Imaging and Meaningful Use Debate

There have been several posts on the blogs I read that have commented on the discussion of imaging at the January meeting of the Health Information Technology Standards Committee (HITSC.) I am frankly a little surprised that this issue has not been raised more forcefully in the last 18 months. Those familiar with the Meaningful Use regulations are aware that imaging standards were not addressed in Stage 1. Imaging is not due for serious consideration until Stage 3 in 2015 according to initial plans. This seems to constitute a significant oversight to me. Let me explain how I see it.

Some form of imaging is used in many hospitals, outpatient primary care, and outpatient specialist patient visits. The variety of patient data stored as images has exploded in recent years. X-rays are now only one of a variety of the types of images needed for patient care. Now images may include x-rays, MRI/CT scans, nuclear medicine studies, electrocardiography, fetal monitoring strips, clinical photographs, photomicrographs, endoscopy video, and more. The old maxim "a picture is worth a thousand words" is especially true in modern medical care.

A number of logical arguments can be made to support federal policy and incentives that would promote the sharing of imaging data. Imaging information has an innate value with respect to patient care decision making and management of problems comparable to that of laboratory results. We have a very mobile population in the US so it is important to develop methods to mitigate geographic silos of imaging information that currently cannot follow patients easily. Imaging data can be foundational to studies in the fields of health care research and public health. Images that can cross the boundaries of individual health care provider organizations will be important for situational awareness in the patient centered medical home model. I assert that safe, efficient, timely, and effective clinical care requires the ability for providers to exchange images through use of the HIT systems. I am prepared to back this up with examples from my recent experience providing clinical care to patients.

As a practicing orthopedic surgeon, I depend on images to treat nearly every one of my patients. Many x-rays are taken at outside facilities-hospitals, free standing imaging centers, urgent care centers, and other physician offices. Frequently, the studies I need are not available for a variety of reasons- the patient is visiting from another geographic area and did not bring the films, the patient forgot to pick up the films or CD from their provider, they bring a CD but because every vendor has proprietary PACS viewing software, those images are hard to access or worse, my system crashes when I try to view the images on the CD. On the other hand, when the x-rays are brought on film, they are hard to organize and finding storage space for the x-ray folders is problematic. When previous images are not available then often the studies must be repeated. This adds to the risks (more x-ray exposure) and expense of the medical care I deliver. Each of the issues I have discussed can be correlated with one or more of the 5 Meaningful Use priority health policy outcomes, goals, and objectives.

I have the sense that there has been a strong primary care bias in the selection of Meaningful Use criteria. When there is the perception that primary providers don't need a capability, then the information technology standards and requirements related to that capability are not included in the regulations. I think there is a mistake here. There has been a trend for primary clinicians to simply read imaging reports rather than to review the images themselves. This may be a reflection of limited training many clinicians receive in their training. Nevertheless, when primary care clinicians review images, not just the reports, they expand their understanding of a patient's disease and also provide an important second look at images that serves as a valuable check and balance to ensure the safety and quality of the care they provide.

In my opinion ONC, the Health Information Technology Standards Committee and the Health Information Technology Policy Committee should make the ability to exchange images a high priority for Meaningful Use Stages 2 and 3. Standards for image exchange must be selected. Transport mechanisms via health information exchange should be supported and promoted even more vigorously.