Technology is supposed to make life easier, but sometimes it makes
things more complicated—at least until you get past the learning curve.
federal government put forth the meaningful use (MU) initiative to
encourage the standardization of electronic health records (EHR) by
physicians, and to improve patient care by reducing errors in data,
facilitating the transfer of records and data, and sending out
However, in a recent study, residents
reported spending most of their time updating medical charts and
documentation, and ordering tests, at the expense of direct patient care
or education.1 The results from the study showed that time spent on indirect patient care increased with the adoption of EHRs.1
the need to meet MU requirements under way and Accountable Care
Organizations (ACOs) around the corner, now is the time for radiologists
to find the tools to help push them past the rising workflow curve.
Making image-exchange meaningful
Staying at the forefront of technology has its growing pains, and adopting image-enabled EHRs is no exception.
government is using the carrot-and-stick method to force healthcare IT
standardization. The goals state that eligible professionals, hospitals,
and critical access hospitals (CAHs) must successfully demonstrate
meaningful use of certified EHR technology every year they participate
in the program.1
Here’s the carrot: The Health
Information Technology for Economic and Clinical Health Act (HITECH)
offers physicians monetary incentives to use EHRs. Radiologists are
eligible providers (EP), who can receive up to $44,000 over 5 years
through Medicare, and $63,750 through Medicaid, over the 6 years that
they choose.1 As of July 2012, nearly 600 radiologists have
successfully attested to Stage 1 MU, which amounts to $10 million in
incentive dollars paid to date.3
Here’s the stick:
Stage 2 of the MU initiative proposes that EPs show that 10% of patients
“view, download or transmit” their electronic personal health
information (ePHI). The proposed Stage 2 optional imaging rule will
require that more than 40% of all scans and tests ordered by EPs or
hospitals be accessible through certified EHR technology.3 Plus, starting in 2015, Medicare payment reductions will begin for those not demonstrating MU.
the introduction of the MU initiative, there has been an influx of IT
tools designed to help eligible professionals, such as radiologists,
achieve meaningful use goals. These technologies include electronic
order-entry with decision support, standardized structured reporting,
secure and ubiquitous access to an image-enabled health information
exchange through cloud-based solutions, and mobile applications.
ACOs: New fee structure
force to be reckoned with is Accountable Care Organizations (ACOs), in
which healthcare providers work together to manage and
coordinate care for defined populations. Healthcare providers, including
imaging services, are part of the ACO, providing care for that group of
patients and being accountable for the quality, cost, and outcomes.
the world of ACOs, radiologists are no longer a revenue center for a
hospital, but instead are transitioning into becoming a cost center for
an ACO,” indicated Barbara Dumery, Director of Diagnostics Solutions
Marketing at Nuance Communications, in Applied Radiology’s Imaging InsideOut blog.
on costs will also force doctors to manage larger volumes of
patients—despite the fact that patient care will become more
time-consuming with growing demand for documentation, coordination of
care, communication with other specialists and patients, and data
“Timely reports are important because the new
fee structure also means physicians across specialties will need to see
more patients,” said Dumery. “As reimbursement moves from
fee-for-service to a per-capita fee, radiologists will need to make sure
they are ordering the appropriate tests, ensure radiology services meet
the needs of the referring physicians, and that they provide good,
consistent results, clear follow-up recommendations, and timely
The use of ACOs in Medicare is still at an early stage,
with the launch of 88 new ACOs in July of 2012 bringing the total number
to 153.4 Radiology groups can take action now to position
themselves as more relevant in this new healthcare era. According to
Dumery, they should start by creating joint ventures with hospitals to
become part of an ACO, demonstrate the value of their imaging services,
and provide more patient-centric services.
Tools to streamline workflow
can technology help radiologists to meet the challenges of MU
requirements and treat more patients? Automation is one effective way to
streamline the workflow.
Over the last
10 years, computerized order entry systems (CPOE) for radiology with
decision support for imaging have been proven clinically viable.6
A recent study conducted at Brigham and Women’s Hospital (BWH) in
Boston centered on a Web-enabled CPOE system with embedded imaging
decision support that was phased into clinical use between 2000 and 2010
across outpatient, emergency department, and inpatient settings. The
primary outcome measure was meaningful use, defined as the proportion of
imaging studies performed with orders electronically created (EC) or
electronically signed by an authorized provider. The secondary outcome
measure was adoption, defined as the proportion of imaging studies that
were ordered electronically.5 The results showed significant increases in meaningful use and the adoption of CPOE.5
ease and convenience of using evidence-based advice and online
scheduling increased utilization to the point that the BWH radiology
department had to meet rising demand for its services. CPOE contributed
to efficiency in ordering imaging exams, said one of the study’s
authors, Ramin Khorasani, MD, Vice Chair of the Department of Radiology at BWH.
it fosters quality care. “It’s better for the radiology profession to
have a case made to utilize evidence-based guidelines for diagnostic
imaging rather than go the route of preauthorization by an entity that
will not be as informed as the physicians requesting exam
authorization,” Dr. Khorasani said.
Structured reporting, voice recognition
reporting and speech-enabled documentation also help radiologists
report more efficiently. If a radiologist is dictating a routine chest
x-ray report, a structured template will recognize the type of exam that
is being dictated, load a template, and prepopulate much of the
With Powerscribe 360 by Nuance (Figure 1), if there
is a contrast agent being delivered, that information will be populated
through an integration with Bayer or Medrad. The program also provides a
radiation dose-reporting template, in which data are automatically
populated through an integration with Radmetrics and DoseMonitor
dose-tracking programs. Another example is an integration between
PowerScribe 360 and Siemens’ ultrasound system, which enters all of the
ultrasound data and measurements (20 min). With these tools, the
radiologist can interpret and diagnose a study when the referring
physician most needs the report—while meeting with the patient.
the data automatically not only saves time but also reduces human error
when inputting data. Structured-reporting templates make reports
consistent, which is helpful for referring physicians. The template
fields also serve as reminders to interpret all of the data in a report,
such as the body part being imaged, to ensure that the radiologist
receives appropriate reimbursement.
Image management tools
tools present another opportunity to automate processes. At Franciscan
Saint Francis Health, Indianapolis, IN, (Saint Francis), radiologists
work with oncologists to review and analyze multi-modality oncology
datasets for tumor detection and monitoring. These doctors use
IntelliSpace Portal, a multidisciplinary data collaboration platform by
Philips Healthcare, which eliminates many manual tasks to improve speed
and consistency. The platform supports a Multi-Modality Tumor Tracking
application, which calculates the quantitative tumor response criteria
based on the percentage change in lesion diameter; plots the figures on a
graph; and stores the results with the image series for the oncology
team to reference. The follow-up series is automatically sent to the
IntelliSpace Portal Server, so the user doesn’t have to spend time
uploading the datasets. Andrew J. Mullinix, MD, Diagnostic Radiologist
at Saint Francis, says the new process cuts reading time by 5 to 10
minutes for a 5-lesion study. By automating several steps, the system
makes the work more consistent, which helps technologists and physicians
to more efficiently process reports. The best part about the
IntelliSpace Portal for J. Louis Rankin, RT (R)(MR) (PET), 3D Technical
Coordinator, Imaging Services, at Saint Francis, is its accuracy and
“The more accurate and consistent we are, the more volumes of data we can build up,” Rankin said.
Time is mobile
spent on indirect care has increased with the adoption of EHRs. The
growing information needs for patient care have led to more time spent
locating or working on a computer at the expense of time at the bedside.1
However, a recent study found that residents who used iPads were able
to enter orders more quickly, and a majority of residents perceived that
the iPads improved their work efficiency.1
signs of similar workflow gains in radiology. Imaging-related mobile
applications (apps) can simplify a PACS administrator’s life by allowing
a number of remote monitoring and remote-control functionalities around
quality control, data movement, and information management.7
Smartphone technology for diagnosing patients was recently put to the test in the first study8
to measure the efficacy of smartphone teleradiology applications in a
real-world telestroke network at the Mayo Clinic. The study compared the
quality of medical images using a particular smartphone application to
the same types of information and images typically viewed via desktop
computers. Mayo Clinic neurologists, working with emergency physicians
and radiologists at Yuma Regional Medical Center (Yuma, AZ), compared
brain scan images from 53 patients who came to that medical center with
stroke. The study showed a high level of agreement (92%-100%) among all
the reviewers over the most important radiological features.
client-server teleradiology systems coupled with high-quality
resolution video conferencing may provide a complete telemedicine
solution that fits in a physician’s pocket and an ACO’s pocketbook.
ACO’s should be able to use these, when indicated, as well as other
fast-evolving technologies for more efficient cost-effective healthcare
delivery,” said Bart Demaerschalk, MD, Professor of Neurology, and
Medical Director of Mayo Clinic Telestroke, and Dwight Channer,
Telestroke Program Manager.
As standard desktop tools such as
DICOM image viewers and image-enabled EHR portals become more widely
available in mobile formats, the use of mobile apps for radiology will
continue to proliferate.
One landmark decision in mobile
radiology apps came in 2011, when the U.S. Food and Drug Administration
(FDA) cleared the first mobile app to allow physicians to make medical
diagnoses using images transmitted to their iPhones or iPads. The app,
Mobile MIM, developed by Cleveland-based MIM Software, supports viewing
of medical images, displaying measurement lines, annotations, and areas
of interest. Although the app was indicated for use only in the absence
of a workstation, the latest radiology apps have been designed without
workstations in mind.
Today, many radiology apps have been
developed for mobile tablets and smartphones. At the 2012 RSNA
conference, expect to see radiologists consulting their Mobile RSNA app,
which is designed to streamline the annual meeting experience. Many
apps, such as Interactive CT and MRI Anatomy, are educationally
oriented, which helps medical students, interns, residents, doctors,
nurses, and radiologic technologists who need to brush up on anatomical
Several PACS-related apps are available for access with a
web browser or as an app for the iPad and iPhone. Siemens Healthcare
offers two syngo.via mobile applications, the WebReport and
WebViewer (Figure 2). While not indicated for diagnostic viewing or
reading on mobile devices, syngo.via WebViewer is designed for fast reading and viewing of images within the hospital network, and syngo.via
WebReport provides referring physicians inside and outside the hospital
with secure access to reports and images. CoActiv provides
EXAM-BROWSER, a cloud-based viewer, that runs on smartphones and tablets
and is designed for quick clinical reviews, even in 3D. Fujifilm
Synapse Mobility by Fujifilm Medical Systems USA (Figure 3) is a
zero-footprint solution that enables access from mobile platforms to the
Synapse suite to display high quality, interactive 3-dimensional
images. It allows user to manipulate images using the zoom, window and
level, and MIP/MPR within the application, just as the physician would
do at a clinical workstation.
Referring physicians often need a
quick professional consultation for images at hand. One app designed to
enhance the referring physician’s experience is RedSnap, a free
cloud-based clinical tool that supports receiving professional
consultations quickly and easily for difficult cases sent via iPhone.
This tool is designed especially for referring physicians and
radiologists in areas of the world where expensive PACS software is cost
“This is especially helpful for referring physicians
to quickly get an opinion from a rad-pro. If a chiropractor has a neck
radiograph and sees something on his viewing box, he just takes the
image, and sends it in seconds to the community, and could receive an
opinion in seconds. Otherwise, if it goes the standard way—it takes days
to weeks to get a read if a referring physician sends a study to an
office,” explained Roland S. Talanow, MD, PhD, a Diagnostic Radiologist
at EduRad, based in Lincoln, CA, who also develops Web-based software
for education and clinical applications.
Another app that
enhances the referring-physician, and ultimately, the patient experience
is MRDS (Medical Report Delivery System). This mobile app integrates
with a RIS-PACS to enable authorized physicians and patients to view
images and reports as soon as they become available from the radiology
Voice recognition apps, including Dragon Mobile Apps,
powered by Nuance, allow radiologists to speak text messages and
e-mails, to search their mobile devices, and to dictate reports. With
the PowerScribe 360 mobile radiologist app, attending radiologists can
off on reports in their queue and consult a radiology-content specific
reference tool to look up terms on the fly.
benefits referring physicians when consulting with patients. Claron
Technology’s Nil app includes side-by-side viewing, arrangement and
comparison of multiple series/multiple studies. Other notable DICOM PACS
apps include TechHeim Mobile PACS, a DICOM viewer app for displaying
and manipulating medical images on Android phones; DICOM Echo, which
tests and validates DICOM connection with DICOM systems; and last year
introduction by Boston-based Partners HealthCare System of mEHR, an
EHR-viewing app that supports a DICOM viewer.
Closing the imaging loop
the loop on the imaging cycle will become increasingly important for
radiologists as they highlight their role in delivering patient care.
Personal (or patient) health records (PHR) can more directly connect
radiologists to patients, as patients will get results after undergoing
an imaging exam. PHRs will also play an important role in Stage 3 of the
MU initiative, which will promote patient access to self-management
RSNA Image Share is a PHR network created to enable
radiologists to share medical images with patients using PHR accounts.
The project was launched in 2009 through a $4.7 million contract with
the National Institute of Biomedical Imaging and Bioengineering (NIBIB)
to build a secure, patient-centric medical imaging-sharing network based
on common open-standards architecture. Images are exchanged over an
edge server linking a radiology department or imaging center’s PACS and
RIS to a cloud-based server. The edge server provides security services
and packages the exam for safe and secure distribution over the
Internet. Once a patient registers on the network, she follows a series
of steps that tell the edge server to retrieve that patient’s reports
Patient enrollment in the 2-year pilot program began
in 2011 at Mount Sinai Medical Center (New York, NY), followed by the
University of California at San Francisco, the University of Maryland,
the University of Chicago, and the Mayo Clinic. Both Dell and lifeImage
provide the cloud-based and vendor-neutral platforms that serve as the
clearinghouse for images and reports from any hospital or imaging center
and deliver them to standards-compliant PHRs.
where time is of the essence, PHRs can enhance imaging workflow by
providing a single repository to access medical data, instead of
collecting data from disparate hospital systems. Furthermore, a PHR may
help reduce the number of redundant imaging exams and the use of CDs and
DVDs to transfer medical data.
The PHR benefits patients by
providing convenient access and storage of their medical information,
and to date, the PHR pilot program has enrolled >300 patients.
the last few months, we have increased the number of patients we
enrolled from 1 or 2 a week to 10-plus. Patients are interested and
understand the benefit of making the images available under their
control,” said David S. Mendelson, MD, FACR, Chief of Clinical
Informatics MSMC, Professor of Radiology, Director of Radiology
Information Systems, Pulmonary Radiology, at The Mount Sinai Medical
Center (MSMC), and Co-Chair Integrating the Healthcare Enterprise (IHE).
“We are just starting a formal survey process, to obtain
detailed information as to the patient and physician experience,” said
Dr. Mendelson. It looks likely radiologists and referring physicians
also stand to benefit just as much as patients from PHRs.
complying with MU criteria and implementing workflow solutions before
the era of ACOs takes off, radiologists will be well positioned to meet
the new demands of an image-enabled EHR environment.
- Meaningful Use. Radiological Society of North America. http://www.rsna.org/Meaningful_Use.aspx. Accessed October 11, 2012.
- Patel Bhakti K, MD, Christopher G, et al. Impact of mobile tablet
computers on internal medicine resident efficiency. Arch Intern Med.
- Addicott R. What accountable care organizations will mean for physicians. BMJ. 2012;1;345:e6461. doi: 10.1136/bmj.e6461.
- Gassman AS, Singh P, Sosa M, Sweeney K. Accountable care organizations. Modern Medicine. June 25, 2011.
- RadiologyMU.org. http://www.healthmu.org/radiology/index.php (accessed when?)
- Ip II, Schneider LI, Hanson R, et al. Adoption and Meaningful Use of
computerized physician order entry with an integrated clinical decision
support system for radiology: Ten-year analysis in an urban teaching
hospital. J Am Coll Rad. 2012;9:129-136.
- Shrestha R. Mobility in healthcare and imaging: Challenges and opportunities. 2012;9;25-28.
- Demaerschalk BM, Vargas JE, Channer DD, et al. Smartphone
teleradiology application is successfully incorporated into a telestroke
network environment. Stroke. 2012;DOI:10.1161/STROKEAHA.112.669325.