RSNA 2009 Spotlights Integrated Healthcare Technology

David E. Avrin, M.D., Ph.D. RSNA Radiology Informatics Committee Chair

Paul J. Chang, M.D. University of Chicago School of Medicine

Through its technology development and partnerships with the federal government, RSNA has a principal role in setting universal operability standards for medical imaging—just as the government launches its $20 billion initiative to expand health information technology (HIT) and achieve a nationwide electronic health record (EHR).

RSNA is formally involved in the White House-directed process for achieving a nationwide EHR, which is governed by the Office of the National Coordinator for Health Information Technology (ONCHIT). RSNA sits on ONCHIT's certification commission as an invited representative and is also working to incorporate medical imaging into EHRs and include image exchange as a routine part of patient cares.

"In this country we have a fractionated healthcare system and a lot of independent players," said David E. Avrin, M.D., Ph.D., chair of the RSNA Radiology Informatics Committee. "We're proposing a much better way of making imaging studies available across enterprise boundaries, and we're putting the control and authorization in the hands of the patient."  (Listen In as Dr. Avrin explains RSNA’s formal role in setting imaging standards)

To that end, RSNA recently was asked by the National Institute of Biomedical Imaging and Bioengineering (NIBIB) to submit a proposal that, if approved, would eliminate the need to provide patients with images on CD—the most common method for image exchange.

Document Sharing Focus at RSNA 2009 IHE^® Demonstration

Some of the latest technological developments can be viewed in real time at the Integrating the Healthcare Enterprise (IHE^®) Image Sharing Demonstration at RSNA 2009.

IHE is a global initiative by healthcare providers and industry to improve interoperability and information exchange. IHE develops standards-based interoperability specifications called IHE profiles and conducts annual testing events called Connectathons for systems that implement those specifications in North America, Europe and several countries in Asia. Comprising more than 250 member organizations around the world, IHE is sponsored by RSNA, the Healthcare Information and Management Systems Society (HIMSS) and several other health professional organizations.

Past RSNA annual meeting demonstrations have helped accelerate adoption of DICOM standards for medical imaging and IHE profiles that improve workflow and systems interoperability in radiology.

"You have users working with industry, staff and vendors on these integration profiles," said Paul J. Chang, M.D., a professor and vice-chair of radiology informatics and medical director of pathology informatics at the University of Chicago School of Medicine and consultant to RSNA's RadSCOPE^® and myRSNA^® initiatives. "Even though it sounds like nerdy stuff, users also have to be involved. That's the only way they're going to get an infrastructure that works for their needs."

At the heart of this year's demonstration is IHE's Cross-Enterprise Document Sharing (XDS-I) profile, which defines a method for sharing medical information across sites and potentially makes the information available to patients.  (Listen In as Dr. Avrin explains some basic goals of the IHE demonstration)

XDS and XDS-I, a related profile supporting exchange of medical images, are used by national EHR programs in Canada and several European countries and have been adopted by the federally supported Health Information Technology Standards Panel (HITSP) in the U.S. HITSP has published standards-based interoperability specifications that will likely be the basis for testing and certification of HIT systems that qualify for federal incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Making images and reports accessible to patients and care providers will help address issues such as redundant studies and excessive patient radiation exposure and eliminate inefficiencies encountered by providing patients images on CD.

'CD Over the Wire' Part of Pilot

In response to an NIBIB request for proposals, RSNA proposed a pilot to develop a multisite image sharing network. "We were asked to make a proposal," Dr. Avrin explained. "This is not a grant it's a contract for services where RSNA and five leading institutions that have expertise in this area to demonstrate a prototype of basically 'CD over the wire' with authentication."

If approved, the network would implement IHE architecture—XDS with complementary profiles for security and patient ID management—to ensure that data are transmitted securely across the Internet with the patients' permission, Dr. Avrin said. Linking this infrastructure to patient-controlled personal health record systems (PHRs) presents significant challenges. "We're trying to put the patient at the center of the authorization process, and in some ways the security is actually more complicated than the transfer," he said. "We're working on a process that meets Health Insurance Portability and Accountability Act (HIPAA) requirements and the expectations of the public."

The network would provide a seamless process in which patients authorize the release of specific healthcare information in much the same way as at a medical records desk. "But this is a Web transaction," Dr. Avrin said. "It's as secure as a credit card, or more secure." Through their PHRs, patients will have persistent access to their full medical record.

Including the patient in the process was critical considering the exploding use of the Internet and the growing patient demand for healthcare involvement, according to David Mendelson, M.D., a member of the RSNA Radiology Informatics Committee and co-chair of IHE International. While IHE was building the technical infrastructure to transmit images on the Internet, he said, consumers were learning to manage their bank accounts, finances and shopping on the same network.

"We recognized that we should now combine IHE technical solutions for image sharing with the consumer's ability to manage their personal information on the Internet," said Dr. Mendelson, of Mount Sinai Medical Center in New York. "It is our hope that a large-scale pilot will bring this into the mainstream in short order."

Interoperability Means Better Patient Care

Data sharing is especially valuable in situations demanding time-critical reports, interdisciplinary collaboration and follow-up of incidental findings, said Dr. Chang, who will present the "Critical Test Results and Electronic Health Records: A Practical Framework" section of an RSNA 2009 Informatics in Practice refresher course.

In addition to accelerating report turnaround, IT can create a virtual forum for real-time collaboration, as is done in person by tumor boards planning treatment for patients with cancer, Dr. Chang said. "I believe the tumor board is our shining moment in medicine," he said. "With informatics we have the potential to do that for everybody."

Additionally, said Dr. Chang, informatics can help assuage an all-too-common problem in the clinical setting: "The patient comes in for trauma, and fortunately doesn't have anything significant, but I see a subcentimeter indeterminate lung nodule," he said. "My report will say the nodule should be followed up in six months. Guess what? No one follows it up. Is it the ED doc's fault? No—she's only focused on the acute trauma. The primary physician never gets the report. Where was the failure? It's a failure of informatics."

Informatics could remedy the discrepancy through an integration profile that alerts physicians at six months to the patient's follow-up status, Dr. Chang said.

Collaboration Urged

While Drs. Avrin and Chang agree the movement towards expanding HIT and adopting a nationwide EHR is slow going, they both urge collaboration among developers, legislators, vendors and users in the meantime.

"We can't just view these information systems as appliances we live with," said Dr. Chang. "We're the ones who understand the workflow, so we need to help guide the vendor community to define and optimize it. In order for us to add value and be relevant in patient care, we have to be collaborators. We have to fully embrace these tools."