Diagnostic Reading #34: Five Must-Read Articles from the Past Week

Carestream LogoTomorrow is a holiday in the U.S., so this week’s issue of Diagnostic Reading will be taking place a day early. This focus of this week’s articles include data interoperability, how dense breast tissue affects mammograms, CT radiation dose levels, cybersecurity, and new findings by the Society of Radiologists in Ultrasound.

1) Q&A: A New Diagnosis for Radiologists – Diagnostic Imaging

An article published in Radiology by the Society of Radiologists in Ultrasound recommending that elastography techniques can be used to distinguish patients with no or minimal liver fibrosis and differentiate them from patients with severe fibrosis or cirrhosis. There were two significant outcomes from this recommendation: patients no longer need invasive liver biopsies to diagnose liver fibrosis, and radiologists will play a huge role in diagnosing diffuse liver disease, a part they did not play before.

2) How Breast Density Can Affect Cancer Screenings – Imaging Technology News (ITN)

Susann Schetter, DO, co-medical director of Penn State Hershey Breast Center recently published comments in an edition of The Medical Minute, a weekly health news feature produced by Penn State Milton S. Hershey Medical Center, on how when it comes to breast cancer screening, the fibroglandular density of breasts affects how well a mammogram can detect cancerous tissues.

3) Cybersecurity is an Increased Business Priority for Healthcare Leaders, Survey Finds – Healthcare Informatics

“The Healthcare Information and Management Systems Society (HIMSS) surveyed nearly 300 healthcare leaders across the industry on the issue of securing patient data. Nearly every single one, 87 percent in all, said cybersecurity was increased business priority over the past year due to the increasing threats to PHI. Two-thirds of the respondents said their organization had experienced a significant security incident.”

4) CT Radiation Dose Levels in Clinical Trial Surprise Researchers – AuntMinnie

“A group of researchers studying the use of CT for kidney stones were surprised by the radiation dose levels they discovered in their multicenter clinical study. Not only were many doses too high, they also varied widely between centers, concludes a research letter published June 29 in JAMA Internal Medicine.”

5) Innovation Pulse: A Better Road to Data Interoperability? – Healthcare IT News

Tom Sullivan, executive editor, HIMSS Media, takes a look at how enabling one doctor to use one EHR to access patient information residing in a different hospital’s EHR from a different vendor may not be best way to give doctors the data they need. He looks at the ability to overlay technologies, one on top of the other, as it might bring us close enough to interoperability.

Diagnostic Reading #33: Five Must-Read Articles from the Past Week

Carestream LogoIt is time for another issue of Diagnostic Reading. This week we focus on the U.S. Supreme Court ruling on the Affordable Care Act, quality in radiology, patient and radiologist interactions, new Joint Commission rules, and Medicare’s slow adoption of telemedicine.

1) Supreme Court Upholds Subsidies in 6-3 Vote – Healthcare IT News

“The U.S. Supreme Court on Thursday voted 6-3 against the plaintiffs in the case of King v. Burwell. The ruling means more than 6 million residents in the 34 states with federal insurance exchanges can keep their tax subsidies for health coverage.”

2) What Exactly is Quality in Radiology? – AuntMinnie

According to a talk at the recent International Symposium on Multidetector-Row CT (MDCT) in San Francisco, it is import for radiologists to think about what the word “quality” actually means in the context of radiology, and it is imperative that radiologists work to define it. The talk discussed how one of the key factors to creating a culture of quality and safety is making sure that staff members can speak freely when they’re worried about a protocol or a patient care situation.

3) Do Patients Really Value Interaction with Radiologists? – AuntMinnie

Dr. Sam Friedman provides his personal opinion on how he thinks that ACOs and the other “risk” programs are simply clever ways to separate physicians from their pay. He points to the June 2015 issue of the Journal of the American College of Radiology, where Cabarrus et al presented the results of a patient survey that found that patients preferred to hear the results of imaging exams from the physician who ordered them.

4) Are Imaging Sites Ready for New Joint Commission Rules? – AuntMinnie

“On July 1, a new era of intense scrutiny and documentation will arrive for CT and other imaging modalities, thanks to new Joint Commission accreditation requirements that become effective on that date. Unfortunately, most radiology departments aren’t remotely ready to fulfill the requirements.”

5) Medicare Slow to Adopt Telemedicine Due to Cost Concerns – Healthcare IT News

“Anthem and a University of Pittsburgh Medical Center health plan in western Pennsylvania are the only two Medicare Advantage insurers offering the virtual visits, and the traditional Medicare program has tightly limited telemedicine payments to certain rural areas. And even there, the beneficiary must already be at a clinic, a rule that often defeats the goal of making care more convenient. Congress has maintained such restrictions out of concern that the service might increase Medicare expenses. The Congressional Budget Office and other analysts have said giving seniors access to doctors online will encourage them to use more services, not replace costly visits to emergency rooms and urgent care centers.”

The Importance of FDA-Approved Medical Image Viewers

Last month, we discussed the importance of having medical image viewers approved by the U.S. Food and Drug Administration (FDA) at SIIM 2015.

The benefits are numerous. Most importantly, with FDA approval, the users (referring physicians) are assured that the quality of the medical images that they are viewing are of a high quality that is appropriate for clinical decision making.

The FDA is very specific in what they consider to be a diagnostic device. It talks about a specific guideline about how a mobile device, or any device, is used for clinical decision making, and right now, the FDA is saying that a viewer must go through the FDA clearance process if it is going to be used for any sort of clinical decision making.

Radiologists’ customers, referring physicians, are looking at the patient medical images for clinical decision making on viewers, and more often these viewers are on mobile devices. Using a medical image viewer approved by the FDA means that there is compliance throughout the healthcare enterprise.

Carestream’s Vue Motion is FDA approved for clinical viewing on mobile devices, be it tablet, iPad, iPhone, or Android. The demo below shows Vue Motion in action and how it can bring an enterprise together around patient clinical data.

Diagnostic Reading #32: Five Must-Read Articles from the Past Week

Carestream LogoAnother week, another issue of Diagnostic Reading to provide with a few articles to read in case you missed them this week. The focus of these articles is on social media to promote research, medical identity theft trends, big data and artificial intelligence, regulatory changes for medical imaging, and optimizing hospital radiology.

1) Social Media Boosts Awareness of New Research – AuntMinnie

The Journal of the American College of Radiology  released a report which found that a blog post promoted on social media generated more than 10 times the page views of research articles published online in two peer-reviewed journals.

2) Medical Identity Theft Hits All-Time High – Healthcare IT News

A majority of medical identity theft victims can expect to pay upwards of $13,500 to resolve the crime. Also, about 50% of consumers say they would find another healthcare provider if they were concerned about the security of their medical records.

3) As Big Data Grows, the Need for AI Comes into Focus – Healthcare IT News

“By 2020, there will be 200 times more data than any physician can absorb,” according to Dr. Anthony Chang, a pediatric cardiologist. “And its doubling every two years.” In a keynote address at the National Healthcare Innovation Summit, he talked about “Intelligence-as-a-Service,” a network that could make it possible for doctors to tap into knowledge from specialists anywhere when they encounter a medical situation that is not responding to treatment.

4) Ready, Set, Go: Regulatory Changes Ahead for Medical Imaging – Radiology Business Journal

“Today, regulatory changes occur all year long, and—in addition to the incredible amount of work required to manage the department, imaging center or practice—it is almost impossible to keep abreast of them. Most administrators are not prepared for all of the changes coming in the next 2 years.”

5) The Mission to Optimize Hospital Radiology – Radiology Business Journal

Radiology Business Journal spoke with radiology leaders at five different health systems to understand how they are optimizing radiology to lower costs and improve care quality. Standardizing care protocols, centralizing operations and creating physician–administrator “dyads” to drive change are key strategies.

Diagnostic Reading #31: Five Must-Read Articles from the Past Week

Carestream LogoAnother week and another issue of Diagnostic Reading. This week’s topics are focused on population health, Meaningful Use and the “Digital Divide,” clinical and claims data, radiology decision support, and radiology’s role in enterprise imaging.

1) Population Health: The Path Forward – Healthcare Informatics

Mixed sentiments were on display among the industry leaders participating in the 15th annual Population Health Colloquium, held on March 23 at the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, and chaired by David Nash, M.D., dean of the Jefferson School of Population Health.

2) Did Meaningful Use Create a ‘Digital Divide’? – Healthcare IT News

A new study from Weill Cornell Medical College, published this week inHealth Affairs, points to the emergence of “systematic differences” between physicians who participated in the Medicare and Medicaid EHR Incentive Programs and those who didn’t. Docs’ participation in the Medicaid incentive program rose from 6.1 percent to 8.5 percent between those two years, researchers say, while participation in the Medicare incentive program rose from 8.1 percent to 23.9 percent.

3) Infographic: Clinical and Claims Data – What Lies Beneath? – Healthcare IT News

“This infographic draws upon the unified clinical and claims data warehouse of Arcadia Healthcare Solutions to show the quantity of data available for 500 patients. Claims records are represented by the “above-ground” green bars – but they’re dwarfed by the vast amount underlying electronic health record data, represented by the brown bars underneath.”

4) Radiologist Decision Support May Cut Unnecessary Studies – AuntMinnie

According to researchers at NYU Langone Medical Center, a decision-support tool that is readily available to radiologists when reading medical images can help them order more-appropriate follow-up exams. After adopting the tool the research team found that radiologists’ adherence to clinical guidelines improved from 50% to 80%.

5) Big Picture: Radiology’s Role in Enterprise Imaging – Radiology Today

“As medical imaging has risen from a radiology-specific concern to an enterprisewide need, hospitals and medical centers have responded to the increasing and broadening demand for images. Making that adjustment is no easy feat, however. Clinicians desire image availability and accessibility wherever they work; making it happen requires scrupulous planning and plenty of hard work.”

Video: What the Future Holds for Digital Breast Tomosynthesis (DBT)

At SIIM 2015, Carestream’s own Ron Muscosky, worldwide product line magager, Healthcare Information Solutions, participated on a panel about digital breast tomosynthesis (DBT).

We covered the audience questions in more detail in an earlier blog post, but in the video below, Muscosky explains the purpose behind the panel, the challenges DBT presents, how vendors are addressing these challenges, his comments on the audience’s participation, as well as what he believe the future holds for DBT.

Diagnostic Reading #30: Five Must Read Articles from the Past Week

Carestream LogoAnother week means another edition of Diagnostic Reading where we highlight five must-read articles published in the last seven days. This week’s articles focus on Stage 3 Meaningful Use, dense breast tissue, VNAs, breast cancer screening, and mobile app adoption among radiologists.

1) Proposed Rules for Stage 3 Meaningful Use – Imaging Technology News (ITN)

Dave Fornell of ITN goes into details for each of the eight objectives for Stage 3 Meaningful Use set in place by the Centers for Medicare and Medicaid Services (CMS). The eight objectives include: 1. Protect Patient Electronic Health Information; 2. Electronic Prescribing; 3. Clinical Decision Support (CDS); 4. Computerized Provider Order Entry (CPOE); 5. Patient Electronic Access to Health Information; 6. Coordination of Care Through Patient Engagement; 7. Health Information Exchange (HIE); and, 8. Public Health Reporting.

2) Making Sense of Dense Breasts – Imaging Technology News (ITN)

Jeff Zagoudis of ITN discusses how as states continue to mandate patient notification of dense breast tissue, the technology for analyzing and reporting continues to evolve. A big issue today is how almost all in the medical community know about the impact of breast density, but that knowledge has not been passed down to patients. The article dives into the how many states in the U.S. are working to notify patients about dense breast tissue, and other modalities to get a second read of the exam.

3) NEJM: Breast Cancer Screening Reduces Mortality by 40% – AuntMinnie

“Researchers from the World Health Organization’s International Agency for Research on Cancer (IARC) found that women ages 50 to 69 who regularly receive mammography screening reduce their risk of dying from breast cancer by 40%, compared with women who are not screened. This translates into about eight deaths prevented per 1,000 women regularly screened, according to the group.”

4) SIIM 2015: VNA Adoption Yields Workflow, Cost Benefits – AuntMinnie

In this session from SIIM 2015, Wake Radiology was able to realize the benefits of a vendor-neutral archive (VNA) such as improved workflow, better management of digital breast tomosynthesis (DBT) images, and reduced storage costs.

5) Q&A: Radiologists at the Forefront of Mobile App Use – Diagnostic Imaging

The Q&A is with David Hirschorn, MD, director of radiology informatics at Staten Island University Hospital, in which he discusses a panel he participated on at ACR 2015 called, “Reshaping Radiology Through Mobile: Apps, Technologies, and FDA Regulations.”

Importance of Viewers in Enterprise Imaging

Marianne Matthews, Chief Editor, Axis Imaging News, recently spoke with Cristine Kao, Global Marketing Director, Healthcare information Solutions, Carestream, and the focus was on viewers and the important role they play in enterprise imaging.

It is not so much the technology as what the viewer enables that makes them so important. Collaborative care between users is at the essence of what makes viewers so powerful because diagnoses and treatment planning need to be based on looking at and having access to the same information.

The interview, which can be watched in its entirety below, also toucheson FDA approvals for enterprise viewers, and which ones need to go through FDA clearance and which ones do not.

DBT: Is It Ready for PACS Prime Time?

SIIM 2015 LogoOn the final day of SIIM 2015, a vendor panel took place that looked at the evolution and adoption of digital breast tomosynthesis (DBT), and whether or not facilities were prepared to handle the influx of these 3D images on their PACS, as well as across their IT networks.

The panel was led by David A. Clunie, PixelMed, and consisted of Ron Muscosky, MSEE, Carestream, Steve Deaton, Viztek, Mark Bronkalla, MBA, Merge, and Bobby Roe, Visage.

After the vendors each took turn describing their own offerings and advice to those who currently use DBT or are planning to, we segued into an audience Q&A that dived into more detail among the seven audience questions. Below are the questions asked, as well as answers provided from the panel.

Question #1: Secondary capture–should facilities be talked out of it?

Answer: The option exists to store in a standalone archive, or in a PACS and then have the DBT images converted. The issue is that once converted into a PACS, facilities now have double the storage needs as two images now exist. Among panel attendees, they all either had DBT in place, and planned to have it within the next 12 months. However, few who were planning deplpy DBT had a plan in place. Essentially, facilities need to put priority on BTO (Breast Tomosynthesis Object) over SCO (Secondary Capture Object) for improved flexibility in storing and sharing images.

Question #2: What is the clinical impact of DBT? Does it take three times as long to read the exams?

Answer: This answer to this question was diverted to the audience, where one attendees traditional 2D mammography took 10-20 seconds to read, versus DBT exams which took 20 minutes. Attendees knew reading DBT exams took longer, but not that long. The panel responded to this answer by saying that DBT was still relatively new and as adoption and familiarity increased, reading time would become more efficient.

Question #3: Will reimbursement for DBT improve? Especially after the stick-shock for installation?

Answer: When DBT was not reimbursed, few were using the technology. Now that more are using the technology, reimbursement is in place, though it is consider poor. For improved reimbursement, the introduction of new competitors will drive purchase and installation prices. Carestream’s Muscosky said that he has been seeing many facilities adding DBT for competitive reasons, because they do not want to lose patients to other facilities that have it installed. There are of course diagnostic benefits to DBT, and in turn providing better patient care. Essentially, facilities should be installing DBT to maintain an edge on the competition, and use it as a marketing device for the facility. A large majority of the audience agreed with this and are currently practicing this themselves.

SIIM 2015 DBT PanelQuestion#4: Regarding size of images–how can DICOMweb help with performance issues?

Answer: One response was that is does not matter one way or the other if facility is handling everything on the server side. Another response was that any image being view for mammography is either lossless or not. High resolution, no bandwidth advantage to the client, because you want to have a viewer that does not need the entire study to start display or the entire object to start display. Server-side issues have advantages but is not a silver bullet. Facilities can user server-side for non-diagnostic, or offer a choice on whether facilities want loss or lossless, and server-side is not truly offering bandwidth advantages.

Question #5: This audience member asked about digital mammography priors for comparison reasons that has resulted in a struggling workflow. She had to alter workflow because her facility cannot get to prior to workstations fast enough. Has this problem been fixed with digital mammography?

Answer: The issue with the attendee’s facility was that there are multiple offices, but read at one central workstation. The facility is sending all studies to all workstation, creating three or four copies. Routers would send study once across, and central location would route once. The solution to this is that intelligent routing would mitigate the issue. Technology that is zero-footprint has not been available, whether supporting server-side rendering or not, but it is moving in that direction. All of this re-routing goes away once facilities move to the cloud. Panelists commented how it is important to focus on not just getting diagnostic tools to diagnosing physician, but also having good bedside manner with patients. Carestream’s Muscosky added that many facilities are converging multiple sites, and data needs to be accessed quickly no matter where from. Data cannot be sent around among facilities and re-routed.

Question #6: Is the industry moving toward supporting motion detection and correction?

Answer: Panelists all agreed that this advancement would need to be completed on the image acquisition side, since these vendors are the ones creating the hardware. They all agreed that it would great to see projection when there is motion, but have not heard of anyone released a motion detector.

Question #7: How do facilities correct hanging protocols that are not working?

Answer: One true way to identify an image according to view, and every view port has to give the user an option to toggle between C-view, and others. Facilities should refer to the IHE DBT framework. There was an idea presented that in the future, vendors should allow hanging protocols that make more sense and are deterministic. Users still want to hang right, regardless of vendor, and new modality gives a chance to hope for the best compliance. In the future, there will need to be a right code that allows users to apply logic and alternate paths to identify mishaps.

PulvinoRich Pulvino is the digital media specialist for Carestream. He attended SIIM 2015 from May 28-30 at the National Harbor in Maryland.


Imaging’s Place in Value-Based Healthcare

SIIM 2015 LogoThe answer to a question asked in a SIIM 2015 Friday morning session was clear–medical imaging needs to make further progress to be in a position to provide value-based care.

This was the focus of Rasu B. Shrestha, MD, MBA, University of Pittsburgh Medical Center, John W. Nance, MD, Johns Hopkins University, and Kevin W. McEnery, MD, University of Texas MD Anderson Cancer Center in the session, “Providing Value-Based Healthcare – Should Imaging Lead, Ride Along, or Get Left Behind?”

Radiology: Data Rich, Information Poor

Dr. Shrestha began the session by focusing on what we mean when we talk about value-based care, how radiology needs to get to where it needs to be, and the opportunities to get there by discussing the barriers that are currently preventing this from happening.

The state of radiology is that the specialty is data rich and information poor. It has commonly had its innovators, and has led the charge in healthcare innovation (film to digital, etc.), but its innovation over the years has also been its downfall, as numerous silos have popped up within healthcare providers. The next stage for radiology is breaking down those silos and extracting the data so we can comb it for information, which according to Dr. Shrestha’s slide, showed that from the information we obtain from data, we can then gain knowledge about the patient(s), and eventually turn that knowledge to wisdom, with increased value provided to the patient along the way.

The main problem with the imaging workflow today is that radiology is image-centric and not patient-centric. The specialty stopped talking to other specialties within the hospital as it drowned in too much data, and not enough intelligence. Moving forward, context will be king–both obtaining context to produce better reports, and providing additional context once the exam has been done and the report created.

Dr. Shrestha’s main point was the importance of data liquidity, which is freeing data from the silos, liquidating the assets because of the immense amount of value it hold. The problem is that radiology has not been able to do this.

The technologies currently being developed will radiology in this direction. The next generation will be patient-centric, predictive protocols, cloud-based VNA, adaptive learning, contextual reports, and value-based imaging.

Radiology can only improve what it can  measure. In a volume-based imaging model, report turnaround time, and number of studies read were the metrics. Moving forward, it will be superior outcomes, patient-centric care, clinical quality metrics, increased transparency, total cost management, and shared savings.

Definition of Value

Following Dr. Shrestha, Dr. Nance of Johns Hopkins University looked at the definition of value, its history in radiology, its current status, and barriers.

He started out with the honest definition of value, which is:

Value = Outcomes/$

Value does not equal quality, efficiency, safety, outcomes, or cost, per se, and he highlighted that there is currently an alphabet soup of organizations (government, nonprofit, associations) currently focused on outcomes, because the current measures are certainly not.

Dr. Nance went through common measures, and how diagnostic imaging is not a big part of them. The Healthcare Effectiveness Data and Information Set (HEDIS), has 81 measures and only three have anything to do with diagnostic imaging. None related to outcomes. Physician Quality Reporting System (PQRS)–254 measures, and only 13 deal with diagnostic imaging. Again, none related to outcomes. National Quality Forum has 636 measures, with 15 having to do with diagnostic imaging, even though imaging account for 14% of healthcare costs.

The fact is that diagnostic imaging lacks outcome measures.

ACR’s Imaging 3.0 is heading in the right direction by seeking to improve the value of radiology. The types of quality measures are focused around structure, process, and outcomes. Structure focused on underlying infrastructure of a system, which has serious limitations. Process measure are most common, contain a lot of value, have some advantages that are actionable, but again, have serious limitations. This is because people gravitate toward measures that are easily extractable, even though they may not be the most relevant.

Why are outcomes so allusive? You need data validity. Stringent national benchmarks, which are often lacking. Large sample sizes and follow up to show differences. There are good examples out there with large, randomized controlled trials, but it is not commonplace yet.

The challenge moving forward for radiology in this area will be diagnostic accuracy, the quality of communication, change in management of the specialty, and the effect on outcomes.

Transitioning from Volume-Based to Value-Based Imaging

Finishing up the session, was Dr. McEnery of University of Texas MD Anderson Cancer Center.

The objectives for his section centered around examining the transition of imaging from volume-based to value-based, and discussing the role of informatics support in demonstrating the value of enterprise imaging in the transition to value-based healthcare.

In a value-based system, Dr. McEnery showed that we must be achieving outcomes at the lowest cost that are patient-centered, focus on the patients’ needs with their outcomes achieved, and focus in the right locations for high-value care.

For high-value, the value-enhancing IT platform accomplishes the following:

  • It is centered on patients
  • It uses common data definition
  • It encompasses all types of patient data
  • The medical record is accessible to all parties involved
  • The system includes templates and expert systems for each medical condition
  • The system architecture makes it easy to extract information

With the change from volume-based to value-based imaging, we will go from being:

  • Transactional to consultative
  • Radiologist-centered to patient-centered
  • Interpretation focused to outcomes focused
  • Commoditized to integral
  • Invisible to accountable

The imaging value patient context that Dr. McEnery showed was:

  • Orders: Appropriate for the patients’ complete presentation
  • Protocols: Optimized to inform the clinical decision process
  • Acquisition: Optimized to inform at safest level, greatest clinical data
  • Interpretation: Focus on findings that are pertinent to patient
  • Reports: Optimized to efficiently show the information, data, and results

Dr. McEnery went on to explain how these changes to value-based care are on the way as health reform continues to take shape. This included the April 1, 2016 deadline of CMS lists qualified decision support providers for ordering professionals, and beginning January 1, 2017, CMS will not reimburse certain claims.

With these changes inevitable, Dr. McEnery ended his session focusing on the clinical decision support (CDS) process and how it will move diagnostic imaging to a value-based process. Essentially, CDS and EMR needs to inform the entire patient process, and significant changes are in process for the delivery and reimbursement of healthcare.

IT systems will need to evolve to allow radiologists to become a part of this evolution. As Dr. McEnery said at the beginning of his session:

“I don’t want to be in the backseat. I want to ride shotgun. I want radiology to ride shotgun in the innovation process.”


PulvinoRich Pulvino is the digital media specialist for Carestream. He is attending SIIM 2015 from May 28-30 at the National Harbor in Maryland, and will be publishing blog posts throughout the event.