Radiology's Playbook for Optimizing Imaging Informatics

YOUR MEDICAL IMAGING CLOUD

EXECUTIVE INSIGHTS Radiology's Playbook for Optimizing Imaging Informatics Executive Insights from Weill Cornell Medicine, Memorial Sloan Kettering Cancer Center, and Ambra Health Introduction New regulations like MACRA, MIPS, and PAMA are changing the radiology landscape with an enhanced emphasis on ordering eﬃciency, turnaround and quality of reads, and patient satisfaction. Keeping your facility in line with new regulations means leveraging informatics to optimize and streamline the ﬂow of medical imaging across radiology and beyond.

Health systems and hospitals with inpatient radiology services are facing challenges around reimbursement and looking to better manage radiology utilization and their own ﬁxed costs. In turn, community hospitals and urgent care facilities also have a growing degree of imaging capabilities.

In a recent HIMSS webinar event, Keith Hentel, MD MS Executive Vice Chairman, Department of Radiology, Weill Cornell Medicine, and Krishna Juluru, MD Director, Imaging Informatics Memorial Sloan Kettering Cancer Center, discussed imaging informatics in a changing healthcare landscape with Morris Panner, CEO Ambra Health, covering:

How to optimize the image order & acquisition process The impact of the latest regulations and how to optimize radiology operations Managing outbound imaging and referral networks

This executive brief provides the latest insights in how healthcare leaders are utilizing image management technology and restructuring their broader informatics technology stack to meet change head on.

2 Executive Panel

Keith Hentel, MD MS Executive Vice Chairman, Department of Radiology, Weill Cornell Medicine Dr. Keith Hentel is Chief of the Division of Emergency/Musculoskeletal Radiology and is Executive Vice Chairman in the Department of Radiology at New York-Presbyterian Hospital-Weill Cornell Medical Center. He is a 1991 graduate of Cornell University (B.S. in Biology) and earned his M.S. degree in Mechanical Engineering from Yale University in 1993. Dr. Hentel is a graduate of Weill Cornell Medical College and was awarded his M.D. in 1998. Dr. Hentel is an Associate Professor of Clinical Radiology at Weill Cornell Medical College and is an Associate Attending Radiologist at the New York-Presbyterian Hospital/Weill Cornell Campus.

Dr. Hentel has been an invited speaker nationally and has published numerous articles and book chapters. Dr. Hentel also serves on many institution-wide committees in the both New York-Presbyterian Hospital and Weill Cornell Medical College.

Krishna Juluru, MD Director Imaging Informatics, Memorial Sloan Kettering Cancer Center Dr. Krishna Juluru is the Director of Imaging Informatics at Memorial Sloan Kettering Cancer Center. Dr. Juluru earned his B.S. degree in Applied Physics from Yale University, magna cum laude, and was elected to Phi Beta Kappa. He was awarded his M.D. degree from Johns Hopkins School of Medicine. His internship year in Internal Medicine at Greater Baltimore Medical Center was followed by radiology residency training in Diagnostic Radiology at Johns Hopkins School of Medicine, where he served as Radiology Chief Resident in 2005-2006. Dr. Juluru’s fellowship year combined his interests in informatics and radiology.

Dr. Juluru has spoken nationally and internationally on topics related to Advanced Image Processing, optimization of radiology workﬂow, and technology assessment. He is also actively involved in the development of applications utilizing Radiology for medical education.

Morris Panner CEO, Ambra Health

As CEO of Ambra Health, a leader in cloud medical imaging, Morris Panner works closely with industry leaders at some of the world’s largest health systems including Stanford Children’s Health and Memorial Hermann. Focused on delivering better care through better technology. Morris is a frequent contributor to business, healthcare, and technology publications. Morris has a BA from Yale University and a JD from Harvard University.

3 Executive Summary

MULTIPLE PACS REMAIN A BIG BARRIER TO SHARING AND ACCESS. They can create signiﬁcant physician productivity challenges with accessing imaging.

MEASUREMENT AND ANALYTICS INCREASINGLY IMPORTANT. Factors like turnaround times, physician ordering, routing, dose measurement, and capacity management are all becoming critical measures, whether for simply monitoring service levels, eﬃciency, or ensuring compliance with growing regulations.

IMAGE SHARING IS SHIFTING TO REAL-TIME. Multi-day turnaround times are increasingly an anathema in a more integrated fast-moving healthcare system. Organizations are setting their goals on moving towards moving images in real time and getting them to the right person to review without delay.

ORGANIZATIONS NEED TO PAY ATTENTION TO PAMA. While there is growing awareness of MACRA and MIPS, providers need to upgrade their technology stack to manage appropriateness of advanced imaging orders.

EARLY ACCESS TO IMAGING AND HEALTHCARE DATA SEEN AS CRITICAL. Providing patient portals to enable entry of healthcare history, or upload/download imaging is an important way to engage patients, reduce administration overhead, and reduce time to coordinate care.

RESULTS SIMPLY AREN’T ENOUGH ANYMORE. Referring physicians and patients are looking for more than just radiology results, they want the imaging too, which is also an important step towards reducing duplicate imaging downstream.

THE CLOUD IS AN IMPORTANT TECHNOLOGY TO IMPROVE IMAGING TURNAROUND TO REFERRERS. Using cloud image management to provide imaging to referrers cuts cycle times from days to minutes or hours and can improve satisfaction.

CENTRALIZATION AND UNIFICATION OF DATA IS A PRIORITY. With an increasing diversity of healthcare information, and more distributed data, organizations are using cloud Vendor Neutral Archives to centralize it more eﬀectively and automatically integrate into imaging workﬂows.

4 Image Ordering and Acquisition Medical imaging is more spread out than ever before across a geographically distributed and diverse referral and patient community. For example, Weill Cornell has a wide range of physicians, some who are aﬃliated with the institution and some who aren’t. They’re also one of the medical schools and practices that are part of the New York Presbyterian Healthcare Organization and have a sister institution with Columbia Presbyterian, part of the Columbia Medical group, along with also providing regional care in the New York City metro area. The net result is patients frequently coming and going―and a real need to streamline image workﬂows across a disparate network.

At Memorial Sloan Kettering Cancer Center, the patient population is somewhat unique because they are focused on cancer care, and see patients both within the region and globally. Memorial handles coordination of care with Disease Management Teams (DMTs), so for example, an ovarian cancer DMT will be comprised of surgeons, medical and radiation oncologists, and radiologists who work specifically with that patient population. For radiology, DMT members refer to the DMT radiologists who are specific to that area, making specific and precise image routing essential.

PACS Remain a Challenge Dr. Hentel noted that a PACS only gets you so far, commenting that, “the same PACS that I have is not the same PACS for a small regional hospital, and it’s not the same PACS we have in our sister institution up at Columbia. PACS are local.” He went on to sum up the operational challenges involved when dealing with multiple PACS observing, “it creates a lot of challenges―maintaining credentials and passwords, knowing where to get the link when you need it, and using another PACS that you just don't feel completely comfortable with. At the very least, it's going to slow down your interpretation.”

Attendees at the event echoed Dr. Hentel’s frustrations with nearly 40-percent saying their biggest single frustration is lack of easy image sharing technology between PACS and sites.

5 GREATEST IMAGE MANAGEMENT FRUSTRATIONS

Lack of easy image sharing technology 0.37

All of the above 0.25

Overwhelming number of orders 0.2

Inability to image enable EMR/EHR 0.09

Imaging on CDs is frequently lost or unavailable 0.09

0% 5% 10% 15% 20% 25% 30% 35% 40%

The Importance of Measurement The saying goes, “you can’t manage what you can’t measure.” It holds true for improving radiology operations to understand the drivers and levers that impact operational performance. Factors like turnaround times, physician ordering, routing, dose measurement, and capacity management are all critical to monitor. At Memorial, Dr. Juluru’s role wearing the informatics hat is ensuring that the right data and measurements are in place, and it’s an area where they’ve made signiﬁcant investments over the past few years. In terms of where they are with metrics, Dr. Juluru said, “I know to the last hour or so how many scans are being done, what facilities within Memorial those scans are being performed, what body parts are involved, what sub-specialties are involved, and right down to, ‘what is the average number of reads a radiologist is doing?’” In the future, they’re looking to expand measurement by analyzing referral patterns to ensure they are providing strong referring physician and patient service.

Dr. Hentel also shared their focus on analytics at Weill Cornell, noting that, “we look at real-time analytics on our equipment, but we also look at ordering patterns, as well, using analytics to see where our orders are coming from, and looking at the supply and demand of imaging.” They apply the data to match resourcing and scheduling with anticipated demand to monitor imaging appropriateness.

6 Moving Towards Better Sharing Weill Cornell has shifted how they share images. “In the last ﬁve years or so, we started to make the investment into doing true image sharing and using technology to move DICOM data from site to site, preferably, in advance of the patient showing up at the site,” said Dr. Hentel. Now, image sharing is an integral part of Weill Cornell’s workﬂow, used routinely when deciding where a patient should be seen and what hospital or medical setting they need to be seen at. Dr. Hentel pointed to where they are headed, concluding that, “ultimately, we're moving towards moving images in real time from whatever site patients are and getting them to the right person to review them at the right time.”

KEY TAKEAWAYS

Lack of easy image sharing remains a significant problem―especially with organizations dealing with multiple PACS, distributed sites, and large patient populations. Organizations are investing in analytics to monitor supply and demand, ordering effectiveness, radiology efficiency, referral analytics, and other measures. Upgrading workflows with image sharing is a vital part of offering integrated care, patient experience, and physician productivity.

Regulations and Measuring Operational Performance New regulations like Medicare Access and CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS), and the Protecting Access to Medicare Act (PAMA,) are all redeﬁning how radiologists and physicians work —ordering eﬃciency, turnaround and quality of reads, and patient satisfaction. With all of this, as Dr. Juluru noted, imaging is under the microscope. “We all know that imaging has been targeted partly because it is probably the cause of one of the highest growth of healthcare costs.”

PAMA—the Elephant in the Room While MACRA is on everyone’s radar, Dr. Hentel commented that PAMA is potentially a much bigger deal. Yet, it remains under the radar for a lot of radiologists. He put it into context noting that, “when you talk about MACRA, maybe six to thirteen percent of your revenue may be at risk from your governmentally insured patients. When you talk about PAMA, potentially a hundred percent of your medical revenue.”

7 THE IMPACT OF THE SHIFT TO VALUE-BASED CARE

Seen some impact, expect more in near-future 0.49

Not very much has changed, but plan to adjust 0.24

Transformed our model 0.18

There’s been no impact, nothing planned for future 0.09

0% 10% 20% 30% 40% 50%

For PAMA, it’s critical to be able to apply appropriate use criteria for advanced imaging orders, which comes into eﬀect in January 2019. Dr. Juluru concurred on PAMA as a substantial area of focus, emphasizing that “the reason why PAMA is so important and why we care about it and invest so much in it, is that it says when an advanced imaging studies get done, and that includes CT, MRI, and PED, that they are done for appropriate reasons.”

The technology and process investments at Memorial to meet PAMA requirements have been signiﬁcant. “Our thinking and technology and resource investments have been directed toward developing appropriate methodologies, clinical decision support guidelines, and implementing those appropriate clinical decision support mechanisms, to make sure that we're delivering the best imaging for the appropriate diagnosis,” summarized Dr. Juluru.

Meeting MACRA and MIPS Reporting Requirements At Weill Cornell, they’re participating in various registries and databases to meet a lot of the qualiﬁcations of MACRA and MIPS in terms of reporting. “We're part of the mammography reporting database, and we're part of the general radiology reporting database. They help organize us to collect the metrics that are important to our practice, but they also give us benchmarking data that we can use to look at our performance against other peer institutions,” said Dr. Hentel.

8 Screening Orders for Appropriateness for Value-Based Care. One of the focus areas is to reduce waste in medical imaging. At Weill Cornell, they have simple questions that they are used as decision support to make sure that the ordering provider is ordering the most correct exam and that they to go through the backend, and change exams, or do it when they protocol the exams. “We have radiologists review every order for advanced imaging that gets done, to make sure that it's an appropriate order to do. Because it takes a lot of time to often correct mistakes that happen, we try to get ahead of those.”

Narrative Results Simply Aren’t Enough Anymore One of the initiatives at Weill Cornell that they’ve completed to reduce duplicate imaging is to “If you're going to operate“ on a ensure their physicians always have access to the patient, you would never do that on images behind the results. “If you're going to someone else's report. Right? You operate on a patient, you would never do that on want to see the images, and have the someone else's report. Right? You want to see radiologist that you work with look at the images, and have the radiologist that you the images too.” work with look at the images too.” Dr. Hentel -DR. HENTEL emphasized it as “one of the cornerstones of what Executive Vice Chairman, Department of Radiology, we've done to reduce duplicative imaging.” Weill Cornell Medicine

Early Access to Imaging and Medical Data is Foundational At both Memorial and Weill Cornell, investing in technology to enable early access to imaging and textual electronic medical record data such as medication history and treatment history, is viewed as better for treatment and overall eﬃciency. Dr. Juluru shared that one of the initiatives they’re engaged with does just that, providing a portal where the patient can enter their medical history, and upload their imaging ahead of time, so when they walk into one of their clinics they’re ready to go. “If your patients who come to a clinic are spending their time dealing with administration and keeping somebody else waiting, it's an operational and eﬃciency issue. We’re already seeing some gains using our patient portal, and we're hoping to see more improvements so that we can use our resources to the maximum capacity.”

9 Weill Cornell uses access to priors to decide whether they will bring a patient into their main campus or if they will allow them to receive care at other locations. They also use access to imaging to decide what's appropriate and what's the best use of the resources they have, prior to the patient coming in. Before they implemented image management this was a challenge.“ In working in an acute care setting, nothing used to be more painful than a patient being held up at an institution before they were being transferred due to lack of access to the CD or because of a delay printing out medical records.”

“Now it’s all about getting all that patient's information, including imaging, uploaded to us before they come in,” says Dr.Hentel. Early access to patient information enables them to be more proactive,” he said. “We routinely go through the information, and if we see a patient that's not getting the right exam, or there's other reasons why they shouldn't be getting the exam, we address that before they show up to the practice.”

KEY TAKEAWAYS

Along with MACRA and MIPS, healthcare providers should pay close attention to PAMA and appropriate use guidelines. Image management and workﬂows are key. MACRA and MIPS registries and databases are important not just for reporting, but also as a source of benchmarking data. Providing referring physician with access to imaging can be a powerful way to reduce duplicative studies. Patient portals that enable entry of medical information and upload of imaging can improve patient engagement, as well as drive administrative eﬃciencies and improve care.

Delivery/Output & the Referral Network Imaging informatics doesn’t just cover patient and imaging acquisition and managing patient workﬂows that are part of care, it also includes getting the information back to the referring network or directly to the patient. As Dr. Hentel put it, “just as important as doing the imaging, is getting that imaging out to where it needs to get to.” He went on to point out that, “when you're a big tertiary referral center and people are sending patients for a higher level of care, they are going to go back out to get their care. We have our PACS here—but less than 50% of our ordering providers have access to our PACS.”

Using the Cloud to Improve Turnaround Dr. Hentel shared their previous state of getting imaging and reports back to referring physicians. “Previously, we would burn CD's, we would print reports, we would somehow

10 have people trying to get the right printout together with the right CD, put them in an envelope, and the provider would wait two to three days to get them, or sooner if we sent them by messenger.” Moving to the cloud has dramatically improved turnaround time. “Now, with our current technology, as soon as the imaging study is done, those images get uploaded into the cloud. As soon as the report gets ﬁnalized, the report is attached to that, and it's automatically sent to the provider electronically. They get both the results and the actual imaging usually within a matter of minutes.”

Polling attendees during the event found that just 35-percent had no plans around using the cloud, with 52-percent already using the cloud in some form, and a further 13-percent looking to adopt in the medium term.

THE STATE OF CLOUD ADOPTION

We are currently rolling out a cloud solution. We plan to use the cloud in 4% the next 12-18 months.

13%

We have no plans 35% regards the cloud. 17% We use the cloud, but not for imaging.

31%

Yes, we use the cloud to solve many issues, including imaging.

Centralization and Unification of Data Providers are looking to Vendor Neutral Archives (VNA), typically in the cloud, to create a centralized store for physician productivity and care. At Weill Cornell, Dr. Hentel sees cloud VNA as a powerful way to create a unified environment, with more complete access to data for physicians. “Our physicians want to see the compendium of multimedia on a patient in one unified environment. We're going to be investing a lot in our VNA, to help combine radiological imaging data with, perhaps, dermatological, or endoscopic data, and their EKG's. It’s all the things that typically don't fit in an HL7 electronic medical record, and yet still need to be organized in a timeline of events that have happened to a patient.”

11 Empowering Patients with Imaging Access Another area is using the cloud to empower patients. Dr. Hentel stated the importance of engaging patients. “Nobody really coordinates their care like the patients do. We've been giving out CD's to patients for years. It's very hard for them to get the image to the person that they need to. They have to physically bring it to the office, and then they have to wait around while people upload it.” Moving to the cloud has enabled them to dramatically improve accessibility and use of imaging for patients. “We've now embarked on directly sharing images with a patient using a patient portal. The cloud is probably the only effective way to do that. We're creating a real network of patient care in a way that we could never do when we kept all that information behind our firewall.”

KEY TAKEAWAYS

Cloud image management can dramatically improve the speed of getting imaging back to referring physicians and patients Removing the need for patients having to use CDs ensures they can better use imaging, and helps patients be even more engaged in their care. Healthcare providers are increasingly adopting cloud VNA to centralize and integrate patient imaging and healthcare data.

Conclusion In an era where efficiency is everything, imaging informatics can ensure imaging gets to the right person, whether physician, radiologist, or patient faster. And by integrating imaging into workflows, and providing a degree of centralization, it’s also a critical step to reducing duplicative imaging. Pairing it with the cloud, enables imaging to be finally freed from the confines of on-premise silos, enabling it to be connected to referring physician and patient portals, download or uploaded with just a hyperlink, or even tightly integrated to EMR, EHR, and CDS systems, to improve accessibility and clinical decisions.

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ABOUT AMBRA HEALTH Ambra Health is a healthcare cloud company dedicated to making digital medical image management accessible to all, from anywhere. Our powerful cloud-based suite streamlines the medical image exchange process and connects patients, care providers, and facilities worldwide. We work with some of the largest hospitals and health systems such as Stanford Children's Health, Weill Cornell Medicine and Memorial Hermann as well as private practices, imaging centers, clinical research organizations, and health information exchanges. Discover what the power of the cloud can do for your healthcare enterprise at ambrahealth.com.