Medical Imaging March Madness – Stage 2 and the Health Affairs IT Study Debate

Doug Rufer

Doug Rufer, North American Business Manager,RIS, healthcare information solutions, Carestream

March was an intense month for medical imaging. The proposed Stage 2 Meaningful Use Requirements were hot off the presses when a study in Health Affairs found that electronic access to imaging results increases ordering of additional tests. What is an accountable care organization and its team of radiologists and referring physicians to do? Let’s dissect each piece.

Imaging Inclusion in Stage 2

On March 7, The Office of the National Coordinator for Health IT (ONC) filed stage 2 meaningful use guidelines with the Federal Register. While still in the comment period and subject to change, the new MU rules finally recognize imaging—an area lacking attention in stage 1—in several ways including a measure focused on diagnostic image accessibility in EHR’s (40 percent of scans and tests being accessible) and more clinical quality measures relevant to radiology (60 percent use of CPOE and adding radiology and labs). CMS also requested comments about requiring 10 percent of images to be transmitted in HIEs. Health Data Management hosted a great MU Stage 2 Webinar (archive available now) that looked in detail at data exchange requirements, online patient access to medical information, and increased CPOE thresholds. With a more direct connection between radiology and the EHR, providers who are embracing meaningful use now have a more complete model for how to improve the quality of patient care while reducing costs.

Health Affairs IT Study

On the heels of stage 2, the results of a 2008 study, “Giving Office-Based Physicians Electronic Access to Patients’ Prior Imaging and Lab Results Did Not Deter Ordering of Tests,” ignited a debate between the study authors and Dr. Farzad Mostashari, National Coordinator for Health Information Technology over claims that the meaningful use of EHRs will have little impact on the cost or quality of care.

Mostashari’s position – the study was dated before the passage of the HITECH Act, lacked consideration for the clinical decision support in certified EHRs, used association to suggest causality, and had no regard to whether more testing was medically necessary.

The authors’ position – there have been no “game changing” developments in past four years, EHR products have undergone only modest tweaks, and “Dr. Mostashari’s unbridled faith in technology is mirrored by his belief that ACOs are the next panacea for health costs and quality.”

My position – the debate’s focus on EHRs is too narrow. To truly understand the study’s assumption you need a more detailed look at the health IT ecosystem vs. a single component—Carestream Radiology Information Systemin particular, the use of a radiology information system (RIS) and its interplay with the EHR deserves more attention. Were the providers studied using a RIS module within the EHR or a standalone RIS system? There is often cost-based pressure to use the EMR’s RIS module, but these modules often deliver limited functionality. Fully featured reporting and embedded voice recognition are usually not included. Built-in rules and triggers for complex exams at the time of scheduling, ordering, or even prior to the exam being started, (including angiography, contrast exams, positron emission tomography [PET], computed tomography [CT] and magnetic resonance [MR] exams) may not be offered—all deficits that could impede efficiency, lead to unnecessary testing and ultimately create higher costs. Perhaps the debate and study shouldn’t be centered on general “electronic access,” but the appropriate combination of health IT systems within the hospital ecosystem.

MU Certified RIS

With meaningful use, certification adds another layer of complexity and opportunity. RIS vendors, like Carestream, are developing certified standalone RIS solutions that both satisfy specific radiology workflow challenges while evolving to address changes in healthcare regulations. These advanced RIS solutions offer tools like:

  • Order entry decision support – The American College of Radiology (ACR) has been working to create a decision support database for several years. The objective is to outline which imaging exams are medically appropriate for a patient’s symptoms or diagnosis. The ACR’s decision support database is currently being tested in several hospitals. Certified RIS platforms are available that support user-defined rules so each facility can set its own standards for the “appropriateness” of an imaging exam. These platforms can be adapted to support the ACR criteria when they are finalized.
  • Exam protocols – Radiologists already use established protocols for ordering complex imaging exams at large teaching facilities and specialty hospitals. Protocol variations involve scan thickness, scan sequences, reconstructions, gantry tilt and other characteristics. The specific protocol is determined by a patient’s diagnosis, stage of disease, type of treatment level and other data. In the future, hospitals of all sizes and other imaging providers may adopt a list of protocols to ensure optimal imaging results based on a patient’s disease state.
  • Quality Outcomes – There is a movement toward establishing guidelines for capturing, maintaining and reporting radiation dose, speed of reports and other factors that can enhance diagnosis and treatment. The RIS is the likely platform to collect and store patient imaging data as part of this effort to help improve patient outcomes.
  • Structured Reporting – Conversion to structured reporting is driven by results from studies that show that up to 80 percent of physicians do not fully understand the radiologist’s diagnosis as presented in the report. Use of paragraph-style reporting based on dictation by a radiologist will likely be replaced with structured reporting that involves the selection of clear, standardized wording to convey a diagnosis. Standardized wording not only will make a diagnosis easier to understand, but it also will enhance the ability for data mining by research facilities nationwide. This can play into the goals of meaningful use and using population based data to improve overall outcomes by ensuring the correct tests are ordered the first time based on patient conditions, while also lowering the cost of care.

What do you think of the Health Affairs debate? Is RIS a missing link in this health IT and meaningful use discussion? 

Q&A With Lead Radiologic Technologist at Scripps Health

Jeremy Enfinger, BS, RT(R), Radiology Lead Tech at Scripps Health

Editor’s Note:  We sat down with  Jeremy Enfinger, BS, RT(R), Radiology Lead Tech at Scripps Health and Adjunct Radiography Instructor at San Diego Mesa College, to get his thoughts on the evolution of the radiography profession, digital x-ray technology and the importance of continuing education and networking.

Q: What impact is health reform having on radiographers and the radiology department?

A: Health reform is driving radiographers to learn how to get by with less, at least for those who are employed by healthcare systems with the foresight to start making changes and cost-cuts early.  We are building staffing and productivity models to best practice examples, standardizing supplies and procedures, and consciously making effort to reduce waste. We see it as a preemptive strike to become more efficient, produce higher quality, and improve patient satisfaction so that when reform budget cuts occur, we will be able to survive.

Q: What advice do you have for radiographers to continue to improve quality and lower dose?

A: For veteran radiographers, I recommend staying current with technology.  We can’t use the same methods to acquire those optimum images that we used to during the film/screen imaging days.  Educate yourselves on digital technology.  For newcomers in the field, listen to the veterans about lessons learned and keep an open mind toward the many changes that are coming our way with technology, dose documentation, and the never-ending efforts to maximize diagnostic quality of images.  There are always improvements that can be made no matter how long you have practiced radiography.

Q: You use portable imaging systems often in your hospital. What are the biggest challenges of mobile x-ray?

A: The biggest challenge I see with mobile x-ray is getting help when positioning the image receptor behind the patient.  Some floors have plenty of staff to assist, but with health reform on the way, expect to see less staff available to assist and more independent manipulation of the patients.  I have seen this practice already starting to take its toll across the country, and I would go so far as to say that as a result, we are going to start seeing more work-related injuries.

Q: What’s your best piece of advice for a rad tech looking to boost their exam efficiency?

A: I recently did a blog post on exam efficiency. Keep it simple:  Be open to new methods of performing your exams, and be willing to learn from the veterans who are already efficient.  You can adopt any of their practices that may boost your efficiency while maintaining your own preferences.

Q: As an adjunct radiography program instructor, you value continuing education. What’s the one continuing education course that has had the most impact on your career and day-to-day work?

A: I attended a two-day workshop for educators on digital radiography at the University of North Carolina when I lived there.  I was amazed at how of the much knowledge I knew for film/screen imaging systems changed for image production and radiation dose requirements with CR and DR imaging.  I can’t begin to describe how often I see techs (who haven’t had any education in digital imaging) observe a “light” image on the monitor, and repeat an exposure by doubling their mAs when the exposure indicator is adequate.  If you began your career working with film/screen systems, you need to fight every instinct you have to avoid this mistake.  This course taught me that there can be multiple reasons for this error, and further investigation is required.  It is important for those of us who understand the appropriate methods for successfully repeating an image like this to educate those who have not yet taken any continuing education courses for digital imaging, as well as to encourage them to pursue it further themselves.

Q: You’ve been blogging about radiology since 2007 and recently started the Topics In Radiology Facebook page and newsletter.  What’s your perspective on social media in the radiology profession?Topics in Radiography Facebook Page

A: I have become a kind of social media addict.  It can be either good or bad for the profession depending on how it is used.  I find that my blog gets a lot of traffic from student radiographers.  This is great because new questions and public interaction are what keep it fueled. The good part about the social media is that most people can get updated with the latest news and events. I even answer some student questions on my blog.  Let’s face it… Radiography is a niche topic that can be difficult to find information on that is easily interpretable.

What seems to be the negative part of social media in the field is that many people get on Twitter or Facebook with their personal accounts, and start connecting with people at their hospital or clinical sites.  This alone isn’t bad per se, but it has caused a whole new challenge for HIPAA compliance and interaction with coworkers outside the confines of the work place. It can be a great tool as long as we treat it with responsibility.

Q: Your Pet Peeves of Rad Department’s blog post was a really good look inside what radiographers deal with everyday. What five things do you like most about being a radiology technologist?

A: I love to interact with patients.  That’s one thing that I miss about my current position as a lead.  I spend more time on the phone than with patients it seems, but I do enjoy the opportunities I still have to provide patient care.

I also like the “artistic” aspect of radiography.  If you follow everything you are taught in your training, you can produce a product you can be proud of.  There can be so many variations from patient to patient, but a good technologist will have many tricks and techniques over the years to obtain optimum images on everyone coming into the x-ray room.

The field is also very flexible.  It’s easy to learn more with additional modality training.  You can also work just about any hours you would like to.  There’s always something new to learn, and you rarely get tired of doing the same thing every day because every patient can be a different challenge to image.

I also like the technology.  There’s just something cool about doing this.  Once you have the skills, you can make it look easy while obtaining high quality images.  There are always new tools and gadgets that are being trialed within a hospital and it can be fun to experiment with the impact on your images.

Finally, I love the camaraderie of the field.  After a few short years, I genuinely feel like I know someone in every hospital for at least a 100 mile radius.  It’s a very small world in radiography, and that world seems even smaller the more time you spend in the field.

Q: Let’s talk radiology humor – techs do have fun, right? What’s your favorite radiology pun?

A: We have to have some fun at work… I’m a sucker for cheesy jokes or phrases.  Here are two of my favorite 1) Tech A: “These are my O.R. scrubs.”  Tech B: “Oh are they?” (insert eyebrow raise).  2) “Don’t lie to x-ray techs… we can see right through you.”

You can follow Jeremy at the Bloggin Radiology blog, the Topics In Radiology Facebook page and on Twitter.

Bringing Digital Radiology to the Developing World

According to the World Health Organization, two-thirds of the world lacks access to basic X-ray services. Because 60 percent of medical conditions seen in first-referral, primary care settings require X-ray to properly diagnose, the lack of X-ray capabilities hinders the delivery of effective, quality medical care.

Healthgreen, a not-for-profit social venture, was created to address the healthcare needs of the underserved with access to essential tools for diagnosis and screening.  Our program began with a project with Dr. Gustavo Casteneda Palacios Hospitalito, a small, rural hospital located 123.8 kilometers from Guatemala City in Rio Hondo, Guatemala. This facility had film-based X-ray, but lacked digital capabilities to make the system functional for the site. The costs of film and the inability to send images to remote experts for analysis were a major burden on the hospital.

In October of 2010, Healthgreen helped bring digital functionality to the hospital with a computed radiography system donated by Carestream and installed pro bono by Jake Thompson and his team from Kane X-ray.

And the CR system arrived just in time.  A mission of doctors had arrived to provide services to children around the country who would otherwise not receive medical treatment and the hospital was at capacity. Without a functioning X-ray system, the mission would not have been possible.  These children could not walk, attend school and rarely left their homes prior to treatment. With the computed radiography system, 440 X-rays were taken and 28 of the more complex cases underwent surgery.   The mission was considered a huge success by all involved.

We continually monitor how digital X-ray impacts the lives of people served by Healthgreen sites.  One of the first X-rays preformed at Gustavo on the CR system was on a woman who came in for a bad skin rash.  An X-ray revealed a large tumor that would need to be removed surgically.  Doctors agree that the X-ray analysis saved her life.

We are encouraged by the impact this hospital is having on the health of their community.  With the new technology provided by Healthgreen and Carestream, the site often performs 60-70 digital X-rays a day.

We look forward to seeing how digital X-ray continues to improve access to and the quality of care patients receive at Dr. Gustavo Casteneda Palacios Hospitalito.

Krista Dany, Project Manager, Healthgreen,


Value-Based Purchasing Must Bring Healthcare Providers & Vendors Together

Mike Brown

Michael H. Brown, vice president, sales and service, United States & Canada, Carestream

Healthcare reform is the new normal. Change will be constant with continuous adjustments to projected regulations, but one mandate is here to stay: Pay for Performance CMS style…popularly known as Value-Based Purchasing (VBP), an offshoot of the Accountable Care Act.

That great American tradition, the lame duck session of congress, likely will generate nothing of substance impacting the rolling changes sweeping healthcare and especially VBP. So it’s time for healthcare providers to prepare to succeed in this new environment. has a great post that shares perspective from providers who have taken the step to simulate a VBP report on the CMS QualityNet website to see where they stack up before the program officially begins. It’s a great first step for healthcare providers to come to grips with what VBP requires of them.

In essence, healthcare providers must compete against one another for reimbursement dollars they previously were receiving for simply reporting their accomplishments. Healthcare system management, patient outcomes and health status—as well as patient opinions of their healthcare experience—will determine how the reimbursement pie gets divided. It’s pure competition with very visible winners and losers.

For healthcare providers to succeed in this new world in 2013, organizations must be able to align with the following:

  •  Effective Quality, Utilization, Risk and Infection Management programs and practices throughout the entire system
  • Reliable performance improvement tools, programs and measures
  • Establishment of and adherence to best practical clinical guidelines and care pathways.
  • Operational efficiency and performance excellence
  • Solid clinician alignment with process
  • Impact on patient satisfaction

And the time is now for providers to turn to suppliers for assistance and answers about the true value and outcomes their products deliver.

Price will remain important. After all, provider revenues are shrinking while costs are growing, but the days of providers and vendors focused mainly on price won’t win the ACO battles building for 2013 and beyond. This is about true performance, impacts and outcomes for providers and vendors together.

What are some immediate changes I see in the relationship between providers and vendors as a result of value-based pricing?

  •  Standardization – An increase in equipment and system standardization to lower cost, drive productivity and eliminate unnecessary variations in the use of products that could deliver inconsistent patient experiences. Clinicians will be more intimately involved in purchasing decisions.
  • Intelligence – Providers will need to collaborate more with the supply chain on data collection to closely study utilization patterns, quality gaps and areas for better clinical outcomes and cost reduction.

I’ll close with a favorite quote from a recent Healthcare Finance News story about preparing for VBP, “Hospitals and health systems that don’t start to prepare now will pay those that do – literally.”

Are you talking to your vendors about value-based pricing? 

Annual National Interdisciplinary Breast Center Conference Stresses “Self-Care” and Continued Education

Julia, Weidman, Marketing Manager, Women's Health & Healthcare Information Solutions, Carestream

The 22nd Annual National Interdisciplinary Breast Center Conference sponsored by the National Consortium of Breast Centers opened yesterday in Las Vegas.

A global audience of nearly 1,000 attendees will participate in more than 120 sessions from 78 world-class presenters focused on the clinical, imaging, administrative and nursing concerns associated with breast health and breast center management.

The celebrity keynote was given by Kelly Corrigan. The New York Times best-selling author talked frankly and engagingly about her battle with breast cancer, and what compelled her to author her book “The Middle Place.”  Ms. Corrigan spoke about the strong bonds she developed with the caregivers who helped her navigate her journey – “the magic we”, and encouraged attendees to “perform the role nobly”.

Elizabeth Clark PhD, ACSW, MPH, executive director of the National Association of Social Workers, delivered the professional keynote “Words that Heal, Words that Harm.”  Ms. Clark raised attendees’ awareness of the context of the words they use, and how powerfully those words impact patients.  Ms. Clark also spoke about the importance of creating communities of hope for cancer patients and the need for caregivers to practice “self-care” to avoid burnout.

Visitors to the Carestream booth shared feedback that this year’s conference featured a nice blend of technology and experience sharing:

“We hear from the best and brightest in the field at this meeting.The multidisciplinary study tracks and discussions about emerging technologies are real learning experiences,” said Bonnie Rush RT (R) (M) (QM) from Breast Imaging Specialists.

Deb Wright, President and CEO of Inner Images was a judge for the poster session:

“Tech-wise there was a lot of molecular imaging. And I was glad to see papers on outreach programs for survivors.”

Dr. Lazlo Tabar commented, “This year’s NCBC has a very interesting program, very comprehensive both for physicians, technologists and nurses.” Dr Tabar also spoke about the sessions he and and Louise Miller RT (R) (M) will hold for technologists focusing on the proper positioning of the breast in screening:

“The radiology technologist is a very important part of the diagnostic team.  They are responsible for proper positioning.”

We’re sure the technologists here at the conference will line up early to get a seat!

Other hot topics like healthcare reform, breast density issues, risk assessment and geonomics and tomosynthesis will be covered throughout the conference, which ends on Wednesday. You can follow the conversation from the conference on Twitter using the hashtag #NCOBC.


Get Charged Up By Saving Energy at Your Facility

In two years, Carestream has cut its energy consumption in half. Much of that savings came from conservation efforts at manufacturing facilities, but we also focused on reducing energy at our office buildings around the world. Our employees take satisfaction in knowing that our efforts did far more than reduce costs—they took a much-needed step toward improving our environment.

Identifying ways to save energy can be easier than you might think. The first step is to appoint an overall energy champion and then establish team leaders willing to be responsible for different departments or areas of your facility. Each leader can recruit his/her own team of volunteers.

Here are two suggestions that can yield rapid savings:

1)      Adjust power usage for equipment when it is not in use. Have each team walk through their area after hours. Are computers and printers still on? You can create automatic sleep settings when systems are not in use for more than 15 minutes. Find out which imaging modalities and other medical equipment can be put into sleep mode when not in use.

2)      Consolidate office equipment (copiers/printers/fax machines), refrigerators and other appliances. Replace personal devices or appliances with energy-efficient devices that can be shared among a group, department or floor of users. Consider converting older appliances to newer energy efficient models. Replacing refrigerators made before 2001 can offer a two-year payback. Flat panel monitors can use up to 70% less energy than a CRT (cathode ray tube) monitor.

If you want to evaluate energy consumption of specific medical or office equipment, contact the manufacturer. Another option is to work with a local university. Talk to professors of industrial engineering or electric engineering. They may agree to have their students evaluate energy use at your facility—and suggest conservation ideas—as part of a class project. Reducing your healthcare facility’s energy consumption can be very rewarding for your employees, your budget and the planet.

Does your healthcare facility have a success story to share about reducing energy usage?

~Cavan Kelsey, Carestream’s Worldwide Director, Environmental, Health & Safety

History Meets Technology as Carestream Innovates at ECR 2012

The beautiful and historic capital of Vienna provided the perfect juxtaposition to the highly technical show that was ECR2012.  The event attracted nearly 12,000 delegates from the EAMER region, who converged to find strategies for improved patient care and greater efficiency in the midst of challenging European economic conditions.

Advancements in health IT captured attention for their ability to unlock new financial models and productivity. Image sharing in the cloud and integrated processing and reporting applications were also in demand, as well as mobile technology to revolutionize image access from anywhere.

Carestream’s Nicolaas Fosselle, Worldwide Knowledge and Training Manager, Healthcare Information Solutions, spent his time at the show discussing how cloud is liberating radiology workflow:


Portable imaging got lots of attention at ECR with delegates looking for a more maneuverable system. ECR marked the first time European customers really got to play with the CARESTREAM DRX-Revolution Mobile X-ray System and see what a difference it will make inside the hospital environment:



It wouldn’t be a radiology conference without an important focus on dose reduction. We had the chance to interview a Carestream Dental and ENT customer Dr Frank Klaus, who told us how the cone beam CT (CBCT) technology in the CS9300 is allowing him to image at a much lower dose with a higher image quality:


If you attended ECR, we’d love to know what you thought of your experience at the show and with Carestream. Please take our quick survey.

If you missed ECR, don’t worry. Our social media team captured a snapshot of the show in a series of videos encapsulating the current trends, customer feedback and hands-on footage of Carestream products in use. Check out the complete ECR 2012 video playlist below:

March Image Challenge – What Is It?

February’s x-ray—a TOASTER—stumped our Everything Rad readers.

But there are still plenty of images!  Here’s the image for March’s challenge.

This month’s “Guess the X-ray” challenge runs until April 2.  The first person to correctly identify the subject of the x-ray will be the winner.

Happy guessing!

Sorry… Carestream employees and their agencies are prohibited from entering.