Images in the HIE: Clearing the Hurdles
Health information exchanges (HIEs) promise to improve patient care and trim costs by providing access to patient data across organizations ... if they can achieve sustainability. Yet, integrating a key component of patient data—images—into the HIE has proven to be problematic and plagued by technical and privacy hurdles.

The rationale

“There are some estimates that inappropriate utilization, which covers a gamut of things, may be as high as 20 percent of the imaging that’s done in the U.S.,” said David S. Mendelson, MD, chief of clinical informatics at The Mount Sinai Hospital in New York City during an educational session at the Radiological Society of North America’s (RSNA) 97th Scientific Assembly and Annual Meeting in November 2011 in Chicago.

“If that statement is even close to true, inappropriate utilization is a very expensive part of the healthcare system and … as a profession, we should be doing everything we can to bring ourselves back to using imaging when it’s appropriate,” Mendelson said.

Indeed, as he peered into the future of image sharing, Mendelson underscored the importance of image communication, not just to the workflow of physicians or care of the patient, but to the functioning of the healthcare system. Better communication, including access to a patient’s medical history and prior imaging studies, is a boon for everyone.

While most organizations still live in the era of image communication via CDs, the last half-decade has been marked by the emergence of the HIE, regional or statewide systems where information is shared electronically among a group of healthcare providers. The eHealth Initiative, a Washington, D.C.-based nonprofit, conducts an annual survey of HIEs. In 2008, the survey identified 42 HIEs across the U.S.; by 2011, that number had risen to 255.

Mendelson noted, though, that most HIEs do not allow image sharing, instead only allow for the exchange of text-based patient data with radiology represented by the exchange of transcribed reports. To bring images into the HIE, a number of issues must first be addressed—some organizational and some technical.

The list of hurdles that must be cleared before there’s a wider integration of images in HIEs include financial sustainability, connectivity and storage issues and the development of an efficient process for providers to access the images.

The bottom line

The most significant challenge facing HIEs is sustainability, Mendelson noted at RSNA. Very few models can demonstrate financial sustainability, surviving instead on the lifeblood of federal or state grants. This point is reinforced by the eHealth Initiative’s 2011 survey, which also determined that of the 196 HIEs responding to the survey, only 12 percent were self-sustaining.

HIEs can attain financial independence when they are funded through transaction fees for the information exchanged or through some other source attributable to the advantages of the HIE, but getting providers to sign on for this investment can be tricky. While the general benefits of electronic information exchange are obvious and well-documented—access to more complete patient information, reduced duplication of exams, easier transition of patient care between facilities, more accurate prescriptions—it’s difficult to determine a specific return on investment for HIE membership.

“There is absolute concern about sustainability, because if you truly have established a community-wide benefit such as this with an intangible return on investment and make it so that it is accessible to all without significant costs, where’s the revenue?” asks Judy Smith, MD, medical director at Roswell Park Cancer Institute in Buffalo, N.Y. The institute participates in the HEALTHeLINK HIE.

Smith, who serves on the HEALTHeLINK board, says sustainability is the focus of extraordinarily difficult discussions taking place in many regional exchanges. There’s not a good model of sustainability that’s been put forward that works for every exchange. The payors reap many of the benefits. Providers’ efficiency gains aren’t as measurable, and aren’t of the magnitude that staffing can be reduced, which is a major cost for any facility, says Smith.

Currently, Roswell Park and the six other founding providers of HEALTHeLINK contribute to the support of the system knowing that there are benefits, however hard to measure, from the arrangement, says Smith.

While there’s no one-size-fits-all model of sustainability, some HIEs have found a way to stabilize the financial equation. Kansas Health Information Network (KHIN), a statewide HIE, has laid out a business model based on annual fees paid by providers, says Laura McCrary, EdD, executive director. KHIN evaluated the total cost of providing HIE services, and divided those costs proportionately among providers based on their organization type. Hospitals currently account for the highest percentage of fees, while physician practices, lab companies, pharmacies and others groups connected to the HIE contribute a set annual fee. KHIN is currently working with several health insurance companies to determine appropriate fees.
KHIN isn’t quite self-sustainable yet, still relying on a healthy dose of grant dollars, according to McCrary, but its business model projects sustainability within the next two years.

Technical difficulties, please stand by

Establishing firm financial footing is no small task, but it is only part of the equation as there are myriad technical stumbling blocks for HIEs, particularly when it comes to including images.

“Initially, we didn’t really recognize the problems that we were going to encounter with storing images in the exchange,” says McCrary, explaining that the massive amount of storage space required for a central image database made the strategy unworkable.

McCrary says they’d like to have a system where a link is included with the report that allows the user to view related images that remain stored at the originating provider’s site, but accessing different PACS requires unique interfaces and different logins, causing some headaches with this strategy as well.

“Right now, we can bring the reports in  easily, but bringing in the images is proving to be much more complex,” she says.

One HIE that has already tackled image sharing is Southern Tier HealthLink (STHL), a regional health information organization serving central New York state. It has offered image exchange since 2006, but after facing connectivity challenges, recently opted to restructure the process to improve workflow for providers.

“Fewer clicks is always our goal for physicians,” says Christina Galanis, STHL’s executive director. She says there were some frustrations with the old way that the HIE was handling image exchange. Providers would see exam results and click a link to an external website with a separate login. They would then have to download a viewer for the images, which too often meant physicians would need to download multiple viewers to look at a single patient over multiple care settings.

To work around this problem, STHL is working with a third party to provide image exchange that uses one universal viewer. Providers will be able to click a link to bring up cached images that display almost instantaneously. Images will be cached for 30 days, and older images will be retrievable within about one minute.

A separate STHL project is addressing the way continuity of care documents (CCDs) are handled. Providers previously exchanged CCDs, which contain information on patients such as visits, medications, allergies and more, by logging into the web portal and navigating the various authentication checkpoints and logins. This method took providers out of the workflow, Galanis says, and they’ve since shifted to a process that automatically transfers a CCD into a provider’s EMR, and most of STHL’s customers now connect this way.

CCDs don’t include PACS images or reports for physicians, so the next step for STHL is to work with the vendors to include a clickable URL in the CCD that will automatically log providers into the image exchange and display images in the EMR.

“The overall objective is to provide better information and also to avoid unnecessary duplicate testing,” says Galanis.

She says the goal is to have all providers migrated over to the new image exchange by the end of the second quarter in 2012, but the CCD image link is being held up by some vendor-to-vendor communication issues. Normalizing all the IT languages is the role of the HIE, Galanis says.

“There are different versions of HL7. There are [continuity of care records] and CCDs. There are different ways that people can consume information. Our job is to convert that.”

Images a hyperlink away

At Roswell Park, CIO and Vice President of IT Kevin Kimball says his HIE only handles reports, but a new image exchange project similar to the STHL strategy is in the works. Roswell Park will be an early adopter and expects to share DICOM images in the first quarter of 2012.

When Roswell Park starts sharing images, it won’t be alone. Tom Unger, program director for HEALTHeLINK, says the new image exchange will begin with the top 20 image-volume submitting providers—or “data sources” in HEALTHeLINK-speak. The HIE will continue to implement the image exchange from highest to lowest volume data source, with some ebb and flow based on the readiness of the provider.

The HIE makes use of virtual private network (VPN) tunnels which port data through edge servers to the exchange, says Kimball. Providers access the data through a 128-bit secure sockets layer (SSL) web portal, called Virtual Health Record (VHR), which also takes HL7 feeds for ADT, lab results and other data. The VHR is accessed by providers following consent of the patient.

Image exchange for HEALTHeLINK will be provided through a commercial agreement with a third party. The third party will provide the infrastructure, says Unger, so the conversion is somewhat turnkey for HEALTHeLINK. A hyperlink will be added to the upper right corner of an electronic radiology report when an image is available. Once clicked by the user, a real-time call is sent to a federated edge server at the data source. The image is transferred via VPN, through the main data center, and presented as a high-resolution image to the user. The original image remains within the firewall at the data source, and what the user sees is the image cached for presentation at the user-browser level.

Technology has advanced to the point where image file size isn’t the insurmountable barrier it used to be, says Unger, with most images rendering in less than two seconds.

“The format and transfer of images today and the way compression works is not like it was even a year ago,” he says. “It’s really efficient. Our testing has proven its [size] is not an issue.”

Other than a few hardware expansions, such as extra edge servers, and working out logistics like the amount of time that images are archived, Kimball doesn’t expect too many challenges when the HIE flips the switch to active image sharing.

“We struggle more now with CDs and this takes those out of the equation,” says Kimball.

Get on board

For providers considering signing on with an HIE, Smith’s advice is to jump in because it provides access to information that may not be readily available otherwise, which translates to better patient care.

One of the key challenges to practices new to HIEs, whether they are a large institution or private office, is patient consent. Smith says figuring out a process to incorporate consent into daily practice is key.

However, financial sustainability concerns still loom large. It’s always a major issue, according to Galanis, who says that STHL has been lucky to receive support from participants, with 20 percent of its financial support coming from hospitals and 80 percent coming from commercial payors.

“We are building systems that provide real value to providers so we hope at some point they will chip in,” she says.

STHL also has a robust business analytics tool and Galanis hopes to get some early benchmarking data once more providers get connected to the new image exchange, building a case to illustrate the benefits of being a part of an HIE.

While HIEs in general, and imaging in the HIE specifically, are still in their infancy, a handful of pioneering organizations have stepped out into the information exchange frontier. As more providers look to create or join HIEs, they will have plenty of examples from these early adopters who have provided a template for imaging in a more connected healthcare world. HI