From the Chair: The StIIMulus Package - SIIM News Summer 2009

Bradley J. Erickson, MD, PhD
Chair

We are all well aware of the current downturn in the economy. It was a major issue in the election, and shortly after, the largest spending bill in the history of the world was passed quite quickly. Few, if any, healthcare facilities have not made significant adjustments to their plans to deal with the current economy. Part of the reason they are making major changes is because it is clear that even after the economy picks up, the government is planning significant changes for the health care system. Even though we don’t know what they are, or the magnitude, a change is highly likely.

The American Recovery and Reinvestment Act of 2009 (ARRA), also known as the “stimulus package,” promises to spend a significant amount of money promoting Electronic Health Records (EHRs) through an incentive system. Those physicians who make “Meaningful Use” of an EHR will receive incremental payments from CMS starting in 2011. That key phrase, “Meaningful Use” has been the subject of much discussion. Several groups have already proposed definitions. While those definitions have included many valid points, none has even mentioned imaging, including the initial recommendations of the HIT Policy Committee. That, despite the fact that imaging is a large part of the cost of healthcare in America, and is one of the most rapidly increasing components. It is also apparent that imaging is a critical component of modern healthcare—blindly decreasing imaging across the board is not a viable option unless we are willing to accept a decline in quality. It is also widely recognized that when it comes to actual data volume, a large part of any patient’s longitudinal medical record is made up of or is dealing with imaging procedures. Images are also significant in the care-process as a significant facilitator/enabler media of much needed, improved inter-disciplinary care-team communication. In contrast with other components of a medical record, imaging is already predominantly digital in format, storage and in means of related communications.

What is required is information to help guide the use of imaging to maximize quality and safety while reducing cost. We will have to do more with less. We will have to become more productive. Imaging Informatics is at the crux of this issue—we are focused on leveraging information to achieve these goals. For that reason, I would like to start a discussion of “Meaningful Use,” focusing on imaging informatics. I hope this informal article will generate a fruitful discussion that will help shape the best definition of “Meaningful Use.” I would propose a few elements that “Meaningful Use” should include:

1. Any modern EHR must include image management support (for radiology images, this means RIS and PACS). As noted above, imaging is an essential component of modern medical care, and ignoring imaging will be counterproductive. In many implementations, the image management tools are not tightly integrated into the traditional “EHR” and may even be from different vendors. I believe the way this might be addressed is that interoperability of the EHR with imaging, as per IHE profiles, should be expected. Yet, to make it truly “meaningful,” image management within the EHR needs to support operational and clinical metrics and benchmarking on a departmental, enterprise, regional and indeed on a population levels.
2. It should provide tools to help guide whether to image, and which imaging examination is performed. There is good data that documents that this reduces costs and unnecessary examinations. The data is good enough that third-party payers have accepted the use of these systems in lieu of pre-authorization.
3. The right examination is performed. Before an examination is performed, an imaging expert needs to review relevant information to assure that the proper examination is performed. This includes determining whether IV or other contrast needs to be administered. Focused questions often require special imaging methods.
4. “Meaningful Use” should also include consideration to make sure that no imaging study performed “goes to waste.” Measuring and reducing administrative “retakes” needs to be an obvious priority. Furthermore, access to already performed studies needs to be provided following the patients'-care priorities (clinically and geographically), not according to technical/storage limitations or provider boundaries.
5. The right examination interpretation. There is increasing access to tools that can aid interpretation, including 3D and 4D visualization tools, computer-aided detection and diagnosis tools, and other image enhancement methods. There is disappointingly less data documenting the value of some of these tools, but the data that is available has shown value in at least some arenas. Over the last few decades, we largely have used the information technology that surrounds us merely for reproducing the traditional interpretation methods in a new digital environment. It is time that we leverage IT to change and reform the clinical practice based on the overall outcome data that needs to be available, broadly and readily. 
6. The right communication. This certainly includes clear and concise textual description of findings and diagnostic considerations. It also includes efficient and effective communications through more direct means in the case of critical results. It also means that the images and reports should be available anywhere the patient might need them. That requires sharing reports and images between hospitals and enterprises. There are now standards for how to accomplish this, but adoption is minimal. Effectively sharing images and reports could significantly reduce unnecessary examinations, which will reduce costs while increasing quality and safety.
 
While SIIM will continue to provide superb education for its membership, I believe that now is a time that SIIM should also educate people outside the society.

Please share your comments and suggestions on this topic on the JDI/SIIM blog or join the discussion on “Meaningful Use” on the SIIM LinkedIn site

Dr. Erickson is a Professor in the Department of Radiology at the Mayo Clinic, Rochester.