The Trouble with Image Sharing, and the Opportunity

Hoarding medical imaging data is one of the most highly profitable, and strategic, tactics of hospitals competing in a fee-for-service market. It also represents a huge opportunity to reduce the high cost of healthcare as reform comes online.

One of the lesser-talked about menu objectives in Meaningful Use Stage 2 is a requirement to use EHRs to receive more than 10 percent of imaging results. Given the current crunch regarding core objectives of Meaningful Use Stage 2, it is understandable that not much is being said about this requirement.

Nevertheless, sharing images goes to the heart of what is possible with healthcare IT. The generation of medical images costs a fortune. Under a fee-for-service model, generating the maximum possible images out of the various departments of a hospital is a huge source of revenue.

As we know, the fee-for-service system is hanging on for the foreseeable future. I'm guessing that if you strip away the generation of duplicative, unneeded medical images, you are probably talking about the difference between many a profitable hospital and those same hospitals running at a loss.

From the technology standpoint, medical imaging systems have been big-ticket items. It's probably true that hospitals in the 1980s, 1990s and 2000s engaged in an imaging arms race, making massive investments in systems that pushed the imaging state of the art to where it is today. Their installation drove many a press release and marketing campaign.

A July 25 op-ed in The Wall Street Journal faults the annual U.S. News and World Report "Best Hospitals" survey for its main focus being on the degree to which hospitals use certain cutting-edge technologies. The main example offered is robotic surgery, but imaging is probably a close runner-up.

Once those hugely expensive systems get installed, however, the hospital's imperative is to keep those imaging systems humming. If those systems aren't generating maximum possible revenue, they become cost centers, not revenue generators.

Now factor in standalone imaging centers that jump into markets, install newer systems, and steal some imaging business away from the hospitals in that market. That just adds to the pressure hospitals feel to maximize utilization.

It's a high-stakes game that won't be changed tomorrow by the Meaningful Use Stage 2 imaging menu option. Quoting Farzad Mostashari as I did last week, "We cannot have it be profitable to hoard patient information and unprofitable to share it."

Arguably, hoarding imaging data is one of the most highly profitable, and strategic, tactics of hospitals competing in a fee-for-service market. It also represents a huge opportunity to bend the cost curve of healthcare, but since it has only been introduced as a menu item for Stage 2, we can expect its impact not to really matter until Stage 3 is implemented, when it will become a core requirement. Don't look for that before 2017 at this rate.

Six months ago, I wrote at length about enterprise imaging, the effort to bring together a common architecture for all medical images. The more I learn about the dominance of the radiology-oriented DICOM format, the more I realize that dominance is impeding innovation in enterprise imaging and image sharing between enterprises.

"Whenever I criticize DICOM in any way, generally pitchforks and torches greet me at my doorstep," said John Halamka, CIO of Beth Israel Deaconness Medical Center, during a discussion of standardization of image sharing at the July 19 meeting of the HIT Standards Committee Clinical Operations Workgroup.

"DICOM is a wonderful format for radiologists who have dedicated workstations inside an institution, but does have challenges in an Internet-enabled, mobile-enabled, Android and iOS kind of world," Halamka added.

"DICOM to me has been a wonderful standard," replied Hamid Tabatabie, founder and CEO of Life Image, Inc. "It has made radiology be years ahead of all the other 'ologies' in ability to transfer and share files. But [here] we are years after; we have run out of lipstick to put on the pig and we can use a new thing."

Now, DICOM isn't dead yet. One recent innovation in sharing DICOM images, the RSNA Image Share, is going strong and growing. But the various specialties each have their own spin on imaging. "An EKG isn't an image," Halamka noted at the July 26 meeting of the HIT Standards Committee Clinical Operations Workgroup. "An EKG is a time series. It's a waveform. And it has absolutely nothing to do with a picture… conceivably, it could be represented as text."

At the opposite end of the spectrum is pathology, where it's all about the image. The challenge is that each of these formats does have its own related non-visual multimedia, ranging from text to waveforms to numerically analyzed specimens.

Bringing pathology into the digital age presents a particular challenge to healthcare. At one extreme are "frozen sections" whose display and analysis may need to be provided remotely while a patient is awaiting surgery for removal of a tumor. There, time is of the essence.

At the other extreme are untapped researching resources such as the Joint Pathology Center, which holds a repository of 60 million glass slides. "It's a tremendous data store that no one has access to," says Mark J. Newburger, CEO and president of Apollo, which provides enterprise patient multimedia PACS to hospitals ranging from Henry Ford Health System to the University of Illinois.

Newburger, an industry veteran, says the future is turning today's proprietary data stores and imaging systems into a set of device drivers, much like platforms such as Windows and OS X provide. Apollo built such an imaging platform in collaboration with The Hospital for Sick Children in Toronto, and even made it possible for clinicians there to build their own such drivers to connect with other image stores.

Meanwhile, hospitals have just now reached the 1990s in one regard. Patients are now bringing in hordes of images on compact disks. Massachusetts General Hospital performs 750,000 imaging exams a year, but also brings in more than 100,000 exams per year from patients carrying CDs into the facility, according to Keith Dreyer, MD, vice chairman of radiology at Mass General.

According to LifeImage, when the average consumer-provided CD arrives at a hospital, 22 percent of them will not open. More than half result in additional re-radiating tests being performed. And even when a CD does open, it takes 4 minutes per CD to copy.

There are also concerns by Newburger and others that the Blue Button initiative underway at ONC remains oriented too heavily toward text, and not enough toward image download and exchange.

The opportunity of image sharing outweighs all these challenges. In this column, I've tried to illustrate potential cost savings and benefits to care. I encourage the HIT Standards Committee Clinical Operations Workgroup to continue its work, and for providers and the industry to join them in their efforts to break through some of these barriers, to share best practices, and make real headway, despite the continuing market forces promoting high cost, difficult sharing and opportunities lost.