Images & the Health Information Exchange: A Work in Progress
Some five dozen health information exchange (HIE) initiatives have cropped up across the nation enabling clinicians to share critical patient information with other caregivers in a timely fashion to allow swift, more-informed care. Currently, the sharing of medical images and radiology reports is very limited through HIEs, but forward-thinking clinicians and IT leaders are working to make seamless image sharing a radiological reality.

Looking towards the future

Health information exchange stands at the threshold of realizing its capabilities. The National Health Information Network (NHIN), an initiative spearheaded by the Office of the National Coordinator for Health IT (ONC), is poised to expand in scope and functionalities to establish standards, security and trust mechanisms for HIE. NHIN specifications were published at the end of January and implemented in March.

For example, the NHIN Limited Production Exchange (LPE) is one of the first instantiations used by the NHIN Cooperative, a private/public collaborate organization that builds, tests and demonstrates core capabilities to enable basic exchange of health information between different HIE networks, patients and other stakeholders.

The NHIN Cooperative—which includes Kaiser Permanente, the Department of Veterans Affairs and the Department of Defense, among others—established and implemented NHIN specifications and signed the Data Use and Reciprocal Support Agreement (DURSA) that allocates responsibilities and accountability to protect the information that is exchanged.

In April, the North Carolina Healthcare Information and Communication Alliance (NCHICA) partnered with health IT company Mirth to deploy Mirth Meaningful Use Exchange (Mirth MUx) to achieve NHIN connectivity. Funded through NCHICA’s contract with ONC, the project will enable the Western North Carolina (WNC) Health Network’s Data Link to connect to the NHIN to demonstrate how an established health information organization (HIO) can become a node on the NHIN and use the NHIN for connectivity with federal partners.

Watching the progress of this effort closely is NCHICA-member Wake Radiology, which employs 60 full-time radiologists among 11 imaging centers spread throughout the Raleigh, N.C., area. Wake Radiology currently makes radiology images available online through a portal supported by ImageCast RIS/PACS (GE Healthcare) to referring physicians, but for the most part it is still sending out radiology report requests by fax, according to Wake CIO Ronald B. Mitchell, MD.

“We’ve had requests for reports to go directly into an EMR system. However, unlike a hospital, we don’t have a large number of doctors using the same [EMR] system,” says Mitchell. “They’re all using different EMR systems and they’re outside our network firewall, which makes our lives a little more difficult.”

If a report is to be sent to an EMR, a one-to-one secure channel must be configured. “Each time you do this, you have to re-customize the HL7 feed, which can be very expensive,” says Mitchell.

“One of the big barriers to exchange is the uncertainty created by variation in state laws and organizational policies,” says W. Holt Anderson, executive director for the Research Triangle Park-based NCHICA. The organization is currently working with its broad membership to adopt standards to effectively exchange clinical information across disparate systems.

“A HIE will enable Wake to provide one secure channel to the HIE, then all the different EHR systems out there will be able to access the reports and images through the HIE,” says Mitchell.

One state, one vision

An area of HIE development for radiology lies in yet another ONC-funded project, the newly announced Beacon Community Awards. In May, the agency awarded $220 million to 15 “Beacon Communities,” which will serve as models for the widespread use of health IT. The Eastern Maine Healthcare Systems in Brewer, Maine, received $12.7 million to expand community connectivity to existing HIEs.

“The most important things a radiologist needs are the relevant prior studies,” says Robert Coleman, director of radiology informatics at Maine Medical Center (MMC), part of MaineHealth. The state has worked hard to advance and standardize its image-exchanging properties for the benefit of the state’s community. In 2001, MaineHealth, the 600-bed MMC and other healthcare providers developed the Consolidated Imaging Initiative (CI-PACS) to explore ways to allow multiple organizations to archive radiology images through MMC’s PACS (Agfa) and to retrieve and display those images throughout each organization’s clinical enterprise.

“It worked and is working with seven hospitals and a dozen imaging centers all sharing a single PACS,” says Coleman.

“One of the big problems with rural hospitals is that they don’t have the capacity to hire their own radiology staff or they have limited staff, so having a shared PACS is an easy way to work with a support hospital to provide a much broader range of clinical care,” says Andy Coburn, MD, professor of health policy at the Muskie School of Public Service at the University of Southern Maine in Portland and principal investigator on the CI-PACS project. “It promotes this idea of clinical collaboration on a regional level without threatening the smaller hospitals because it provides real access to expertise that rural hospitals can’t afford.”

However, relevant priors from health systems that acquired their own PACS remained a challenge, according to Coleman when explaining the progression to the One Maine Health Collaborative, a project initiated about three years ago between MMC, Maine General and MaineHealth. The Collaborative put together the Image Transfer Protocol and Image Transfer Registry, built on DICOM standards, to record and share clinical DICOM data between PACS electronically. Instead of the laborious process of burning, sending and importing data from CDs, data can be transferred within minutes. At MMC, the incoming DICOM data are “pre-processed” using UltraGateway (UltraRad), then sent to the PACS.

“The problem is that it’s still a point-to-point service,” laments Coleman, “It’s difficult to setup because you’ve got to establish VPN connections with each site, configure the DICOM senders and receivers at each site and train users at each site. Once it’s configured, it’s relatively error prone in the sense that it’s a manual process on both sides.” Additionally, the DICOM data does not “plug and play,” says Coleman, who adds that the incoming DICOM data sometimes causes issues in the local PACS when received. Despite its inconveniences, the system is used often and MMC transfers 30 studies a week on average.

HealthInfoNet, Maine’s nonprofit statewide HIE, is set to receive $4.4 million, made available through the American Recovery and Reinvestment Act of 2009 (ARRA), to be used to transition the organization from a two-year demonstration phase toward statewide implementation. The Portland-based organization is currently in the investigative stages of an initiative to build out a statewide imaging repository along with a statewide work group as a partial backup to the existing repositories and a means to coordinate information between provider organizations, according to Devore S. Culver, executive director and CEO.

“It’s currently being evaluated while developing a strategy that is cost-effective to hospitals,” says Culver. The project will seek to reduce the cost of operations by having a central repository and clean up the coordination of images between facilities as people move between care—hopefully driving down the cost of redundant care. Culver says that a series of recommendations should be presented by late summer or early fall.

Central imaging on center stage

Many eyes are watching emerging standards such as Cross-enterprise Document Sharing for Imaging (XSDi)—a means to process all imaging datasets across institutions—but Mitchell believes XDSi may not always be the best approach for sharing DICOM datasets as it requires a large bandwidth to send and receive images and a large storage capacity. “The EHR provider also needs to provide an image viewer,” says Mitchell. “A better model could be similar to that adopted by the Rochester Regional Health Information Organization (RHIO) which avoids downloading the whole image data set.”

Radiology practices participating in the New York-based Rochester RHIO send DICOM images to a central cache (eHealth Global Technologies), which get pushed onto the RHIO for sharing. The images remain in the central cache for 30 days to provide immediate access for recent exams, while older exams can be retrieved within a couple of minutes from the original PACS when needed. Additionally, Rochester RHIO uses an HIE system (Axolotl) to send the reports—which include an embedded link to the cache where the images are served up via the web--to physicians connected via the RHIO.

“The benefits are obvious,” says Daniel Jacobson, president of Rochester Radiology Associates in Rochester, N.Y. “The RHIO was set up with the most altruistic ideas in mind to help doctors get information and share information. A direct consequence of that is better patient care because when images are shared across the RHIO, they are readily available across different health systems in our community.”

“Since they are readily available, scanning isn’t repeated which leads to decreased costs and decreased radiation doses,” adds Jacobson, who has been sending images into the cache for a year.

Looking towards the future, radiologists will continue to wrestle with electronic imaging sharing across their regions and standardization specifications. Yet, radiologists are not the only practitioners who will be affected by the oncoming HIE reform. “The federal government is working to enable a wide range of innovative and complementary approaches that will allow secure and meaningful exchange within and across states, but all of our efforts must be grounded in a common foundation of standards, technical specifications and policies,” wrote David Blumenthal, MD, MPP, national coordinator for HIT, in a statement in May.

Make no mistake, current methods of health information exchange will change. The question remains a matter of how and when.