With all due respect to the learned leadership in the department of Health and Human Services and the Office of the National Coordinator for IT, it is my opinion that the early phases of the plan to award incentive payments to hospitals and physicians for  “meaningful use” of “certified” electronic health record systems is missing a key foundational component.  Without the appropriate technology foundation for clinical systems to capture, store and share image data objects across all ‘ologies, the EHR technology deployed by the providers will present a substantially incomplete view of the patient’s record.

According to a paper written and published by the  Markle Foundation Connecting for Health, 2009 titled “A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR – Achieving the Health IT Objectives of the American Recovery and Reinvestment Act”, there are seven Principles for Meaningful Use and Qualification for Certification of EHRs.  The first four of these seven principals are actually quite revealing.

1. The overarching nationwide goals of health IT investments are to improve health care quality, reduce growth in costs, stimulate innovation, and protect privacy.
2. These goals can be achieved only through the effective use of information to support better decision-making and more effective care processes that improve health outcomes and reduce cost growth.
3. Meaningful use should be demonstrable in the first years of implementation (2011-12) without creating undue burden on clinicians and practices.
4. The definition of meaningful use should gradually expand to encompass more ambitious health improvement aims over time (i.e. image data).

The first three principals represent the kind of thinking that led to the decision to initially focus on what may seem to be the type of data objects that are relatively easy to access in electronic format.  At first glance it seemed to me that the early phase focus on Medication Management, Laboratory Results and Care Summaries, and the postponed inclusion of Medical Images, was a calculated attempt to capture, manage and distribute the kind of small data objects that are still being recorded on paper.  Score one for the Primary Care physician struggling to manage a barrage of paper-based information trapped in an inch thick manila folder.  I’m thinking “It’s a noble effort and besides, they’re little objects, so that should be easy!”

Then I began looking at this decision from another perspective.  Perhaps IHE and the Imaging Device manufacturers have been so successful convincing everyone that medical image data is so well organized under DICOM and therefore so easily distributed, that our thought leaders believe that there is no need to offer incentives to hospitals or physicians for meaningful use of image information.  Obviously Medical Image data is easily accessible within the hospital’s network and the internet or via those ubiquitous CDs.  With image data so clearly under control, the focus of those financial incentives should be placed instead on bringing the remaining paper-based sectors up to the same enviable status of Medical Imaging.

Forgive me, but I don’t see it that way.

From my perspective, working as a consultant to the Radiology PACS and Enterprise Archive market segments, DICOM is not so tight a standard that data exchange between disparate systems is assured.  In fact, the PACS vendors have deliberately created separate silos of medical images that (by their design) sequester their image content from universal access.  Once the images are delivered to another application, there is just enough proprietary information in a DICOM image header to assure that the best delivery and rendering of the image will be achieved by the vendor that created the image (Imaging Device) or by the vendor that modified and currently stores it (PACS).  The problems encountered during attempts to exchange image data between disparate systems using CDs are legend.  As for replacing the use of film by the referring physicians, most PACS have inadequately addressed the imaging needs of those physicians working in the hospital and especially those working in their offices and clinics off campus.  The consequences are complex, cumbersome and expensive. Can’t get the film anymore, but can’t get the electronic copy?  Not a problem, just redo the exam.

So the American Recovery and Reinvestment Act of 2009 (ARRA), the economic stimulus package enacted by Congress last February, is designed to reward hospitals and physicians with Medicare and Medicaid incentive payments for making “meaningful use” of “certified” electronic health records systems.  Back in May, Cheryl Proval in an article for Imaging Biz.com quoted Mr. Charles Christian, CIO and health systems manager of Good Samaritan Hospital, Vincennes, Indiana, and chair of the HIMSS board of directors. “The Medicare and Medicaid health IT incentives alone – which will be distributed through the states – could add up significantly for both hospitals and physicians. A 75-bed hospital, for 2011 through 2014, stands to reap $3.5 million: That’s probably twice what its annual bottom line is.  A 250-bed hospital has the potential to earn almost $6 million over four years, and a 750-bed hospital could qualify for nearly $12 million.”  The incentive bonanza estimated for the hospitals was used by PACS Consultant Michael Cannavo to launch a thread on Antminnie.com the very next month.  Vendors and Providers alike have been speculating ever since as to how to get their fair share of the funding.

Forgive me once again, but I think it’s going to be much more difficult than anticipated to collect on those incentives, if the focus of the first two years is on the accessing, sharing, and meaningful use of the electronic copy of Medication Management (recent medications), Laboratory Results, and Care Summaries.  While it’s a reasonable assumption that these data objects might be accessible and deliverable via HL-7, the last time I looked at the HL-7 “standard”, it was more open to interpretation than DICOM, and we know how well that’s working out as the type of standard that assures data exchange.

With the hope of finding significant movement towards interoperability between the type of systems that manage Medication, Lab Results, and Care Summaries, I recently visited the IHE website, specifically the Frameworks tab and discovered that there are no profiles as yet for Medication Management systems and that the Lab profiles were only recently tested in February at a European connectathon.  My hope is that Care Summaries would either be created in the electronic charting component of the EHR or could at least be managed as scanned documents.  My interpretation of the results of my research is just this: [1] Medication Management is not even on the radar and [2] the process of interconnecting Laboratory systems with external data repositories for the purpose of accessing and sharing lab results is just getting started, ergo [3] the sharing of Care Summaries through the EHR may be the only achievable objective of the first two years.

My conclusion is that the effort to access and distribute Medication and Laboratory data is many years behind the Radiology community’s efforts to standardize data format and communication protocol based on the DICOM standard.  If conformance to a single flavor of HL-7 is a requisite for accessing and sharing the kind of data that is the focus of the next few years, and the vendors proceed at the same pace as we have witnessed in the Radiology and now the Cardiology markets, it is going to take a tremendous volume of Care Summaries to justify the $Millions in incentive payments through 2011.

Here is my suggestion, and I make this in all seriousness to the hospitals and independent delivery networks out there.  Tuesday, August 25, 2009. in an article appearing on the HealthImaging.com website, the following was reported: “The Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) are asking for industry help through an official Request for Information (RFI) in determining the current status of the U.S. health IT infrastructure, and the steps needed to be taken to further develop that infrastructure.”

I suggest that we collectively lobby for the inclusion of Image Data along with Medications and Laboratory in the first phase.  Image data makes up approximately 85% of the patient’s medical record.  Repeating a lab test because we can’t find the result does cost time and money, but not of the magnitude of time and money that it takes to repeat a CT.  We are so close to being able to reliably and easily exchange Radiology and Cardiology study data and push it out to the most remote and clunky desktop (via a Server-side Rendering UniViewer).  All that is needed is a little funding for the PACS-neutral Archive movement, and we can set a fine example for Medication Management, Laboratory, and the more ambitious health improvement aims that would focus in the future on such data types as problem lists, allergies, vitals, findings, procedures, care plans, hospital discharge summaries, patient registration forms, etc.

Let’s argue that an incentive plan that focuses on the short term unattainable is no incentive plan, and that investing an appropriate expenditure in Neutral Enterprise Image Archiving is exactly what is needed right now to provide the required technological foundation to support “meaningful use” of images and then all of the other data objects to follow.