Radiology Images and MU: Vital, but Not in the EMR…Yet

This article from talks about 2 of my favorite topics in health informatics and their co-relation (I share very similar viewpoints, especially on the part where medical imaging is not only radiology).


A diagnostic picture is often worth more than a thousand words. But whether—and how—to include images in the EMR as a requirement for meaningful use is an ongoing discussion. Thus far, images have been excluded from federal discussions of the criteria for meaningful use. At the grassroots level, however, the debate over images and meaningful use is lively to say the least. Many physicians claim images are a vital tool for accurate and timely diagnosis and should be at least considered in the scenarios for meaningful use. Others believe healthcare providers have too many other requirements on their plates right now.

As advances in imaging continue to show greater detail, often in real time, images in the EMR could provide a more complete patient record than text-based notes and lab results alone. But meaningful use isn’t the only issue for images—even if images are eventually required for demonstration of meaningful use, vendors, healthcare facilities and users will still have to address image storage and management.

Images overlooked
Janice Honeyman-Buck, PhD, FSIIM, believes the inclusion of images in the EMR is critically important, and was surprised the proposed meaningful use criteria for 2013 did not address the integration of medical images into patient records. “The referring physician needs to see the radiologist saw,” says Buck, editor in chief of the Journal of Digital Imaging and associate professor and director of informatics in the Department of Radiology at the University of Florida. While the physician may not need access to the entire study, key images would better help to illustrate the patient’s condition.

“It’s a matter of setting priorities, but what I’m afraid of is that hospitals will be going for the [MU] criteria now, and then in about 2015, they won’t have the infrastructure necessary to handle the images because they are so big,” she opines.

Why the omission? Honeyman-Buck says a “rift” between radiology and health IT may be one of the reasons images were excluded from MU criteria. “There has always been sort of a separation between radiology, which handles the images, and health IT, which integrates all the information about the patients,” she says.

Better communication is one way to alleviate that separation, says Honeyman-Buck. There is a need for “more of a collaborative effort between the people [in radiology who] really know how to handle the images, bandwidth requirements and the huge storage requirements, working along with people [it IT] who are really in charge of all the information in the EMR.”

When and if radiology images do become a requirement for meaningful use, Honeyman-Buck believes storage and display issues will be the largest barriers that facilities and practices must overcome.

For display, she says, “radiology works hard to make sure their displays are in a quality-controlled environment. They have the power it takes to navigate through huge studies, and this is not something that [is] easily transferable to other locations.

“In current operating systems and computers, there are limitations to the file system for how many individual files can be stored in one place, so radiology has been working with this problem,” she says. “It’s not insurmountable, but it is a challenge.”

Inclusion caveats
Including images in the context of an EMR has its limitations, says Gregory A. Spencer, MD, FACP, CMO, of Crystal Run Healthcare, a multi-site healthcare system based in Middletown, N.Y. Spencer cites the screen size and resolution limitations of today’s computers as restrictions: “Typically, people are working from desktops or even laptops, if they are taking the EMR into the room with them,” he says. “You are not going to spend thousands of dollars on a monitor if 99 percent of the time you’re looking at a [physician] note. I think from a diagnostic perspective, it’s very limited in the utility and the quality.”

Spencer notes that the inclusion of images in the EMR is a “convenience” rather than a “show-stopper.” With regard to MU discussions, “I think the demand isn’t quite there for it yet,” he says. However, when the demand for image capability does grow, “there would be a lot of retrofitting and vendors scrambling to incorporate that in their next version.”

Crystal Run Healthcare uses a NextGen EMR interfaced with its Carestream RIS/PACS. Within the EMR, “you have to enter the patient demographics again [once a report is brought up] to actually view the images, and we are working on embedding a URL for an image. It’s just a matter of the demand for that,” Spencer explains, noting that the URL will launch a browser to a non-diagnostic quality image, which would suffice for the primary use of patient education. He says demand from physicians thus far for viewing images in the EMR has been limited.

Integrating images in the EMR would not provide a great benefit for many specialties when measured against the amount of work required to make it happen, he says. However, EMRs that accommodate integrated images would provide significant value to some physicians—including orthopedic and oncology practices.

Seeing is believing
Bradley Erickson, MD, PhD, of the Department of Radiology at the Mayo Clinic in Rochester, Minn., and the Society for Imaging Informatics (SIIM) chair, says inclusion of images in the EMR is “critical.”

“One of the greatest advances of medicine in the past 30 years is that basically images have replaced a lot of much more invasive procedures, like exploratory laparoscopy, so I think having images available to physicians is critical,” he explains.

And if the availability of images for the physician is important, so too is image integration into the EMR, Erickson says. The implementation would promote efficiency, because physicians would be able to view an image or series of images, comment back and forth with one another regarding what they are seeing, which could reflect their decision-making process.

Like Honeyman-Buck, Erickson says he was disappointed that images were left out of the meaningful use requirements for 2013. “I think it reflects the fact the decision-makers are not aware of how influential or important images are in the practice of medicine, or they just have other interests that drove them to make the criteria rather than improving medicine,” he says. “Compared to some of the requirements that are in meaningful use, I think … the inclusion of images would be a small requirement.”

For example, one current requirement calls for documenting smokers down to age 13, which will be much more difficult to implement than requiring EMRs to include some level of imaging, according to Erickson.

Mayo’s Rochester facility uses a GE Centricity EMR, integrated with an internally built repository. All new images are automatically forwarded to the repository; the EMR can record user annotations and user-specific viewing preferences, Erickson explains. All new images are available, as well as archived images by way of an image storage and retrieval system. The clinical image viewing system interfaces to the enterprise image archive to achieve this, he notes.

Bracing for the future
The use of the EMR as a one-stop organizer for patient information—including images—is very compelling, says Spencer. Honeyman-Buck believes it is something that will become a requirement: “Images will be included at some point.”

Hospitals are gearing up to implement EMRs that meet the current meaningful use requirements, but this could make it more difficult to accommodate an image-enabled EMR in the future, because facilities may not have the appropriate bandwidth or storage when images become an EMR requirement, she says.

Erickson says inclusion of images is not just a radiology concern, and facilities should have a plan in place to include images for various specialties, such as cardiology, dermatology, pathology and ophthalmology. This will enable facilities to use “one standard user interface that the various physicians need to get used to,” he explains.

“I suspect it may be more than just ‘including’ them,” he notes. “I think there will be requirements to send and receive a certain percentage of studies from other facilities using electronic [not CD-based] mechanisms.”

“Plan from the beginning,” stresses Honeyman-Buck. “Make sure that whatever EMR system you are developing or putting in can grow and expand in five years so that the images can go into it.”

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