One of the most important discussions in healthcare today centers around the shift from fee-for-service care to value-based care. The goal is to improve the quality of care for the patient by changing how healthcare systems are reimbursed for their services.
In the traditional fee-for-service model, volume was the name of the game. More patients, more admissions, more tests, more examinations all equaled more money. But this volume-focused approach didn’t necessarily mean patients were receiving the best quality of care or receiving better outcomes.
Today, the Affordable Care Act, together with the Medicare Access and CHIP Reauthorization Act (MACRA), carries a new mandate – a shift from volume- to value-based care. The new model is strictly focused on improving healthcare in three core areas: quality, cost and outcome. The results will be closely measured and monitored, and healthcare systems will be compensated accordingly, with penalties imposed for healthcare acquired conditions, recurring readmissions, and never events. The ultimate goal: To provide better patient outcomes at lower, more manageable costs.
In the quest to fulfill this goal, new techniques and technologies have emerged that can improve both the quality and cost of patient care, including advancements in electronic health records (EHRs), an increased use of patient imaging, telehealth, and more. But these changes have also exposed challenges facing IT healthcare professionals including barriers imposed by inaccessible and siloed images that need to be overcome to provide the kind of collaborative care that is most beneficial for the patient as well as the healthcare provider’s bottom line.
The EHR’s Critical Challenge
To simultaneously improve the quality and outcome of care while reducing costs clearly requires a new system of collecting and sharing information about patients among multiple caregivers, a directive that EHRs were intended to address. While establishing EHRs did provide a way to collect, access, and share data about a patient in a more expedient and organized manner, there has been one critical flaw: EHRs typically don’t present the whole patient story.
Important information such as patient images, documents and other clinical multimedia files are not always married to the EHR in consistent and relevant ways that allow these elements to be viewed in the proper context by providers both inside and outside of the patient’s primary healthcare system. As a result, access to medical images and other multimedia data is fragmented, and doctors are left to make care decisions often without a comprehensive patient record to contribute to their decision-making process. Even when medical images are accessible within the EHR, it is often challenging for the provider to locate them as they may be scattered in encounter notes or accessible only by a link buried deep within test result records.
While many organizations include access to radiology images from within the patient’s EHR, images and documents produced in other image-centric departments like cardiology, ophthalmology, wound care and dermatology typically remain siloed and out of the care team’s reach. And while advances in the functionality of select EHRs now allow some level of digital photography management, it is rarely possible to see a patient’s complete longitudinal imaging history all in one place, regardless of image type, as has been the norm for years with patient laboratory result histories.
There is a Better Way
Enterprise imaging offers a remedy, yet its role is often misunderstood. One of the biggest misconceptions among healthcare CIOs today is that enterprise imaging is strictly about moving the storage of patient images from today’s Picture Archive and Communication System (PACS) to vendor-neutral archives (VNAs).
While PACS have long provided the means to acquire, store and view Digital Imaging and Communications in Medicine (DICOM) images, those images were relegated to silos housing only those produced within image-intensive practices such as radiology, cardiology and ophthalmology. While this approach was adequate in the traditional fee-for-service model, it makes a real-time multidisciplinary approach to sharing these images nearly impossible. As value-based care becomes more widely understood, however, it is becoming clear that the ability to share multidisciplinary images among the wide array of providers in any care continuum is a significant benefit to both patients and providers alike. Among other outcomes, the lack of visual images in the continuum of care can contribute to unnecessary readmissions, the very antithesis of value-based care.
Enterprise imaging solutions are purpose-built imaging engines that give healthcare systems a modular, phased approach to managing images as well as the ability to deliver real-time collaboration among caregivers, all on a single platform. And, because it’s a pervasive solution, enterprise imaging offers healthcare providers a clear and cost-effective detour around the roadblocks currently standing in the way of true value-based, patient-centric care and the financial rewards associated with delivering it.
If a picture is worth a thousand words, then a patient’s EHR is clearly incomplete without the myriad images produced on a daily basis. And if repeating studies delays care, increases costs and decreases patient satisfaction and possibly outcomes, then enterprise imaging, which provides a modular multidisciplinary workflow, may just be the interoperable image and information network needed to complete a successful value-based care strategy – and the key to an optimized EHR and a maximized return on investment for the healthcare provider.
Let’s examine a few use cases where Enterprise Imaging provides this missing link to value and quality care.
Increasing Efficiency of Care
To be successful in a value-based model – and to fulfill the requirements for better quality, cost and outcome – it’s imperative for clinicians to have relevant patient information available on demand. Providing a platform for a variety of disciplines to acquire and retain images and to subsequently make that information universally available at a variety of care locations is what platform-based enterprise imaging is all about.
Consider the patient examined by a general practitioner who orders images to be taken; later, the patient needs to see a specialist. If that specialist doesn’t share the same EHR as the facility that acquired prior radiology studies, the patient is inserted into the clinical information delivery process.
To avoid costly and time-consuming repetition of scans, patients have become personally responsible for moving their images from one physician to another. When possible, patients can request electronic transmission of the images, a process often hampered by a lack of homogenous technology between the sender and receiver. When electronic transmission is not possible, this means the patient must take the images to the specialist on a CD, a practice which leaves the specialist focused on getting the technology to work in order to view the images rather than focused on the patient during their encounter.
Enabling the provision of existing images and related documentation to a specialist before the patient arrives, however, gives the specialist time to review the scans and determine a potential treatment plan before seeing the patient in person rather than delaying care, and engendering frustration, while waiting to successfully review existing images or take new ones.
Shortening Time to Care
When a patient is ill – and worried about being ill – every minute and medical encounter counts.
By making previously acquired images accessible to all points of care along the way, time won’t be wasted repeating the same images or waiting for physicians to have collaborative conversations with each other; the information and images will be available for each practitioner to see where and when they need them to make the most informed diagnosis and treatment plan possible.
If a family physician thinks, for example, that a patient may have an enlarged thyroid gland, the physician looks at bloodwork, feels the patient’s neck and refers the patient to an endocrinologist. The endocrinologist meets with the patient, performs a brief examination, then orders a radiology ultrasound for the patient. The patient takes off work again to have the ultrasound study, then another time to go back to the endocrinologist to discuss the results. The physician reports that radiology finds an enlarged node that requires a biopsy. The patient is scheduled for another radiology appointment and a needle biopsy is performed, then the patient is scheduled yet again to meet with the physician for the results – more time off work, more waiting, more anxiety building at each step along the way.
Today, however, most medical schools are teaching students to perform ultrasound exams. Therefore, many physicians are now capable of performing simple ultrasound studies on their own. In this example, the endocrinologist could have performed the initial ultrasound, reducing costs and saving valuable time and stress for the patient.
But, now our healthcare information systems need to catch up with this broadened clinician technical capability. Until recently, physicians had no effective way to capture and meaningfully store patient demographics with images from point of care ultrasounds, which meant the tests were performed, but the images were not accessible for future reference or billing documentation. In most cases, before the ultrasound was performed, the physician typed in the patient’s last name and allowed the machine to assign random numbers as an identifier. No demographics, no key words attached, and the images were not archived or married to the patient’s EHR. When the ultrasound unit ran out of storage space, the images were simply erased. Now, what happens if the endocrinologist in our example says a biopsy isn’t presently indicated and suggests the patient be checked again in six months? There’s no record of the previous ultrasound available for comparison.
Even the most simplistic use cases speak to the increased quality of care patients can receive when physicians are empowered to use ultrasound technology – and to store the images in a meaningful and accessible way via an enterprise imaging platform. Using ultrasound guidance to help with needle and line placement, for example, helps assure that the first stick is the right stick during the procedure, and it also allows, in most ambulatory encounters, for the physician to be reimbursed for the use of ultrasound guidance after it is performed. Under the value-based model, reimbursement for services such as these can occur only when clinicians can provide documentation of the ultrasound images.
The most innovative enterprise imaging vendors have recognized these problems and have done something about it by creating solutions that both facilitate provider efficiency and assures the retrievability, and thus, continued use, of medical images. A powerful Enterprise Imaging platform allows the provider to easily select a patient’s name from a work list and acquire the images. The rest is left to technology. In the background, patient demographics are assigned to the images, the image set is routed to the Enterprise Imaging VNA and subsequently made available within the patient’s EHR. Now, in the case of the endocrinology patient, the ultrasound study is readily available for use as a prior comparison when the patient returns for a follow-up visit. And for the clinician who used ultrasound guidance during the ambulatory procedure, reimbursement is virtually guaranteed.
Of note is a patient-centric, interactive timeline made available by the leading solutions. This functionality offers a big leap forward in understanding the patient’s story, with its thumbnail-enabled, study-by-study, unified view of the patient’s images. By leveraging the investments made in capturing medical images, this a formidable example of information technology advancing value-based care.
A Word About Workflows
A common mistake that healthcare organizations often make is to assume that a radiology workflow will enable the successful acquisition of images in a non-radiology environment.
It is important to keep in mind that image acquisition is the business of radiology, and as such, the existing radiology information systems that enable a radiology workflow are designed specifically for a radiology environment staffed with many different roles from scheduling to the technologist to the radiologist. This type of system, and its required workflow, is not at all suited for non-radiology physicians using other image capture systems, such as ultrasound, in the delivery of care to their patients. Therefore, organizations that follow this path find it necessary to create workarounds and complex rules to support the needed agility of a non-radiology practice, and many times, the clinicians are unhappy with the result.
Alternatively, with a mature Enterprise Imaging platform, the technology takes care of the demographic documentation, marrying the image to the patient’s EHR in the background. And because Enterprise Imaging offers the ability to create practice-specific workflows, there is no need for rogue workarounds or costly overhead to manage special rules.
Part II continues the coverage of how accessible images enable stronger outcomes, which helps healthcare organizations support their value-based care goals.
About the Author
Kim Garriott is the Principal Consultant, Healthcare Strategies, Logicalis Healthcare Solutions