A MUST-HAVE INFORMATIONAL RESOURCE FOR IMAGE ENABLING THE EHR

Transcription

1 A MUST-HAVE INFORMATIONAL RESOURCE FOR IMAGE ENABLING THE EHR

2 02 04 EHR VISION IS INCOMPLETE UNTIL IMAGES COMPLETE THE PICTURE THE OPPORTUNITIES AND CHALLENGES WITH ENTERPRISE IMAGING It is with great pleasure that I introduce the inaugural issue of the Agfa HealthCare Enterprise Imaging Review. We created this publication, dedicated to the clinicians and patients for whom Enterprise Imaging was developed, to provide the latest news, reports, and insights on this valuable technology THE BRAINS BEHIND ENTERPRISE IMAGING; HOW INTELLIGENT INDEXING & WORKFLOW EMPOWERS CLEVELAND CLINIC S MYPRACTICE IMAGE-ENABLED EHR FOR THE CLINICIAN, THE VALUE OF ENTERPRISE IMAGING IS IN PATIENT OUTCOMES SHARING ULTRASOUND IMAGES VIA A COMPREHENSIVE IMAGE-ENABLED EHR IMAGES ON THE GO BUILDING STRONGER RELATIONSHIPS WITH REFERRING PHYSICIANS WITH IMAGE-ENABLED EHRS Q&A CORNER Agfa HealthCare Enterprise Imaging Review Publisher: Agfa HealthCare Editor: Miriam Ladin miriam.ladin@agfa.com The Agfa HealthCare editorial team would like to thank all those who contributed to this publication. Agfa HealthCare, as publisher of the Agfa HealthCare Enterprise Imaging Review, is not engaged in providing any specific medical advice or opinions on any medical symptom or condition. Permission to photocopy editorial content is granted only for the private personal use of the subscriber. Copying for any other use is expressly prohibited. Agfa, the Agfa rhombus, IMPAX and XERO are trademarks of Agfa HealthCare Corp., or its affiliates. All other trademarks are held by their respective owners and are used for editorial purposes with no intention of infringement. All information contained herein is intended for guidance purposes only. Characteristics of the products and services can be changed at any time without notice. Agfa HealthCare strives to ensure all information is accurate, but shall not be responsible for typographical errors. For more information, please contact Miriam Ladin at miriam.ladin@agfa.com 2015 by Agfa HealthCare Corporation 10 South Academy Street Greenville, SC, All rights reserved I hope you will find practical information within -- useful ideas that can be applied both to long-term strategies as well as incremental improvements to your health system. As organizations strive to compete, even as they provide increasingly rapid and cost-constrained quality care, fostering collaboration between stakeholders becomes essential. The trove of images that your specialists create provides a bonanza of visual tools to help drive communication, engagement, and, ultimately, improved delivery of care. In this issue, we will discuss how leading trends in Enterprise Imaging are shaping hospital enterprise strategies. In upcoming issues, we will share information on the many ways Enterprise Imaging can help hospitals navigate the challenges facing today s executives and clinicians, including healthcare reform requirements, maximizing federal reimbursement, and how to support the paradigm shift from volume to value-based healthcare. At Agfa HealthCare, we believe an image-enabled EHR can help improve a clinician s diagnostic abilities, a hospital s financial stability, and most importantly, patient satisfaction and engagement. The ability to view a patient s longitudinal image history in the context of the EHR, accessible from anywhere along the continuum of care, can help align your hospital enterprise with pressing initiatives, such as increasing the quality of care, reducing long-term costs, and creating secure, universal access to care documentation. We look forward to sharing our collective years of experience, our thoughts on best practices, and receiving feedback from the healthcare community. We encourage you to voice your opinions by letting us know what areas of discussion you would find most helpful. We hope you enjoy this issue of the Agfa HealthCare Enterprise Imaging Review. Sincerely, Miriam S. Ladin Director, Marketing Communications North America Agfa HealthCare 01

3 Healthcare enterprises have steadily moved all manner of written descriptions of patient history and current treatment to digital format. Prodded by the 1-2 punch of the HITECH Act s timeline for meaningful use of electronic health records (EHRs) and the Affordable Care Act s precepts of data-guided, coordinated care, the value of having all pertinent information on a patient easily accessible in an EHR is becoming quite evident. Yet for all the progress in implementing the means for a patient-centric approach to finding, viewing, and being able to act on the sum of information gathered throughout a continuum of care, something important is missing from this picture. That something is -- pictures. DICOM images such as X-ray, CT and MRI scans often are essential to discovering and communicating clinical intelligence that helps both the ordering physician and subsequent care providers understand what s at issue with a patient. Clinical value also is derived from other modalities used in cardiology, pathology, dermatology, endoscopy, ophthalmology and so on. The absence of these images is a significant omission, and it only will get more significant over time. Cheryl Petersilge, M.D., medical director of MyPractice Imaging Solutions at Cleveland Clinic, recently said healthcare professionals make sure lab results are based in (the EHR), and scan all kinds of documents into the record to make sure there is a central repository of all patients information, yet healthcare professionals leave all of the imaging data dangling. The omission is glaring, Petersilge explained: Images are data, images are information about the patient. So if we don t have all of that information in the chart, we haven t really created a comprehensive medical record. Without images, the EHR is missing clinically important information. The importance of such information to the EHR should make a CIO consider the relevance of images to advancing the capabilities of the EHR. But hospitals already are exhausted from implementing all the structured data required for an enterprise-wide EHR. Feeds for laboratory, pharmacy, scheduling, demographics and other sources of a comprehensively documented record have to be all in place, informing direct care and subsequent analysis. The temptation is to put the inclusion of images on hold. But delays in completing the record with immediately available images -- in context with a patient s other charted information -- ignores the larger picture of what is needed to provide quality healthcare in today s environment, which demands the management of multiple levels of risk mitigation and the delivery of services within pre-set reimbursement ceilings. The need for images will become evident for their value in quality metrics and cost control--and putting off their inclusion in the EHR could leave healthcare organizations at risk, with a voluminous task in a too-short amount of time. 02

4 THE IMPLICATIONS OF DELAYING AN ENTERPRISE IMAGING STRATEGY ARE POTENTIALLY SUBSTANTIAL: If and when the requirements for earning financial incentives in future stages of the meaningful use program expressly include making images available in the EHR, the entire healthcare industry will face a sizable project at the same time, fighting for vendor priority and implementation resources on a typically tight timeline for HITECH attestation. If healthcare organizations build the rest of the comprehensive EHR without enabling images, they likely will have to undo and redo the infrastructure they have in place to get to enterprise imaging and improved access to images via the EHR. Under bundled-service reimbursement, gain-sharing and other forms of contracting that put providers at financial risk to manage care on a fixed payment, the inability to see images along with other data on patients constitutes a lost opportunity to streamline care coordination, reduce duplicate or repeat orders, and maximize revenue and bonuses. The merging, affiliating, and consolidating that are necessary to form clinically integrated networks and which likely will accelerate in the coming years pose terrific challenges for information executives responsible for tying disparate imaging systems together. An enterprise imaging capacity with an elegant path to the EHR would lessen the challenges. NO LONGER ENOUGH Since the introduction of the DICOM standard for radiology, new frontiers in the sharing of clinical images have led to technical innovations in archiving and transfer, only to be overtaken by new and more complex demands time and again. A proliferation of image modalities, simultaneous with the expansion of healthcare focus beyond standalone facilities, continued to outpace existing technology. PACS storage approaches served individual facilities well and responded to increasingly complex clinical and IT demands with improved functionality. The need to consolidate healthcare enterprises and provide access to patient images spurred new techniques of centralized, diversified aggregation. This recent technology, a vendor-neutral archive or VNA, addresses the challenges of freeing images from their point of creation and systematically collecting them for storage in a central repository. But then what? Just as VNAs addressed the need to break down silos of storage, healthcare organizations need a means of breaking down silos of information and access to complete the objective of making all information portable among care givers. Correlating images to their corresponding electronic patient records and delivering them on demand is a very different task from consolidating data storage. And being able to display images acquired by multiple, multispecialty devices using a secure, single sign-on viewer on a physician s desktop, laptop, or tablet is yet another. Care of a patient is no longer an isolated, single provider event. Medical problems are episodic, and often chronic, requiring multiple clinicians at different times and locations to contribute to cure or recovery. With the mandated evolution to EHRs as the main access point to information for clinicians, images now have to be worked into the routine workflow of healthcare delivery and coordination, whatever the image-capture device. The difference between a VNA and a fully image-enabled EHR is significant. VNAs are no longer sufficient to meet the clinical, efficiency, and security needs of today s health systems. FINGERTIP ACCESS It is possible in the age of digital networks to rig the image archive so clinicians can log on and thumb through electronically, but that s not how doctors work. Instead, the objective has to be making sure that whoever needs it has access to it, easy and fast, and integrated into their workflow, said Kristen Clickner, vice president of information technology at Sentara Healthcare, Norfolk, Va. Because it s really simple for me to say, Well gosh, if you want to go look at that image, I can give you a sign-on code to that system. But we ve found that unless it s right there at their fingertips, and fast, they re probably not going to view it. Doctors throughout Ochsner Health System in and around New Orleans have that fingertip access. Any contents of a medical record are available to anybody, anyplace, anywhere in the system, said Lynn Witherspoon, system vice president and chief medical information officer. That includes all images. The viewer is embedded in the EMR, so any physician anywhere can click on that link, get the images in context within their own work space, and access the images should they wish to do so. Importantly, access should be with the associated report, Clickner explained. Even with pictures of a wound, you would want the assessment of the wound care nurse or wound care physician or the infectious-disease guy talking about what he s seeing, and here s a picture to prove my point. Very seldom are you going to have just a picture without that context. At Sentara, said Clickner, the radiology image is embedded in the radiology report that the radiologist dictates. They can say, Here s what I see, and you get a link that you can click on to open it up to take a look at the actual image. Some could say that the imaging report, available now in the EHR, is sufficient to describe the image and findings, but anybody who generates those reports or uses those reports will tell you it s very hard to do an adequate description of the findings, said Petersilge. It s the old saying, A picture is worth a thousand words. 03

5 Continuing the wound-care scenario, Petersilge gave this example: A patient has an ulcer on the foot, being followed in wound clinic, and comes into the ED in the middle of the night saying, My wound is worse. That s the only information that poor ED doc has to go on, unless he can pull up a picture of the wound from a week ago and see if the wound really is worse. Even with the description in the note, he s not really going to know. Without access to the longitudinal history of patient images, is it really reasonable to believe that the most appropriate, efficient care can be provided? MITIGATING RISK Providing easy access to image information within the clinical context is a key service that an enterprise imaging platform delivers. A comprehensive platform that tags medical images for ubiquitous EHR access would help reduce risk associated with situations of too much or too little information, such as having multiple patient screens open simultaneously or having inadequate historical information. As competitive healthcare organizations move closer toward zero tolerance for avoidable errors, the importance of utilizing all collected patient information at each point of care rises dramatically. With the accountable, risk-bearing model of care delivery, healthcare leaders are increasingly tasked with managing change to facilitate safe, efficient, and well-documented treatment. Hospital executives have a decision: Do they see a case for getting ahead of the curve and building a strategy to enable enterprise imaging within the EHR, with its benefits of efficient knowledge coordination and support of quality care? Or do they wait until the government gets around to writing the requirement into a mandated set of functionality requirements? Petersilge sees value in strategizing as early as possible: What I think they need to do is realize that this is going to be necessary to complete the EMR, and if they re early on in their EMR implementation, it s always easier to build toward these strategies rather than to build without keeping these strategies in mind. Even if a healthcare organization is planning to image-enable the EHR several years from now, you ve explored what you need to create in your foundation to make sure you don t go down a blind end that you then have to back out of and re-navigate in a different direction, she said. You don t have to do it all at once; you can do it in stages. But in the final analysis, You re going to have to do it. The sooner healthcare systems plan for patient-centric image sharing, the more reasoned and efficient the implementation will be. The better the implementation is, the better the results. As experience with many EHR and other IT projects have taught, strategizing now rather than later will likely reduce expense in cash, rework, training, and wasted resources. JOHN MORRISSEY IS A VETERAN HEALTHCARE REPORTER AND WRITER BASED IN CHICAGO. 04

6 THE OPPORTUNITIES AND CHALLENGES WITH ENTERPRISE IMAGING Why The Priority Principle Is Needed More Than Ever William Corsten, Regional President North America Agfa HealthCare 05

7 Over the past 20 years, I ve had the opportunity to work with providers and health systems across many settings of care, and there has been no greater time of change and growth in healthcare than is occurring today. These changes are ushering in exciting advances in patient treatment and enabling procedural efficiencies across the entire care continuum. That said, these changes are also creating new complexities for hospital and health system executives that must be addressed before positive action can occur. There is no better example of this dynamic than medical imaging. The role of medical imaging has evolved significantly in recent years, moving from the departmental level to an enterprise-wide solution. What was once the domain of radiology and to a lesser extent cardiology, is now widespread throughout the hospital setting with studies indicating that medical imaging is performed in upwards of forty different departments. The reason is simple. Images have become the heart of a clinically rich medical record and are as much a part of today s diagnostic process as blood pressure and body temperature. However, the importance of imaging as a medical tool has necessitated the exchange of information and communication across multiple departments, provider settings and geographic boundaries. For medical images to be truly impactful, images must now be integrated within a health system s EHR. If not, those images are essentially invisible to other caregivers within the organization. Moreover, if workflow is not developed to create, integrate and consolidate images across the enterprise, the process can become more burden than benefit. This creates a conundrum for hospital and health system executives. While the value of enterprise imaging is clear, the implementation can appear daunting. As I survey the landscape of medical imaging, it is evident to me that in order for positive change to occur, solution providers Agfa HealthCare being one must do a better job of putting themselves in the shoes of the hospital or health system executive. We need to fully understand the needs and pressures that they face before we can truly offer a solution. A long time ago, I realized that if you put others interests before your own, you both will find success. I call this philosophy the Priority Principle, and I believe it is a key to unlocking the potential of Agfa HealthCare and enterprise imaging, as a whole. Fundamentally, healthcare providers are looking for ways to deliver better outcomes at lower costs. EHR and enterprise imaging are helping providers achieve that goal. However, it s the adaptation of technology into a dynamic global workflow and care plans that is going to be the true agent of change. Without question, the potential of enterprise imaging to support population health management and other key healthcare initiatives worldwide is vast. And the opportunity for Agfa HealthCare to play a historic role in the ongoing evolution is significant. Our in-depth knowledge and understanding of clinical workflows, combined with our breadth of information technology experience, sets us apart. To get there, we are evolving our client organizations and their skill sets, the tools we use to support them, and the best practices we demand of ourselves. Agfa HealthCare is focused on delivering greater value and understanding of our clients healthcare systems, their complex needs, and the opportunity to help improve patient outcomes. 06

8 07 Enterprise imaging is not a storage strategy. It has to be much more than a VNA.

9 Presented at the CHIME14 Best Practices Institute Solutions Showcase HOW INTELLIGENT INDEXING & WORKFLOW EMPOWERS AN IMAGE-ENABLED EHR The value of enterprise imaging a centralized system that integrates images from any clinical specialty into a patient s EHR and makes that comprehensive information available to any clinician in the enterprise is increasingly understood and appreciated by forward-thinking hospital CIOs and healthcare executives. As these leaders recognize, the modern hospital enterprise is a dynamic and complex environment where patient care is often managed by an array of specialists from numerous departments, each of whom is responsible for a specific piece of the patient s diagnosis and treatment plan. Combine this with the additional clinical and financial demands of healthcare reform legislation, including HITECH (Health Information Technology for Economic Clinical Health Act) and initiatives of the Center for Medicare Advocacy (CMA), as well as the ACA (Patient Protection and Affordable Care Act), and it is clear that hospitals are forced to contend with a variety of sometimes competing elements to ultimately provide the best patient care possible. To help manage these challenges, the majority of hospitals have adopted EHR systems that enable observational and diagnostic data, such as blood pressure, presenting symptoms, and medical history, to be readily accessible and connected directly with a patient s administrative record. However, in today s increasingly visual world, medical images, such as CT scans, x-rays, ultrasound exams, and ophthalmology studies, as well as digital images of wounds, surgery, and dermatology, have become critical to the treatment regimen, providing physicians with the ability to examine a patient thoroughly and efficiently over time. The adoption of EHRs, combined with the clinical importance of imaging data, have presented a natural and necessary directive for hospitals to align observational and diagnostic data with corresponding medical images via the EHR, thereby improving physician-to-physician consult capabilities and strengthening evidence-based decision making. Further, revenue pressures from revenue entitlement reform, including new models for care delivery and payment, such as accountable care organizations (ACOs), are driving the need for improved imaging efficiency to help decrease costs and improve care. And though not yet mandated, the inclusion of imaging as a component of Meaningful Use criteria is making enterprise imaging increasingly unavoidable. Given this backdrop, many hospital CIOs and IT specialists are seeking solutions that will enable their organization to implement an any image, any time, from any location strategy. There is no better example of this than Cleveland Clinic. Recognized as one of the country s most forward-thinking hospitals, Cleveland Clinic is a fully integrated health system comprised of 1,440 beds at its main campus and more than 4,450 total beds throughout its system of family health centers, community hospitals and regional and international hospitals. Distinguishing the network further, its MyPractice Imaging program recently initiated an EHR optimization project that provides physicians access to medical images generated by any participating Cleveland Clinic imaging service line. This innovative service redefines the electronic health record by making virtually all medical data, including most images, regardless of capture modality, available to the clinician, inside the EHR, at the point-of-care. CLEVELAND CLINIC S VISUAL HEALTHCARE EVOLUTION Like most hospitals, the roots of enterprise imaging at Cleveland Clinic can be traced to radiology. Its radiology department was among the first to adopt digital technology for capturing and storing imaging data and was also among the first to adopt a picture archiving and communication systems, or PACS, for managing the files and a radiology information system, or RIS, to manage workflow. As other specialties developed their own image capture devices, the systems remained siloed within the specific department or group. Clinicians outside of radiology or cardiology, for instance, were unable to access those patient images at their own departmental workstations. Rather, they had to go physically to the department to connect to the system or request the data be shared, originally via film and eventually CDs. As enterprise-wide, text-based EHRs became standard tools within Cleveland Clinic, the hospital s IT leadership, led by Dr. C. Martin Harris, Chief Information Officer, and his team, including Dr. Cheryl Petersilge, Medical Director, MyPractice Imaging, and Louis M. Lannum, Director, Enterprise Imaging, began to consider the value of aligning the vast troves of medical images being generated at the hospital and its affiliates into a centralized system. 08

10 WORKFLOW & INDEXING THE AGFA DIFFERENCE Agfa HealthCare developed its enterprise imaging platform with the understanding that without flexible clinical workflow and advanced indexing capabilities, a VNA cannot provide the tools required for the delivery of quality, contemporary, reform-driven healthcare. However, giving physicians access to the aggregate of images associated with a particular patient is not a simple task. Most departments have their own solutions for capturing images, and their strategies for managing patient imaging workflow, indexing, storing, and distributing those images vary greatly. Agfa HealthCare developed its enterprise-level platform based on its own extensive PACS and VNA experience. Agfa HealthCare recognized that PACS are effective departmental solutions, but are not enterprise systems able to handle the ever-increasing image data volume from different departments and multiple systems. Similarly, VNAs are optimized for storage, but not for enterprise imaging workflows, such as department-specific image acquisition, electronic ordering, clinical metadata creation, and billing automation. Recognizing this challenge and seizing the opportunity for innovation, Agfa HealthCare developed a workflow centric platform that is able to meet departmental and enterprise requirements. In designing its Enterprise Imaging Suite, Agfa HealthCare understood that image-enabling the EHR is not just about viewing, archiving, and distribution. Instead, it must align these services with workflows that meet specific department requirements, and also integrate throughout an entire hospital or health system. Interoperability and flexibility were key design goals. As Dr. Petersilge recalled, For Cleveland Clinic and MyPractice Imaging, the enterprise imaging opportunity was recognized when we had to replace our PACS. At that time the opportunity to have and the value of having an enterprise archive was recognized. Similar to other hospitals embarking on an enterprise imaging strategy, the team at Cleveland Clinic began to evaluate vendor neutral archive (VNA) technologies because of their ability to store images from a variety of imaging formats, including DICOM and non-dicom, as well as digital photos, and serve the images up to software-based or web-enabled viewers accessible from workstations throughout a hospital.. However, as the team more closely weighed available VNA options, it became clear that providing enterprise storage was but a piece of the enterprise imaging puzzle. To truly deliver the power and value of an enterprise-wide image platform, the MyPractice Imaging team realized that workflow and indexing standards had to be established across all departments and clinicians who utilize the system. What we needed was a thinking VNA, which could do several things. It had to manage, in one place, the context of all the images, their indexing, where they came from, and where they should appear in the EHR. There would thus only be one connection back to the EHR, remarked Dr. Petersilge. The thinking VNA we selected was the Enterprise Imaging Suite developed by Agfa HealthCare. In today s modern hospital, nearly every department generates clinical images. Radiology and cardiology remain the most prolific, but departments as disparate as obstetrics and gastroenterology also produce images and are doing so on a more frequent basis, stated Lenny J. Reznik, Vice President, Marketing North America, Agfa HealthCare. As such, a true enterprise imaging strategy must account for thousands of potential workflows. CLEVELAND CLINIC & AGFA HEALTHCARE INNOVATING TOGETHER In implementing its enterprise imaging strategy, the MyPractice Imaging team prioritized the order in which departments would be integrated into the system. Radiology was the first to go on line, given its importance as an imaging leader within the hospital. Following radiology, the MyPractice Imaging team deliberately chose to get other departments involved rapidly as it did not want the new system to be perceived incorrectly as radiology-only. The rationale was clear to Dr. Petersilge and the MyPractice Imaging team. An enterprise imaging system, much like a system-wide EHR, is intended to be used across multiple departments and medical disciplines. If there are significant disconnects or disagreements in how the system will function, then it will never operate as intended. As a result, cross-departmental support is a must for an enterprise imaging strategy to succeed. Cleveland Clinic s gastroenterology service was next in line, due to its position as one of the largest and most highly rated departments in this field in the United States. Additionally, with endoscopy, colonoscopy, and other image-rich procedures, the gastroenterology service line would particularly benefit from increased collaboration between their clinicians and referring physicians. 09

11 After that, women s health imaging was connected along with its trove of images, including fetal ultrasounds. The pulmonary function and ophthalmology service lines soon followed. Dermatology was a noteworthy addition, as it necessitated the implementation of workflows for relatively simple, but prolific, digital cameras. As more departments were integrated, the value of Agfa HealthCare s workflow and indexing capabilities became even more profound. Dr. Petersilge noted, Developing a foundation for indexing was a big challenge. New types of orders and new types of reports would be coming in to the EHR, and this incorporation needed to be done in a thoughtful and systematic fashion. Workflows needed to be developed for each new department that was brought on board. We did not want to use a one-size-fits-all approach. Agfa HealthCare s enterprise workflow engine is designed to accommodate these variables by coordinating the individual department workflows (where images are generated) with enterprise and regional workflows (where images are accessed and collaboration occurs). Doing so, the technology drives automated management of activities of the department, not only at the desktop but also at the back-end, allowing for introspection into other systems to bring patient-centric data into the workflow. Moreover, the workflow engine can be adapted as needs change throughout the enterprise or within a department. As activities and new processes occur, Agfa HealthCare s Enterprise Imaging Suite is able to connect the dots from an image to a report, building a reference that feeds back into the EHR and is understandable across the entire enterprise. Workflow encompasses everything from creating a work list on a modality, to order generation, to notification to the EHR that a study exists, remarked Dr. Petersilge. It is critical that the workflow fit into the operational foundation established at the enterprise level. It is also important that the workflow enhances and does not encumber the work of the person generating the image, otherwise they are likely to find work-arounds which can lead to failure to properly store images or failure to properly index images. ordered the tests. The results have been dramatic. A process that used to take hours is now accomplished in minutes. Image acquisition the process by which an image is initially acquired has also witnessed marked improvement. Now, the primary rate-limiting factor is the time it takes for the patient to physically travel to and from the department where the images are taken. The image enters the shared system immediately. Less easy to measure, but no less significant, is the time gained by the physicians who would otherwise have to engage in hunt and search activities to locate images. Now every user knows exactly where the images are located. Additionally, Cleveland Clinic has virtually eliminated the physical delivery of paper-based medical records, and the physical delivery of films or CDs, creating both cost and efficiency benefits. Additional, notable results of the Enterprise Imaging Platform are its effect not only on the delivery of clinical services, but on back-office concerns such as risk mitigation. By providing auto-indexing of patient images at the point of image capture, and providing access to any clinician, the likelihood of medical errors is reduced. Centralized visual documentation of medical status in the form of digital camera images provides a HIPAA-compliant, traceable care history for immediate and future viewing. The Platform allows the hospital enterprise to take control of protecting medical imaging information in a secure, vendor neutral environment, enabling business continuity and disaster recovery services. In executing its enterprise imaging strategy, Cleveland Clinic is now able to increase value of its medical images by removing the shackles that once rendered the images prisoners of the department that created them. Reznik added, Understanding that most health systems need to drive doctors to use the EHR as the primary interface to patient information, Agfa HealthCare designed a workflow-centric platform that enables physicians to use native EHR terms and functionality to access and store images. Our mission is to help health organizations improve the delivery of quality care by optimizing their EHR investment. THE ENTERPRISE IMAGING DIFFERENCE For modern hospitals, the ability to maximize data usage efficiency is becoming a competitive advantage. Not only can it vastly improve the operational and fiscal performance of a hospital, but it can also foster an environment of collaborative and informed patient management, supporting today s model of shared decision making, accountable care. With greater access to data (in its many forms), physicians are able to consult easily with one another, and patients and their caregivers can take a more active role in the treatment process. Since its implementation, Cleveland Clinic s enterprise imaging solution has benefited the hospital in number of areas. Most striking, it has enabled significantly greater efficiencies in turn-around time how quickly information gets back into the hands of the physician who 10

12 Of course the design, development, and optimization of EMRs have been progressing for a long time now, but a consistent oversight in this development process has always been the underestimation of the growing importance of images in the modern practice of medicine and the lack of means to fully integrate the images into the EMR. - C. Martin Harris, MD, MBA, CIO Cleveland Clinic 11

13 Today, words like value and patient-centric care are echoing through every medical meeting, and enterprise imaging is becoming an integral part of that conversation. Electronic Health Record (EHR) systems are, in many ways, the bellwether of today s healthcare reform. Expensive and information-rich medical images are often disconnected from a patient s electronic record and, as a result, redundancy in testing is common. With reimbursement moving from volume-based to a value-based model, a comprehensive record can help to improve workflow efficiency and increase reimbursement by reducing duplicate testing and claim administration. Additionally, having access to a comprehensive medical history that includes images gives the physician a more thorough view of the patient. And, while radiology and cardiology are still the greatest, singledepartment contributors to the medical imaging cache, other specialties are now seeing the value in visual communication. From photographing wounds in emergency and followup care, to endoscopies, to fundascopic images from the Ophthalmology Department, the advantages of visual healthcare are immense. Every doctor I know is extremely visual, explains Louis Lannum, the Director of Enterprise Imaging at Cleveland Clinic, Once physicians and practitioners and other hospital providers are able to see beyond the text-based EHR into a more visual world, it is going to enable better medicine, and better clinical practice. VNAS AND PACSS: INTERFACED VS. INTEGRATED IMAGE SYSTEMS While VNAs attached to PACSs have become popular, many of these solutions only provide an interfaced portal that can link to the EHR, but the information is not integrated in the context of a patient s care encounter record. Cleveland Clinic, an international health system comprised of regional and community hospitals, family health centers, and outpatient surgery centers, is acting with a broader, but deeper, strategy: Instead of taping USB drives or CDs to patients as they are moved about (often a standard procedure within and between networks), images are available via the EHR and can be easily accessed by practitioners at every hospital within an enterprise. At Cleveland Clinic, for example, all patient information is accessible at any of their more than 35,000 workstations. IMAGES AND MEANINGFUL USE: THE TRANSITION FROM THE FEE-BASED MODEL TO A VALUE-BASED ONE As medical reimbursement transitions from a volume-based to a value-based system, finding ways to reduce redundancy and improve workflow has become a top priority among C-level executives and clinicians alike. Based on the progression of Meaningful Use criteria, it is imperative for medical enterprises to incorporate imaging systems sooner rather than later. As a result, imaging platforms are becoming an invaluable tool and although it can be a challenging transition implementation provides powerful clinical and operational value. A fully-integrated, interoperational system, like Agfa HealthCare s Enterprise Imaging Suite, can connect clinicians, and patients, on a transparent, information-rich level, thus contributing to improved patient outcomes. Surgeons can use Agfa HealthCare Enterprise Imaging to enhance their preparation process, while primary care physicians can leverage it to deliver more detailed, image-rich patient consultations. Physicians can access it to streamline their collaborations, especially between specialists and GPs within the hospital. Someone might ask why physicians need images in the EHR now when their current methods have served them for so long, says Charles Morris, Global Enterprise Imaging Business Manager at Agfa Health- Care, This is one of those you-don t-know-what-you ve-been-missing-until-you-have-it scenarios. Once physicians have access to the image-enabled EHR, just try taking it away. They won t let you. There are a couple of different ways of making images available to your clinicians, explains Cheryl Petersilge, MD, MBA, Medical Director, MyPractice Imaging, at Cleveland Clinic, There s the interfaced way where you have all these different image-management systems and each has its own interface, usually not within the EMR and they re not connected so you could close out of the EMR for Patient A, have all their images up on the screen, then open up Patient B s EMR, and actually potentially attribute the images from one patient to another. Agfa HealthCare s Enterprise Imaging portfolio (currently implemented in such facilities as Cleveland Clinic, Ochsner Health, and UC Irvine Health as well as internationally), automatically pulls medical images into the patient s EHR, from virtually any device, in virtually any file format, and tags it with clinically relevant metadata so that information is securely accessible throughout your enterprise. From digital camera photos to MRIs, from videos of CT scans to colonoscopies, medical images, along with the accompanying metadata information, are made viewable in a centralized, patient-centric context that enables quick searches and fast consolidations of desired values. You can display all these different modalities together and compare the findings from one modality to the next not just an Ultrasound and a CT but a photograph and the CT or an arthroscopy image of a meniscal tear right up against the MRI, says Dr. Petersilge. Having a highly efficient image capture system ensures that accurate, protected patient information is available where and when it is needed. 12

14 CLINICAL & BUSINESS USE SERIES SHARING ULTRASOUND IMAGES VIA A COMPREHENSIVE IMAGE-ENABLED EHR BENEFITS TO QUALITY CARE DELIVERY ENTERPRISE IMAGING ADVANCES YOUR MISSION TO DELIVER HIGH QUALITY CARE WHILE IMPROVING OPERATIONAL EFFICIENCIES. THE COMPREHENSIVE IMAGE-ENABLED EHR CAN HELP SUPPORT YOUR GOALS TO: IMPROVE PATIENT OUTCOMES REDUCE RISK IMPROVE COORDINATION OF CARE IMPROVE DIAGNOSTIC ACUMEN IMPROVE WORKFLOW MAXIMIZE REVENUE ENTITLEMENTS AS IMAGING INFORMATION, SUCH AS ULTRASOUND, BECOMES ACCESSIBLE TO MORE DEPARTMENTS WITHIN AN ENTERPRISE, THE ABILITY TO STORE, ACCESS, AND SHARE THOSE IMAGES IS INVALUABLE. A COMPREHENSIVE IMAGE-ENABLED EHR ALLOWS PATIENT INFORMATION, INCLUDING DICOM AND NON-DICOM IMAGES, TO BE ACCES- SIBLE BY ANY DEPARTMENT. FROM SCHEDULING TO BILLING, FROM TIME TO DIAGNOSIS TO TREATMENT PLAN COMPLI- ANCE, AGFA HEALTHCARE ENTERPRISE IMAGING PROVIDES THE ABILITY TO OPTIMIZE YOUR EHR INVESTMENT, AND MOST IMPORTANTLY, HELP IMPROVE PATIENT CARE. THE CHALLENGE Over the past decade, with ultrasound (US) devices shrinking dramatically in size and cost, ultrasonographic imaging has become one of the most commonly ordered studies throughout the health system. In fact, right now, hand-held ultrasound point-of-care studies, as well as conventional US studies are likely being performed in dozens of departments and by dozens of clinicians in your hospitals and facilities, from anesthesiologists to obstetricians, cardiologists to emergency room doctors, and more. Where are all these ultrasound images going? Are they being used effectively to optimize the health of the patient and the success of your hospital system? Or, are they being hidden away on CDs in a file cabinet in each siloed conducting department, relatively inaccessible to physicians, auditors, or anyone else who might need them today, next week, or six months down the road? If the ultrasound images are not being immediately uploaded to the patient s permanent electronic health record (EHR), the answer, very likely, is closer to the latter. This situation needs to be addressed to assure that risk to the health system and to patient care - is mitigated. THE SOLUTION With Agfa HealthCare Enterprise Imaging, the EHR of tomorrow is here today. Already proven in use at major health systems throughout North America, the comprehensive visual healthcare platform quickly and transparently captures ultrasound images, as well as images from other clinical specialties, and links them to the patient s EHR. In seconds, they are available to any appropriate healthcare professional in the care chain for seamless continuity of care. Intelligently indexed within their clinical context, these images are also readily accessible to optimize reimbursement, or minimize audit or legal risk should the need arise. 13

15 SEE THE DIFFERENCE THAT A COMPREHENSIVE IMAGE-ENABLED EHR COULD MEAN TO THE USE OF ULTRASOUND AT YOUR FACILITIES. YESTERDAY S EHR Mary C., 82, is brought to your Emergency Department by her daughter, Karen. Mary is complaining of severe abdominal pain and is obviously in distress. After taking Mary s vitals, your ED team orders an ultrasound of the area and the radiologist sees a suspicious growth in Mary s lower intestine. Wanting to discuss the findings with a gastroenterologist, and ascertain next steps, the ED physician and the radiologist put in a call for the gastroenterologist to come to the Emergency Department to view the ultrasound images with the team. Since all the gastroenterologists are currently in another part of the hospital or at other facilities, the ED doctor is told that it will likely be between 90 minutes and two hours before someone can come physically to the ED to look at the images and potentially order additional studies. (Alternatively, he is told, he may also burn a disk of the DICOM images and courier them over to one of the gastroenterologists.) Meanwhile, Mary, very upset and confused, and being comforted by her daughter, is fitted with an IV and placed in an ED bed, where she demands frequent attention by the nurses, creating a bottleneck in the busy Emergency Department. She and the staff will wait in this way for two and a half hours until a specialist is able to come to the ED, view the ultrasound, concur with the team and place an order for a CT scan. TOMORROW S EHR Mary C., 82, is brought to your Emergency Department by her daughter, Karen. Mary is complaining of severe abdominal pain and is obviously in distress. After taking Mary s vitals, your ED team orders an ultrasound of the area and the radiologist sees a suspicious growth in Mary s lower intestine. Needing the opinion of a gastroenterologist in order to ascertain next steps, the ED physician puts in a call for the specialist to view the images as well as discuss the radiologist s report. About fifteen minutes later, ten miles away at one of your sister hospitals, a staff gastroenterologist sits down at a terminal in his office, accesses Mary s EHR, reads the ED physician s description, and reviews the ultrasound images along with the radiologist s written report. He enters his impression directly into the EHR, referencing the images and the report, and initiates an order for a CT scan. Minutes later, before Mary, Karen, or the ED staff have to wait any longer, Mary is wheeled down to the Radiology Department and prepared for the scan. TEXT AND IMAGES AVAILABLE ANYTIME, ANYWHERE, IN ONE VIEW THE AGFA ADVANTAGE: IMAGES IN THE CONTEXT OF THE EHR This clear improvement in the delivery of Mary s care as well as the smooth workflow of your ED and the collaboration of specialists multiplied by every patient getting an ultrasound anywhere in your hospital system, can be yours today with Agfa HealthCare s Enterprise Imaging Suite. And this is only one small example. What if, next week, another physician handling Mary s case wants to see the ultrasound and accompanying report? She can access it in seconds, rather than having to wait for a disk to arrive. What if six months from now, CMS asks to see the ultrasound as proof for reimbursement? Could you find it? With Agfa Health- Care s Enterprise Imaging Suite, it s right there in the record, quickly available. What if Karen thinks that her mother s case was mishandled and her attorney demands copies of all studies performed? Secure documentation, linked within a patient s clinical context, can reduce the resources required to access information, reducing burdensome employee search time and risk mitigation efforts. Clinically relevant information is at your fingertips, in the EHR, quickly and easily available. CREATING A CENTRALIZED, SINGLE POINT OF STORAGE FOR PATIENT IMAGES FROM ANY CLINICAL SPECIALTY With your EHR system now enhanced with images, think of the improvement in quality of care, workflow, cost savings and efficiency improvements that can be achieved throughout every hospital and facility across your health system, as stakeholders have fast access to every aspect of a patient s history not simply that information expressed in text. Doctors can see every study or image for themselves, whether DICOM or non-di- COM, without special access to the department that created them. With ubiquitous image sharing, clinicians can readily discuss cases with colleagues, no matter where in the world they are located, enabling informed decisions and efficient delivery of care across the care continuum. THE AGFA HEALTHCARE ENTERPRISE IMAGING SUITE IS A CARE-CENTRIC CONSOLIDATED PLATFORM THAT INTEGRATES IMAGES FROM ANY CLINICAL SPECIALTY INTO YOUR PATIENT S EHR, AND ENABLES ACCESS TO THAT COMPREHENSIVE INFORMATION BY ANY CLINICIAN IN YOUR ENTERPRISE. 14

16 IMAGES ON THE GO With Agfa HealthCare Enterprise Imaging XERO Viewer, a rural hospital offers referring physicians the support they seek to enhance care quality and patient relationships. 15

17 When Hunt Regional Healthcare, in Greenville, Texas upgraded its Agfa HealthCare IMPAX PACS, it was a great opportunity to add the Enterprise Imaging XERO Viewer. While the hospital knew that having easy access to medical images from the many multispecialty departments creating them would be helpful to their staff, they did not anticipate the high level of positive impact that XERO Viewer would have across their enterprise. Today, XERO Viewer spans many departments at Hunt, including cardiology. THE ONE-STOP SHOP FOR IMAGING XERO Viewer is designed to provide cross-specialty image access across the entire enterprise, with enhanced viewing, collaboration, and sharing. Regardless of a medical image s origin or file format, the universal viewer uses XERO technology to make it accessible within a single web viewer. Whether the images are stored in Agfa HealthCare s own PACS or VNA solutions or in a third-party system, XERO viewer leverages a hospital s technology investment and provides secure access to imaging data. The viewer functions as a sort of one-stop shop for imaging, helping it to increase Hunt s presence in the local patient market and to attract referring physicians. If we want to grow, we have to offer referring physicians services that support them in enhancing the quality of care they provide, and allow them to better serve their own patients, comments John Ervin, Director of Imaging Services for Hunt. XERO Viewer does that for us. The referring physicians are thrilled with the mobile access to images, available over a simple internet connection, on their laptops or even their ipads. It gives them more flexibility in where they can work, and it lets them take their images with them wherever they go. They can show the images to specialists or patients, anywhere. The use of images in patient and family consultation may contribute to improved understanding and compliance with medical care. AN INDISPENSABLE TOOL XERO Viewer has created great word of mouth for us, adds Tim Robinson, PACS Administrator. When a physician sees a colleague accessing images on his ipad, he wants to do that, too. So it s supporting our growth ambitions, as well as improving the satisfaction of our own clinicians. As Ervin explains, At the same time, referring physicians don t want you messing with their computers. XERO Viewer lets them see their images with just a simple Internet connection, without adding any software. So the solution is helping to increase our imaging volume and propel our growth. From basic, mobile access to medical images, to facilitating inter-departmental collaboration, Agfa HealthCare Enterprise Imaging XERO Viewer has proven to be an indispensable tool for Hunt Regional Healthcare. XERO Viewer provided Hunt with the simple, elegant solution they needed to elevate their level of patient care and physician satisfaction. DRIVE NEW REVENUE WITH SATISFIED PHYSICIANS XERO VIEWER PROVIDES ACCESS TO PATIENT IMAGING DATA DIRECTLY FROM YOUR IMAGING ARCHIVES WHATEVER THEY ARE. Image-enable your EHR with images from the entire hospital enterprise or a select department to enhance the clinician s ability to deliver patient care. Seamless integration with the EHR. Compatible with solutions from top vendors. Single sign on, ticket based authentication and the use of RESTful web services let you securely image-enable a comprehensive EHR cost-effectively. Patient context image and text data drive more informed assessments, in turn, leading to more confident care decision. 16

18 BUILDING STRONGER RELATIONSHIPS WITH REFERRING PHYSICIANS WITH IMAGE-ENABLED EHRS As technology advances, opportunities abound for hospitals to create unbreakable bonds with their local physicians FRANK PECAITIS, Senior Vice President, Sales North America Agfa HealthCare The referring physician whether a primary care doctor or a medical specialist is a key constituent of every hospital. Strong relationships with area physicians are not only important in ensuring optimal patient care (and reducing patient recidivism), but physician loyalists provide hospitals with reliable sources of potential revenue. In fact, according to a recent survey by Merritt Hawkins, a national physician search firm, a single physician generates in excess of $1.4 million dollars in net revenue annually for a hospital. It is no wonder then that hospitals go to great lengths to develop and nurture relationships with potential physician referral sources in order to build revenue and remain competitive. Against this backdrop and to counter the constant threat of referral leakage hospitals are adopting a variety of strategies and tools to remain engaged with their referral sources and position the hospital as a true care partner. Forward-thinking hospital executives are leveraging advances in technology to make it cheaper, easier, faster and more convenient for physicians to refer patients, while remaining an integral part of the care process. Central to this effort is the electronic health record (EHR). It is difficult to deny the overwhelmingly positive impact that the EHR has had on patient care. True, the EHR will never cure a disease or mend a broken bone, but the ability of a physician to have access to a patient s complete medical history at the touch of a button has empowered physicians to make more informed and efficient medical decisions, thereby improving the delivery of care. Additionally, and equally important, the EHR is enabling a new level of connectivity among physicians inside and outside of a hospital s walls. Data can now be easily transferred among a team of clinicians, allowing all involved to have equal input in the treatment regimen. However, until recently, only observational and diagnostic data, such as blood pressure, presenting symptoms and medical history, were readily accessible via a patient s medical record. Medical images, such as CT scans, x-rays, ultrasounds, as well as digital images documenting wounds, surgery, ophthalmology and dermatology, were not part of the EHR equation. This absence of critical information creates blind spots in the ability for physicians to get a complete picture of the patient s condition. Moreover, the inability to share medical images with a patient s primary care physician often left the trusted doctor on the outside looking in. The good news for hospitals and referring physicians is technology has progressed to the point where medical images can now be accessed across an entire hospital enterprise, both inside and outside the hospital walls, via the EHR. Commonly referred to as enterprise imaging, this capability is serving to transform how physicians access and share clinically relevant images and, in turn, their ability to more efficiently and effectively treat patients. What was once the domain of a hospital s radiology or cardiology department is now open to all clinicians; including the family doctor. For hospitals, the ability to enable such imaging access to referring physicians can be a significant competitive differentiator. It demonstrates that the hospital is striving to be a center of medical excellence by integrating technologies that enhance the care process. One of the results is an improved continuum of care for the patient and for all physicians who participate in the treatment program. If a physician goes from an inpatient to an outpatient setting, he or she can access the EHR in either location without the need to lug around paper charts, diagnostic image prints, or CDs. Additionally, newly developed, mobile-based imaging viewers can even enable patients to access, view AND create clinically relevant images medical selfies which can then be uploaded to the EHR. A patient being treated for a diabetic foot ulcer, for example, now has the ability to produce and share relevant wound images within a highly secure application, enabling all physicians including the primary care doctor to monitor the treatment progress and remotely view images to determine if a visit to the examination room is warranted. What does this all mean for the hospital executive who must lead in today s increasingly complex and challenging hospital economic environment? How can visual healthcare improve the hospital s ability to maximize the full value of clinical services and ensure revenue entitlement? By creating an uninterrupted, information-rich workflow environment in which technology-based systems enable ALL clinicians to be connected and equal players in a patient s treatment, hospitals are able to build nearly unbreakable bonds with their referring physicians, helping to ensure a steady stream of patients through their doors. 17

19 Q&A CORNER: CLEVELAND CLINIC S ROAD TO AN ENTERPRISE IMAGING STRATEGY result, cross-departmental support is a must for an enterprise imaging strategy to succeed. CHERYL PETERSILGE, MD, MBA Medical Director, MyPractice Imaging, Cleveland Clinic Second: Is there a vision of what an executed strategy will look like for their enterprise? is critically important and goes hand-in-hand with securing support across the hospital or health system. Before any enterprise imaging strategy is executed, it is incumbent upon the clinical, administrative, and IT leaders to fully understand what such a system will look like and the results it is designed to deliver. Lastly: Is the proper governance in place? Considering the scope of an enterprise imaging system, there must be processes and policies in place as well as individuals to own those processes and policies to ensure that the system operates in accordance with its vision and delivers the results that are expected. 1. WHEN WAS IT THAT YOU AND THE MYPRACTICE TEAM AT CLEVE- LAND CLINIC FIRST BEGAN TO REALIZE THE POTENTIAL OF ENTER- PRISE IMAGING? WAS THERE AN AH-HA! MOMENT OR WAS IT MORE A BUILDING PROCESS BASED ON SHARED PERSPECTIVE? Actually, there aren t many ah-ha moments in healthcare IT these days. Every strategy, every decision requires careful thought and planning considering the scale and costs of the systems that are now required. For Cleveland Clinic and MyPractice, the enterprise imaging opportunity was recognized when we had to replace our PACS. At that time, the opportunity to implement and the value of having an enterprise image library was recognized. I think this is typical of how hospitals have transitioned or soon will transition to enterprise imaging. It s a natural evolution, which is the way it ought to be. 2. WHAT WERE THE INITIAL CHALLENGES THAT YOU HAD TO OVER- COME STRATEGICALLY, OPERATIONALLY, AND TECHNOLOGICALLY AS YOU BEGAN TO IMPLEMENT YOUR ENTERPRISE IMAGING SYSTEM? Developing a foundation for indexing was a big challenge. New types of orders and new types of reports would be coming in to the EMR, and this incorporation needed to be done in a thoughtful and systematic fashion. Workflows needed to be developed for each new department that was brought on board. We did not want to use a one size fits all approach. While the majority of image generating departments have been extremely satisfied with the service and concept, some image generating departments are still buying into the concept, which I view as a net positive because, at the end of the day, for such a system to work properly, it must serve every department optimally. 3. WHAT ARE THE TOP THREE THINGS A HOSPITAL OR HEALTH SYSTEM NEEDS TO CONSIDER IN ORDER TO SUCCESSFULLY DEVELOP AND EXECUTE AN ENTERPRISE IMAGING STRATEGY? First: Is there support from across the enterprise both administratively and clinically? An enterprise imaging system, much like a system-wide EMR, is intended to be used across multiple departments and medical disciplines. If there are significant disconnects or disagreements in how the system will function, then it will never operate as intended. As a 4. WHAT IS WORKFLOW TO YOU AND WHY IS IT SO CRITICALLY IMPORTANT TO ENTERPRISE IMAGING? Workflow encompasses everything from creating a work list on a modality, to order generation, to notification to the EMR that a study exists. It is critical that the workflow fit into the operational foundation established from the enterprise, otherwise chaos will reign in the EMR. It is also important that the workflow enhances and does not encumber the work of the person generating the image; otherwise they are likely to find work-arounds which can lead to failure to properly store images or failure to properly index images. 5. WHAT ENTERPRISE IMAGING INNOVATION(S) DO YOU SEE ON THE HORIZON OR WANT TO SEE ON THE HORIZON? In the future, we will see new ways to display all of the images in ways that enhance a clinician s ability to organize and consume the information. Additional tools will be incorporated into the universal viewers to support needs of a wider spectrum of imaging modalities. Greater interaction beyond simple co-display of images and text information will take an image enabled EMR to the next level. MYPRACTICE IMAGING SOLUTIONS Cleveland Clinic s MyPractice Imaging Solutions team has seen the direct benefits of implementing an enterprise imaging strategy at Cleveland Clinic and they can help you achieve those same benefits and reduce risk in an accelerated time frame. Faster, Comprehensive Diagnostic Results Informed Decision Making Practice Model HIPAA Compliant Operational Efficiency For more information about MyPractice Imaging Solutions, please call: , or via at: imagesolutions@ccf.org 18

20