACR, radiology department chair at the Medical College of Georgia at Georgia Regents University and chair of the ACR Economics Committee on HOPPS/APC, first saw an HIE, the workflow was anything but convenient. The HIE, called the Georgia Regional Academic Community Health Information Exchange (GRAChIE, pronounced “Gracie”), required that radiologists log into the GRAChIE website to see if there were results for a given patient. Although better than not having any patient history at all, it was “not practical to check the HIE on every radiology exam you interpreted,” says Rawson. “It was not a very streamlined workflow.”
But radiologists should not be dissuaded from using exchange technology if at first the workflow is not ideal. The radiologists at Georgia Regents Medical Center asked their information technology team to streamline the workflow. “Now we are inserting the HIE into our PACS process as opposed to having to break out of our workflow and log into a separate system,” explains Rawson.
On the Same Page
No matter how a given HIE may operate, they are a proven way to supply providers with the most complete picture of a patient. Raymond K. Tu, MD, FACR, partner at Progressive Radiology in Washington, D.C. and chair of the ACR Medicaid Network, says that he often sees clinical scenarios like Mrs. Martin’s, wherein a patient has imaging done in one jurisdiction. Fortunately, patients in the Washington, D.C., area have the option to allow their records to be entered into the Washington, D.C., HIE. By plugging area doctors into a network to exchange patient data in this unencumbered way, the D.C. HIE allows providers to tailor patient care based on more complete medical histories than are available to most radiologists.
While ease of record sharing is a key reason to participate in an HIE, it’s not the only advantage. According to John M. Benson, MD, FACR, director of medical imaging at Mount Desert Island Hospital in Bar Harbor, Maine, analyzing patient information is an important feature of his state’s independent nonprofit HIE, HealthInfoNet.
The software provided by HealthInfoNet has many capabilities, explains Benson, such as comparing a given hospital’s performance to the rest of the state’s hospital market. “Say you want to know where you stand with regard to bounce-backs to the ER,” he says. “If you’re a major outlier, you’ll want to know that so you can improve care management and communicate better with primary care physicians.” In addition to these metrics, says Todd Rogow, chief technology officer at HealthInfoNet, the HIE provides data to support the hospital’s budget and strategic planning process. Practices can use “real time data to track and trend volumes and market share by service area, disease, payer, and patient demographics.”
Despite the advantages, many radiologists do not take part in HIEs, and it is to their detriment, says Tu. As HIEs gain traction and become widely accepted, Tu asserts, radiologists need to be in on discussions about how the network will operate. The last thing a radiologist wants is an exchange without a radiology portal.
“One of the things you see is that networking is key in being invited to the table for HIEs,” says Tu. As a good first step, Tu recommends radiologists engage with their local board of medicine. “The board of medicine will know who the HIE contractors are. HIE implementation is mostly subcontracted out to various companies,” notes Tu. “It’s unlikely that a state is going to set up the exchange themselves. The board of medicine will know who the HIE administrator is, and then you can take that information back to your practice leaders” to get the ball rolling on becoming involved.
Alternatively, if it is not practical to speak with the local medical board in a given area, J. Raymond Geis, MD, FACR, assistant clinical professor of radiology at the University of Colorado School of Medicine in Fort Collins, Colo., recommends asking a client hospital’s CMIO or a state radiology society for assistance. “It is vitally important that radiologists and imaging informatics specialists be involved when HIEs…are formed, as they are primarily focused on sharing HL7 data,” states Geis. “An entity setting up an HIE may view images and DICOM data as too complicated, or not worthy of their efforts. Also, the entity may not have any experience with DICOM, the file structure for most medical images.” At a time when radiologists are working to re-establish themselves as vital to the health care process, participating in an HIE is a good way to demonstrate this value to referring physicians and patients alike.
By Chris Hobson, Imaging 3.0 content manager