A strategy to value-based healthcare
We’ve eradicated small pox, sequenced the human genome and begun to practice precision medicine, so why is it so hard to provide our clinicians with standardized access to all patient medical data across a healthcare enterprise?
Likely because, as a result of disconnected IT solutions and subpar (or non-existent) interoperability, health systems and hospitals lack a patient-centered longitudinal record that includes medical images.
U.S. health systems’ information flows are a mess, according to a research study at a leading West Coast academic medical center – more like ships passing in the night than the smooth and efficient flow we need.
As we endeavor to move toward a value-based paradigm, it is time to draw attention to the effects that the lack of a standardized, patient-centric longitudinal imaging record has on both hard and soft return on healthcare investments.
Let’s take a look at where we are, where we need to be and discuss how to plan a strategy to successfully implement an efficient and effective solution that supports value-based healthcare: a single, integrated platform that manages all images and associated data across the enterprise, completing the EHR strategy. The 10-point plan presented here works for any size healthcare enterprise.
Where We Are
Here are the very real conditions under which dedicated healthcare providers toil on a daily basis, according to a research study at a leading academic medical center.
The study found:
- A lack of integration of imaging technology with EHRs
- Low-quality images taken off high-quality diagnostic imaging systems
- Nurses manually uploading images rather than attending to patients
- Ultrasound scanners producing images that are neither archived nor billed Clinicians unable to locate prior images
- Staff re-doing ECGs because they are too hard to find when needed
- HIPAA issues with images on smartphones and no archival strategy
- Cybersecurity issues with images sold on the black market
- Mounting costs for extra tests
- Scheduling delays in expensive surgical suites
- More than 50 percent of physicians ordering extra tests to avoid malpractice issues Overall, suboptimal patient care as clinicians cannot locate needed tests and studies
Real Health System, Real Problems
And here is the big picture, detail by detail, of an example from a leading teaching hospital. If you work in healthcare, this may sound painfully familiar.
Some 80 percent of healthcare system data today are visual. The majority are fragmented and not available enterprise wide. Physicians and clinicians looking to see images from bedside ultrasound scans are often out of luck because images are not fully integrated in the EHR or PACS; there is no system in place to do so.
Not only are images not available and not archived but, due to the lack of documentation, the health system is missing out on billing for many exams. Line placements, anesthesia and biopsy guidance are all reimbursable but the health system can’t submit unless they have archive proof of the study.
The study finds that ultrasound images too often live on the cart or portable device until they are copied over. With average reimbursement of $28.75 per exam, lost revenue opportunities add up quickly.
Many imaging studies that succeed in being billed are done so improperly. A common example: when a chest x-ray study includes a pelvis image and the hospital fails to label both within context. If the images are not properly stored and intelligently indexed within their clinical context, caregivers may not be able to locate one or the other, they must redo it - exposing the patient to more radiation and costing the system unreimbursed expense and time.
Staff at the health system estimate they lose $5 million on completed scans that are not billed, while the average healthcare facility is missing out on at least $100,000 a year in additional revenue. Some 80 percent of facilities surveyed are not billing for all of these procedures, according to Centers for Medicare and Medicaid (CMS) data.
When we read “To Err Is Human,” the Institute of Medicine’s historic 1999 report, we were collectively shocked by the statistics that 44,000 to 98,000 people each year die in U.S. hospitals as a result of preventable medical errors.
Beyond the tragic cost in human lives, medical errors cost U.S. hospitals between $17 billion to $29 billion per year and result, as well, in loss of trust and lower satisfaction by both patients and health professionals. Society pays too, with losses in morale, job productivity, school attendance by children and lower levels of population health status.
The state of managing patient images and data is similarly disturbing. It’s time we face a heralding wake-up call about the pandemic of issues with medical imaging and IT: the fragmentation of technology and therefore, the fragmentation of the information required for timely, appropriate care delivery, and the inherent risks in security, data accuracy, cost, and in many cases, unrecognized and lost revenue.
It is very real and truly pandemic, according to the study that focused on the interactions of people, their computer systems and the resulting workflows throughout the health enterprise.
Many factors conspire to produce today’s suboptimal circumstances, but the study points to situations likely to be familiar to physicians, administrators and leaders in a variety of health systems, large and small, academic and for-profit.
To thrive in a value-based world and truly transform healthcare, hospitals and healthcare networks need to integrate knowledge, systems, culture and care, and the need exists to control patient data and the custody of medical imaging data.
If you work in healthcare, these findings demand your attention.
- Medical error is the third leading cause of death in the U.S.1
- 1 in 5 Americans report they have experienced a medical error.2
- The most commonly reported errors relate to diagnosis and patient- provider communications– both KEY topics to medical imaging.2
- Healthcare data breaches cost on average $380 per record.4
- More than 50 percent of physicians say they order unnecessary tests to avoid potential malpractice suits, amounting to 5 to 10 percent of all the exams ordered each year.
- Fines paid to the Office of Civil Rights for HIPAA violations can range from thousands of dollars to several millions of dollars.5 Class actions additionally can increase the cost of a data breach.
- Malicious or criminal attacks are the primary causes of data breaches in the U.S., accounting for 52 percent of incidents, with human error and system glitches each accounting for 24 percent.4
- There is a 1 in one million chance of a traveler being harmed while in an aircraft. In comparison, there is a 1 in 300 chance of a patient being harmed during a healthcare experience according to the World Health Organization.3
-AN EYE ON OPTHALMOLOGY
In ophthalmology, there are six imaging systems, some state-of-the-art, e.g., a separate sytem for imaging the lens of the eye. For the ophthalmologist to view the image, he or she has to walk down the hall 75 feet to a designated room equipped with the proper viewer. The images are not viewable or accessible anywhere else in the health system.
Many of those ophthalmology patients have diabetic retinopathy coupled with problems such as high blood pressure (BP) and kidney issues. Each healthcare provider who sees one of these patients wants to know their BP. But because they cannot access that statistic in the EHR, they have to send the patient to the Emergency Department (ED) for a BP check—even though it may have been taken less than an hour earlier. The data are simply not accessible.
So back to the ED the patient goes, often with eyes dilated, making it hard to see in what typically amounts to a 15-minute walk to the ED and a 15-minute walk back to the provider’s office. Many of the patients have trouble with circulation and walking, making the trip longer and more arduous. In addition to the delay in care and havoc in scheduling, patient frustration is obvious. Five or six patients a day, the head of the ED says, make the roundtrip just for a BP reading.
In another department, located in an outpatient clinic, standard practice is to redo 100 percent of ECGs, even if the patient had one earlier in the day or the previous day, because it is too hard to find them in the EHR. In one clinic, the study found that two EHRs being maintained. Each time a patient comes in, staff enter information in both systems, doubling the chance for data input errors.
-PAIN POINTS OF PAIN MANAGEMENT
When it comes to accessing images, inconsistency appears to be the norm according to the findings.
Some departments get only the reports when what they want are the reports as well as images. Some departments get only the images without the reports. The Physical Therapy and Pain Management Department gets partial images without notes. Other departments see very low-quality images of studies that were taken on very high-quality, expensive systems.
The lack of consistency is most apparent in the medical records department.
Many departments have three separate systems for locating records. There is no master patient index. The medical records department has 38 full-time employees dealing mostly with scanned images, most often information not in the EHR.
Because information is so hard to find, it requires a level of expertise and focused time of staff to know where to find items. Change in staff, from retirement or other causes, creates significant loss in productivity as there are no training manuals to teach new staff the work-arounds developed over decades.
-PROBLEMS ARE MORE THAN SKIN DEEP
A leading dermatologist keeps his own records on his own IT system and doesn’t share with anyone else because some of his clients are famous and he doesn’t want to risk a data leak. So all patient history and images are cut off to the rest of the health system, which this physician’s patients use for other care.
-MISSING THE MARK
The Burn and Wounds Center, like most such departments, annotates images to monitor changes to burns and wounds.
But often they are unreliable, with the markings somehow migrating away or moving when they’re saved electronically.
When a physician or nurse goes back to see a prior state of a wound, the lack of consistent image retention and standardization results in varying levels of quality and marking that may be inconsistent with other images.
-FACTS FALL FLAT
The Urology department spent several million dollars on a system that images urine flow, offering exquisite images of flow and temperature by color.
The tool is very helpful to urologists when they are viewing the images but the archival process relies on faxing and scanning, rather than integrated electronic transfer, resulting in fairly primitive black and white images.
Therefore, when printed from the department’s archive at a later care episode the image quality is poor also. This may diminish the ability of the clinician to rapidly and confidently provide appropriate care at a future appointment.
-SNEAKERNETTING IS NOT CAREGIVING
There are about six times as many nurses as physicians, consistent with ratios across the country. Nurses (and some eager physicians) are constantly “sneakernetting,” that is, physically shuttling hardcopy images or CDs between storage and care locations, to meet physician requests. Typically, these images are not archived for future reference, nor is their use documented for billing purposes.
Nurses work with many kinds of images, such as preserving jpgs of pressure ulcers for treatment and documentation. They take images with digital cameras and smartphones, and it is a challenge to archive them. Often the quality, as well as the image itself, is not preserved.
It is frustrating for nurses both in creating the original images as well as trying to locate priors for evaluation of progress or decline. As noted, a significant use of such images is for pressure ulcer documentation, which is enormously important today in the way hospitals are evaluated for quality measures and reimbursed by CMS.
When nurses must spend time playing sneakernetting messengers, they are obviously not engaged in their primary mission: caring for patients.
If we take a reasonable assumption that each nurse adds to his or her workload an average of one hour per day sneakernetting, we must face the situation that there is either a significant loss of hands-on care during each shift or added cost. Either way, professional resources are being squandered. This affects patient satisfaction and efficiency of care, reducing value-based care.
Studies show that patient satisfaction scores improve when patients perceive nurse staffing is sufficient and there is strong teamwork and care coordination. (Press Ganey. 2017 White Paper: Performance Insights: Health Care Improvement Trends.). When this is lacking, satisfaction decreases.
If the health system improved image transfer not only would patients be more satisfied but they would save money, too.
Nurses are overworked, with 37% of nursing staff reporting overtime, which is compensated at 1.5x the hourly rate by U.S. federal law.
Generally, $37.00 is the Medscape average hourly rate of an RN. (Medscape RN/LPN Compensation Report, 2017).
If an hour a day of administrative tasks can be reduced, it could effectively reduce overtime by over $400,000 each year.
Other departments across the hospital upload a wide variety of images to the EHR, or at least they try. Many cannot retain them. Too often, the study finds, physicians, nurses and clinicians say it’s “a futile pain in the neck” to try to upload images. Thus, often diagnostic or monitoring images are never added to the EHR for future reference.
Many clinicians still clip hardcopy images to a paper chart that is accessible to very few, within that departmental silo. To clinicians in the broader enterprise, it’s as though the study never took place, so retakes, costly in time, resources and satisfaction, are common.
Delays caused by lost or insufficient images are common, even expensive delays, such as ORs and surgeon scheduling. For example, there’s a pancreatic surgeon who needs images for surgical planning. He reports needing to reschedule up to 60 percent of his OR time because he doesn’t get the images he needs in a timely manner, or the images available are too primitive and poor quality to be relied upon in the OR.
Other physicians say there are times they want to print an image but it is too hard and clumsy so they just give up. Roughly 4 percent of physicians’ time is wasted chasing images or trying to get an image from a source such as a CD, and many would argue that that figure is conservative. Wasted time and revenue yet again can add up quickly especially for physician salaries.
As they typically do around the country, patients at this medical center bring in disks of past imaging exams.
Most often the physician thanks the patient profusely and puts the disk on the desk. At the next appointment, he or she hands it back, never having viewed the images because the image viewer available at the desktop won’t allow it.
Pandemic Issues Abound
When they exist, images might not be securely maintained. Across the hospital is an impractical system of individual servers in individual departments and doctors’ offices. Different groups have ad hoc cybersecurity (or none) because they’re on separate servers. Each of these servers could be physically taken or virtually tapped.
On the black market, a credit card and social security number are sold for between $2 and $6. A healthcare record is worth about $60. The cybersecurity issues are significant, and hospitals can pay large fines for breaches and HIPAA violations. And let’s not forget the cost and disruption of lawsuits brought by patients. And what about the damage to reputation, staff morale, and future business when the breach hits the front page of the local newspaper and airwaves of the local TV channels?
Not only is reimbursement compromised, as discussed, costs are out of control too, for extra imaging exams performed, staff and patient time for repeat exams, scheduling delays and wasted OR time, to name a few examples. Patients may stay an extra night in the hospital if imaging studies and reports don’t reach physicians in time to discharge them. Patients, caregivers, physicians, nurses, technologists and clerks are frustrated. As one senior physician points out, if they have to redo an MRI or if scheduling is overly delayed, patients may go somewhere else and never come back as well as tell their friends or social media about their negative experience.
Healthcare is all about providing timely, quality care. Because contemporary medicine relies on both images and data, care is clearly suboptimal when diagnostic information is disconnected from the patient record and physicians cannot find images and reports, communicate with one another and make confident decisions supported by the best evidence.
Fragmentation is endemic in our care delivery systems. A fragmented, decentralized healthcare information delivery system can be neither best practice nor value-based. Fragmented information leads to fragmented care. Patients see multiple providers in multiple locations who cannot access one another’s data. Patient records are notoriously incomplete across the continuity of care.
Where We Need to Be
Let’s look back at small pox, considered the only disease modern medicine has eradicated. Why? A vaccine became widely used across the globe – ubiquitously available and deployed. So what is the vaccine needed to fix our fragmented healthcare delivery system and allow imaging to add value to and complete the patient record?
ANSWER: A single, integrated enterprise imaging platform that puts a full set of tools into the hands of clinicians to capture, store, view, and exchange images “anywhere, anytime” they need them. That single point of access includes images from any clinical specialty, connecting previously siloed caches of images, and enabling physicians to look at prior images and seamlessly learn comprehensive information about each patient. The comprehensive patient health record is the attainable preventive medicine. It helps to better manage each episode of care, and helps health systems better manage population health.
Clinical standardization, a consolidation of IT resources and IT interoperability — the top three strategic priorities of health system executives surveyed by The Advisory Board Company–need to be key ingredients, too.
While 84 percent of hospitals now have a basic EHR in place, data integration and interoperability across hospitals and health systems lag. Coherent enterprise data management strategy and execution, data governance, cybersecurity strategy and stopping the “not in my backyard” mentality are required to successfully achieve healthcare transformation.
These strategies are needed to bring staff activities, computer systems and processes across the health network into alignment to realize value.
The development of the anti-fragmentation vaccine requires thoughtful change management leadership and commitment to quality improvement. The risk of allowing the status quo inefficiencies to continue is to cripple value-based care before it barely got started, while the rewards of deploying an Enterprise Imaging platform can be enormous. Let’s explore how to successfully transform individual departments’ medical imaging into powerful enterprise-wide assets.
Healthcare systems need to take advantage of IT systems and the business intelligence they enable to redefine business models, rethink processes, quality and cost structures that better address patient needs.
A TEN POINT PLAN - Start Right to Reach Value Realization
1. First Develop a Strategy, Not Just a Purchase Order
To achieve healthcare’s complex objective of delivering value-based care while reducing unnecessary costs, progressive healthcare leaders see new opportunities for quality and collaborative practice, as underutilized medical images evolve into a strategic asset of the organization. Yet hasty action on this awareness also can prove a cautionary tale, as some “early adopters” neglect to fully define enterprise goals and mistake a big-box storage infrastructure topped with a viewer layer as a complete solution.
The successful approach to empowering physicians to make informed decisions through multi-specialty collaboration is a multi-year strategy to achieve secure access to a single comprehensive patient record. The goal must not be simply to archive imaging data – the goal is to provide tools that, hourly and daily, foster a re-invigorated environment of collaborative and informed patient management.
Images are key data in the continuity of care and therefore need to be managed via standardized workflows and accessibility to serve the aspirations of value-based care.
2. Emulate EHR Convergence
Our lives are constantly improved by innovation that converges technologies and disrupts the status quo, bringing benefits to both our professional and our private lives. Your own smartphone, for example, converges dozens of once-standalone devices and applications (you can quickly name more than five, right?), delivering significant convenience and cost savings. Similarly, EHRs converge multiple patient information systems that were once standalone, unconnected silos.
Health systems often have as many as 70 different service lines that capture and consume imaging – clearly, a similarly converged single platform technology is required to bring order and drive value of these disparate systems, workflows, and behaviors across the enterprise.
Choose a vendor with deep knowledge and wide breadth of experience connecting the most healthcare disciplines, who can help you design your strategy to align with broader clinical, operational and financial goals.
Consolidation reduces cost, complexity, and the resource-draining need for multiple integrations. Look for a purpose-built platform consisting of modules to leverage your EHR investment incrementally as part of your organization’s strategic plan, not the vendor’s.
3. Be the Wise Leader
Long-term success benefits from a right beginning, and your success will be accelerated by collaborating with a vendor who brings to the project experience in governance best practices that include step-wise metric assessment.
As with any large IT project, adoption is key to a successful return on investment. Change management initiatives can become simply an expensive PowerPoint deck without adoption. Source a team with a proven record in helping institutions build a governance framework, including a cross-departmental strategic decision-making body, implementation processes, and agreed-upon critical metrics definitions.
Only consider a vendor that respects and values your long-term success and offers consultative experience to align the program with your leadership goals. Demand a team that will work with you to support your goals of quality delivery of care and cost containment as well as define measurement units for goals such as clinical productivity improvement, process efficiencies, and improved revenue capture.
Look for a team that seeks to understand your multiple clinical workflows and challenges to develop adoptable processes and support your institution’s change management. Seek out a vendor that is proactive in developing a baseline and monitoring success—measuring for you and with you before, during and after the step-by-step deployment and course-correcting throughout the process.
Additional information can be found in Enterprise Imaging Governance: HIMSS-SIIM Collaborative White Paper.
4. Standards, Protocols, and Frameworks
Interoperability is a priority for lasting IT, and hence clinical, value. Insist on a deep commitment to industry standards to help support your technology investments today and in the long term.
5. Massive and Incremental Scalability
Anticipate the IT needs for interoperability due to merger and acquisitions (M&As), accountable care organizations (ACOs), and other regional collaborative initiatives.
Look for a solution that is natively built to grow and connect previously disparate systems as needed.
6. Advanced Care Coordination through Seamless Access to Shared Information
Assure your institution gains a network-aware platform to drive collaborative care both within the hospital walls and with affiliates. Easy access to patient images helps foster an environment of collaborative and informed patient management, supporting today’s model of shared decision-making and value-based care across multiple points of care, regardless of specialty.
Set as your strategic goal to improve the quality of care by enabling pervasive multispecialty imaging and data access. Format should become a non-issue — the long-term solution should house studies from virtually any device, from virtually any format, DICOM, or not.
Unfettered information sharing – online, in the cloud, and with a single-click url – puts the patient first and helps reduce unnecessary imaging exams and fragmented care. This is the clinical apex of Enterprise Imaging and why we place it as a central consideration in this 10-point plan.
7. Risk Mitigation, Anyone?
Enterprise Imaging enables accurate attribution of metadata to episodes of care, providing actionable information and a trail of documentation, for use in revenue and risk mitigation gains.
Look for a solution that enables a controlled environment for managing and sharing images, including a secure Single Sign On framework that provides context controlled and audited access to data. By consolidating the number of systems to manage, the long-term Enterprise Imaging platform helps to limit the total number of potential points of data breach by replacing “rogue media” such as thumb drives or personal email attachments with a controlled, audited enterprise-wide multimedia platform.
Contextual, intelligent indexing of medical images and document data from each episode of care leverages their clinical value across the enterprise – providing powerful, proven support of clinical productivity and patient satisfaction.
8. Encourage Secure Communication and Engagement among Stakeholders
Advances in easy-to-use mobile applications allow both patients and clinicians to review sophisticated information on demand yet securely. Expect efficient use of patient and system time with universal, zero-footprint applications that enable engagement such as “medical selfies” to speed rapid, remote assessment of healing states, or mobile viewer access to images to help speed discharge by busy physicians.
9. Support Multiple Imaging Departments’ Productivity with Standardization
Task-based workflows provide consistency and efficiency. Demand task-based standardization to bring one learning curve application across multiple service lines, with enough flexibility to support unique actors and workflows. Non-radiology departments such as Ophthalmology, Wound Care, Dermatology, Cardiology or Surgery cannot thrive with Radiology workflows and so require their own flexible processes.
Encounter-based workflow will enable the appropriate level of metadata to be associated with those images at the point of acquisition without a lot of overhead for the person who’s actually acquiring those images. Business Intelligence reports should be available to help identify inefficiencies. Measure and modify, then repeat.
10. Information Lifecycle Management
Work with vendors to identify organizational objectives and records management policies and create solutions to the challenges of information lifecycle management (ILM).
Among the issues: How should a data retention policy guide read/write access to medical image metadata? By what criteria should your organization decide how and when to delete or dispose of medical images?
These ten points can assist to accelerate and maximize the usefulness of your Enterprise Imaging program while achieving actionable and measurable value realization.
From department image acquisition workflows through interoperability of disparate systems, to clinical decision drivers and patient experience enhancement, a thought-through Enterprise Imaging platform strategy is a must-have initiative to improve the delivery of quality care by replacing costly, risky inefficiencies of the past.
Making It Happen
It’s time to wrap our heads around the pandemic of issues with medical imaging and IT and offer our health systems solutions to solve the fragmentation of care delivery, design security and data management, improve delivery of patient care and efficiency, reduce waste, rein in lost revenue and reduce overall costs.
We need to organize and present comprehensive patient information intuitively for each caregiver. We need to evolve from being data-rich but actionable-poor to a knowledge-based information-driven care delivery approach. We need to maintain secure custody of medical images within the enterprise and leverage them as strategic assets of the entire organization. Clinical, operational and financial goals need to come together around a patient-centered longitudinal patient record that genuinely completes the EHR initiative.
The shaking of heads at misfit and antiquated systems needs to be replaced with the nodding of heads at shared decision-making with people, their computer systems and processes orchestrated together to create value-based healthcare. It’s 2018. We have the technology, guidance and the drive to make it happen.
Authors’ Note: We are grateful to Dr. Ross Koppel, Ph.D., FACMI, University of Pennsylvania for his insightful study of the interactions of people, their computer systems, and medical image management that detract healthcare resources from value-based care today. We describe his findings here in the hope that recognition will help drive the adoption of the Enterprise Imaging IT platform strategy and improvement of precision medicine treatment in our care systems.
Miriam S. Ladin is director, marketing and communications, North America at AGFA HealthCare. Focused on strategies that drive adoption and commercial value of disruptive technology offers, she is an evangelist of the integrated platform approach to enterprise imaging IT as a key to achieve patient-centric, value-based care.
Mary C. Tierney is vice president and chief content officer of TriMed Media Group, a multimedia provider of websites, magazines and content. For more than two decades, she has been watching the trends in and writing about the clinical, operational and financial facets of healthcare, with special focus on healthcare IT, healthcare leadership, radiology and cardiology.
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2. NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute. Americans’ Experiences with Medical Errors and Views on Patient Safety. Cambridge, MA: Institute for Healthcare Improvement and NORC at the University of Chicago; 2017.
3. World Health Organization, Patient Safety Fact Sheet, 1 February 2012, http://www.wpro.who.int/mediacentre/factsheets/fs_201202_patient_safety/en/
4. Ponemon Institute and IBM. 2017 Cost of a Data Breach Study: Global Overview.
5. HIPAA Enforcement Rule, 45 C.F.R. Part 160, Subpart D, § 160.400 et seq.