Read this open letter to Dr. Blumenthal, National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, written by Joe Marion, MBA, a SIIM member. Mr. Marion offers his suggestions to Dr. Blumenthal regarding the definition of “meaningful use” in relation to the ARRA, or stimulus package.  The letter was posted August 23, 2009 on Healthcare-Informatics.com.

Please see Dr. Erickson’s JDI post for more on the definition of ”meaningful use.” Additional SIIM information and resources on the ARRA can be found at www.siimweb.org/StIIMulus.

Technorati Tags: ARRA

Lately I’ve heard several people voice frustration over the problems importing radiology studies on CDs from outside an institution into a PACS archive.  It’s important to be able to do this for patient care, and the treating physician needs to be able to view the images using existing workstations or web-based solutions, but in order for a study to be verified as correct, it needs an accession number.  This requires creating an order for each study on each CD  prior to importing the images.  Technically, it’s a solvable issue, but logistically, someone has to place the order with the correct study date and description, patient information, etc.  And if the ability to import CDs is distributed throughout an institution, the personnel in a department other than radiology may not understand the importance of ordering the study and obtaining an accession number and then associating the accession number with the imaging study.

So, what are people doing about this?  I see a lot of presentations on this topic but without a clear description of how they solved these impediments to importing and verifying studies from outside CDs.

Everyone who implements a WIFI network in the hospital knows that it has to be secured from unauthorized access.  So maybe this will work, maybe it’s a hoax.  An aluminum oxide paint that resonaantes at high frequencies has been developed by researchers at the University of Tokyo to surround WIFI environments, protecting them from intrusion.    Does it work?  We’d have to try it out.  See the blog on this paint at: http://www.smartplanet.com/technology/blog/thinking-tech/the-real-value-in-anti-wifi-paint/1668/

It’s October 1^st and the beginning of Breast Cancer Awareness Month.  I am reminded that both my mother and grandmother had breast cancer, two close friends have died from breast cancer, and my daughter’s best friend was diagnosed at the age of 34.   When my sister and I investigated BRCA genetic testing, we were discouraged because if we had a genetic risk of getting cancer ourselves, and our health insurance companies found out, they may drop our coverage. 

We have five  JDI online-first articles with Breast Imaging topics I want to draw to your attention.  The first one is entitled “Effect of Dose Reduction on the Ability of Digital Mammography to Detect Simulated Microcalcifications”  by Yakabe, Sakai, Yabuuchi, Matsuo, Kamitani, Setoguchi, Cho, Masuda and Sasaki.  In their article, their research suggests that a certain level of dose reduction in digital mammography may be an option.  The second article is entitled “A Statistical Approach for Breast Density Segmentation” by Oliver,  Llado, Perez, Pont, Denton, Freixenet, and Marti.   Their research centers around evaluating the density of a breast by segmenting its internal parenchyma in either fatty or dense  surrounding tissue.  The third article is entitled “A New Fast Fractal Modeling Approach for the Detection of Microcalcifications in Mammograms” by Sankar and Thomas.  As the title suggests, they describe their fast method for modeling mammograms by using deterministic fractal coding to enhance microcalcifications.    The fourth article is entitled “Effect of Pixel Resolution on Texture Features of Breast Masses in Mammograms” by Rangayyan, Nguyen, ayres, and Nandi.  This group analyzed breast masses at various pixel sizes to discriminate mammographic breast lesions as benign masses or malignant tumors.   And last but not least, the fifth article is entitled “Validation of Results from Knowledge Discovery: Mass Density as a Predictor of Breast Cancer” by Woods, Oliphant, Shinki, Page, Shavlik, and Burnside.   The purpose of the study was to identify and quantify the association between high breast mass density and breast malignancy using inductive logic programming and conditional probabilities.  Their results show that both measures indicate that mass density is an important adjunct predictor of malignancy.  This article is also open access, provided by SIIM for articles deemed to be of high interest to the SIIM community.

All women readers should consider joining the Army of Women, www.armyofwomen.org.  This organization has one research goal – to prevent breast cancer.  They need women without breast cancer as well as those who are newly diagnosed or who are survivers.

When you manipulate your images so they’ll be good figures for publication, did you ever think about how much manipulation is used to make them look good and when you might over-step on the manipulation to make them more “significant”?  There are numerous examples in publishing where authors needed to make a deadline, get a promotion, receive more grant funding, or just become known for their findings where images were “enhanced” selectively to prove a result.  For example, authors have copied parts of a gene sequence and pasted them into another one to show results, or they have added more evidence of abnormal cells in a microscopic slide to make their case.  In some cases, these are naive researchers who have demonstrated the results they hoped with the original figure, but want to make sure everyone can see their findings clearly.  In some famous cases, the authors / researchers committed an unethical act that resulted in setbacks to legitimate research.  I have not seen any evidence of this in figures submitted to JDI, but want to try to set some guidelines for authors / researchers.

If your figures come from medical images and you want to enhance the entire image using window / level, magnification, edge enhancement, unsharp masking and other common tools, this is usually OK.  When you select a region of interest and only manipulate that section and you do not describe what you did to the image accurately, then that is usually not OK.  So what I believe should be our rule of thumb for manipulation of medical images for publication is this.  If you can perform the action using a typical PACS workstation, then that action is permissible and probably desirable.  Please do window / level to make the best possible figure.  Do crop the figure so we can focus on the important parts.  If edge enhancement or unsharp masking help make the region of interest more clearly defined, then use it, but apply these filters to the entire image.  I recommend you make the image look as good as possible on the PACS workstation prior to capturing it and resizing it using the tools described in Tony Siebert’s e-tutorials.  See www.siimweb.org/e-tutorials for Tony’s work.

I just returned from an Editor’s Forum where editors of Radiology journals meet to discuss issues, ideas, problems and other things related to publication.  It’s always educational, exciting, and stimulating.  This year we worked on “figures”.  How do we get figures in the correct resolution and size for publication from PACS?  It turns out that Tony Seibert has agreed to do five online tutorials on this issue and more.  The first three tutorials are published on the SIIM web site at www.siimweb.org/e-tutorials.  You will find a tutorial on image characteristics – that tricky question of how the size of a pixel in the PACS world translates to dots per inch for publishing.  The next two tutorials are demonstrations of capturing images and then manipulating them for publication using open-source or free software.  We are all aware that Photoshop, the “gold standard” of image manipulation is expensive and complex and Tony has made the process of preparing figures simple, affordable, accessible for all authors.  Check it out and watch for his next installments on graphs, line drawings and powerpoint.  Next time we’ll talk about how much manipulation is ethically allowed.

What are you reading this summer?  This is the time of the year when many of us indulge in recreational reading.  I just read a really scary book, one others might want to consider, called “One Second After” by William R. Forstchen (of course I read it on my Kindle).  It’s the story of what happens after a high-altitude nuclear device is exploded resulting in an Electro-Magnetic Pulse that instantly disables anything with electronics.  This includes cars, airplanes, electricity, computers, networks, communications - in fact, the entire infrastructure as we know it now.  For sure PACS is gone as well as most imaging equipment and all EMR.  The story takes place in a small town in North Carolina and is most frightening because it could happen.

What do you think?  Do you have another book to suggest, maybe with a lighter theme?

Bradley J. Erickson, MD, PhD, FSIIM
Chair

The American Recovery and Reinvestment Act of 2009 (ARRA), also known as the ‘stimulus package’, promises to spend a significant amount of money promoting Electronic Health Records (EHRs) through an incentive system. Those physicians who make “Meaningful Use” of an EHR will receive incremental payments from CMS starting in 2011. That key phrase, ‘Meaningful Use” has been the subject of much discussion. Several groups have already proposed definitions. While those definitions have included many valid points, none has even mentioned imaging, including the initial recommendations of the HIT Policy Committee. That, despite the fact that imaging is a large part of the cost of healthcare in America, and is one of the most rapidly increasing components.

It is also apparent that imaging is a critical component of modern healthcare—blindly decreasing imaging across the board is not a viable option unless we are willing to accept a decline in quality. Imaging encompasses not only radiology images, but also pathology, ophthalmology and the rapidly growing field of telemedicine. Imaging-specific criteria should be included in the definition of meaningful use because imaging is a large part of the cost of healthcare in America, and is one of the most rapidly increasing components. It is also widely recognized that, when measured by data volume, the largest part of any patient’s longitudinal medical record is comprised of images and related data. Images are also significant facilitators and enablers of improved communication among the inter-disciplinary care-team.

What is required is information to help guide the use of imaging to maximize quality and safety while reducing cost. We will have to do more with less. We will have to become more productive. Imaging Informatics is at the crux of this issue—we are focused on leveraging information to achieve these goals. For that reason, we wish to advance the following as important components of meaningful use of EHRs for imaging physicians:

1. Electronic medical records must enable the sharing of images and associated data between health care organizations.  Images should be available anywhere the patient might need them. This requires sharing of reports and annotated images between health care organizations. There are now formal standards and best practices (e.g., Integrating the Healthcare Enterprise) for accomplishing this task.  But despite the proven successful use of these standards by some institutions, adoption remains minimal.   Effectively sharing images and reports could significantly reduce unnecessary imaging examinations, which will reduce costs while increasing quality, improving timeliness of treatment, and enhancing patient safety.

2. Electronic medical records must provide decision support for the selection of the right imaging examination.  For example, currently available decision support systems can help the requesting provider determine whether an intravenous contrast agent should be administered, and can suggest more appropriate and less costly alternative tests.  Evidence now shows that order entry decision support reduces imaging costs and unnecessary examinations.  This scientific evidence is strong enough that some third-party payers have already accepted the use of these systems in lieu of pre-authorization.

3. There must be recognition that physicians do not all do the same thing. One of the listed elements of ‘meaningful use’ is focused on e-prescribing. While this is useful to some physicians, a substantial number of physicians do not prescribe medications outside of the immediate delivery of medications during a procedure. As such, e-prescribing should NOT be a required component of meaningful use for some physicians. At the same time, imaging physicians should make use of decision support tools where appropriate, including 3D and 4D visualization tools, computer-aided detection and diagnosis tools, and other image enhancement methods.

Certainly, there are more elements that some will wish to propose. Indeed, my original list was longer, but some of those were more ‘stretch goals’ than items that could realistically be in place for most practices in the next 2-4 years. It is worthwhile discussing some of those pieces (e.g. structured reporting is certainly something that would increase efficiency, value, and quality) but I would like to have this blog post focused on near-term practical targets.

Please share your comments below.

Dr. Erickson is a Professor in the Department of Radiology at the Mayo Clinic, Rochester.

My husband and I ate lunch at the Popeyes in the Atlanta airport last Friday.  I know . . . fast food is not good for us, but that’s not the topic of this blog.  Popeyes had a greeter and dining area helper named Dwayne who welcomed people, helped them get their food to a table while navigating with a rolling suitcase and other stuff people tend to carry around when traveling.  He brought diners straws, forks, and honey, whatever they needed so they didn’t have to get up from their seat.  He helped clean up the tables and kept everyone laughing with his stories and his help. 

Here’s my point; we and everyone else commented on the great customer service and how Dwayne made a real difference.  On travel days when people are tense and usually a little stressed, it’s great to find someone who brightens your day.

I recently authored a chapter on providing great customer service for the new SIIM sponsored book named “Practical Imaging Informatics: Foundations and Applications for PACS Professionals” which is available for preorder now on the SIIM website and will be delivered in August, 2009.    If you follow the link to http://www.siimweb.org/index.cfm?id=5784, you will be able to view the table of contents and authors, I think you will find that this comprehensive text will be a great resource for everyone, PACS Professionals, IT professionals, technologists, radiologists, and administrators.    If you can’t preorder now, be sure to order your copy at the SIIM 2009 Annual Meeting next week.

Our first “Point / Counterpoint” article is available for everyone as open access on the Journal of Digital Imaging online first.  This article poses the question “Who should administer and maintain Radiology IT systems.  George Bowers, a principal at the Baltimore-based Health Care Information Consultants, argues that the CIO of the organization should manage Radiology IT to avoid duplication of costs and maintain consistency of services.  David Channin, MD, from the department of radiology at the Feinberg School of Medicine at Northwestern University in Chicago, argues that Radiology is dependent on IT, is more complex and valuable, and in fact lead the way in developing systems for medical informatics.  He argues that the management should remain firmly in the Radiology department.   You can find the article at http://springerlink.com/content/f5842326533t7380/?p=cc5ac4821c4f458b877975deb55afd17&pi=2 .

It is interesting to note that on April 30, 2009, Jonathan Batchelor wrote about the issue and the JDI article in HealthImaging.com.  Read it at http://www.healthimaging.com/index.php?option=com_articles&view=portal&id=publication:44:article:17280 . 

I spoke at HIMSS about the evolution in Medical Imaging Informatics and the expected rapid growth in imaging in all areas of medicine and the need to proactively plan for administration and management of the infrastructure needed to support these systems.  After my presentation, I met Stephen L Grimes, FACCE FHIMSS FAIMBE, the past president of the American College of Clinical Engineering.  He strongly believes that Clinical Engineers need to be involved in the integration of imaging informatics throughout an institution.  I have been working on a project involving imaging in a large multi-institution environment and the group with the most knowledge of imaging modalities, networking, PACS, and archiving has undoubtedly been clinical engineering at the hospitals.  

Let us know what you think and look for the debate at SIIM 2009 on this topic, it should prove interesting and informative for everyone.