The Value of the CIIP: Part 4 – Interoperability

By Luke Bideaux, BSRT, CIIP

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May 28, 2019 -- Interoperability in healthcare opens the door to a wide range of efficiency gains, business opportunities, cost savings, and improved patient outcomes -- in theory, anyway. Actual results are largely based on an organization's commitment to dedicating the resources needed to achieve these benefits.

Imaging practices, which include practices that perform health imaging within any medical specialty, have their own set of challenges that must be addressed by professionals who understand the intricacies of these challenges and have the skill set to solve them. Just as I've done with part 1, part 2, and part 3 of my series on the value of the certified imaging informatics professional (CIIP), this article will illustrate different approaches an imaging practice may take to interoperability and achieving the resulting outcomes.

Interoperability proficiency

Interoperability within health imaging is a vast and complex subject. With the need to integrate imaging systems both internally and externally on the rise, who should leaders rely on to ensure their organizations are progressing at necessary rates?

Professionals from clinical backgrounds, including radiologic technologists or radiologists, may be able to help set functional integration requirements. For instance, radiologists may explain that they need the PACS to display certain data from the electronic health record (EHR) in a specific place when they open a study, but it is unlikely that they would have the ability to develop an integration specification outlining how to make this desired behavior a reality.

Conversely, there are many software engineers who can program and configure all types of integrations, including ones based on application programming interface (API), extensible markup language (XML), HL7, DICOM, the Integrating the Healthcare Enterprise (IHE) Cross-Enterprise Document Sharing (XDS) standard, etc. However, if asked to analyze and optimize the operations of an imaging practice, most software engineers would have trouble determining which modifications would have the most meaningful impact on workflow efficiency, cost, and patient outcomes.

Professionals from a wide range of backgrounds (e.g., radiologists, technologists, engineers, IT professionals, etc.) have been able to broaden their skills through education from the Society of Imaging Informatics in Medicine (SIIM) and other sources to meet the ever-increasing need of interoperability within health imaging. Some of these professionals have attained the CIIP designation from the American Board of Imaging Informatics (ABII), which is a great way to demonstrate a baseline-level of competency in health imaging interoperability. To achieve this highly regarded designation, a professional must pass a board exam, which includes interoperability-related components that are specific to health imaging. The ABII's Test Content Outline details numerous interoperability-related topics, such as master patient index, IHE guidelines, and medical imaging standards, to name a few.

Let's dig into some real-world scenarios in which a CIIP's expertise becomes crucial to solving interoperability challenges within a health imaging practice. Read on as we follow our fictitious practice Adventure Health down two very different paths -- one with the help of CIIP resources and one without.

Option 1: CIIP

One of Adventure Health's top objectives is to satisfy the needs of the outside referring community that supplies it with a significant portion of its imaging volume. Adventure Health allocates $260,000 to help pay for data integration costs needed to integrate these practices, sending CIIP resources to meet with key referring groups to understand their integration needs and identify opportunities for improvement.

Following these meetings, the CIIPs learn the needs of the referring practices and develop strategies to streamline the process for the referrers from order entry to result and image review. As a result, over 60% of the key outside referring groups for Adventure Health are now live with a bidirectional integration for orders and results. In addition, the CIIPs implement electronic image-sharing solutions, which all referring providers have access to if images need to be viewed, downloaded, or imported into their own systems.

Adventure Health has experienced a 20% increase in overall referrals from outside practices since the completion of its integration initiatives, and referring physician satisfaction rates are at an all-time high.

Radiologists at Adventure Health have experienced massive improvements in workflow efficiency since their leadership dedicated CIIP resources to help configure the systems they use to work together as one. When a study is launched from the radiologist's worklist, the patient's chart in the EHR and report template in the voice-recognition system are loaded in context. With just a click of a button, radiologists have access to load the study within additional integrated systems, such as advanced 3D or nuclear medicine software.

The team is also in the process of integrating a new artificial intelligence (AI) module that will also load in context from the study that was launched from the worklist. Third-party systems for ancillary workflows, such as peer review, are also integrated into the primary reading environment, so the radiologists never have to separately log in to another system. This tight level of integration allows the radiologist group to become 14% more efficient overall. The group is excited about the future that AI brings to its image interpretation workflow and is confident that the team is equipped to integrate it in a way that will keep the group running efficiently.

Patients at Adventure Health were able to provide valuable feedback on their interoperability needs. CIIP resources address interoperability needs related to imaging, resulting in a significant improvement in patient experiences. The Adventure Health patient portal is now fully integrated with the imaging systems to provide patients with the ability to view, download, and burn their own studies. Patients are no longer asked to transport their imaging CDs between imaging and referring facilities, which results in fewer patient care delays and happier patients overall. Although the goal of seamless imaging interoperability with all healthcare facilities has not been reached, patients agree that Adventure Health stands out as a leader in the community for driving positive change forward.

Option 2: No CIIP

Adventure Health is aware that if it hopes to survive in a competitive market, then it must find a way to satisfy the needs of the referring community that supplies a significant portion of its imaging volume. Competitors have developed numerous bidirectional integrations with the referring groups' EHRs, making it easy for the groups to order exams electronically and review images and results from their own systems. As such, competing imaging providers seem to be winning the favor of key referring groups, which is no surprise.

Adventure Health's previous attempt to implement a bidirectional interface with a key referring group was a complete failure. Although a total of $15,000 was paid to the organization's software vendors, the integration ultimately failed because of poor design and a lack of practical understanding of the workflow. As a result, the staff has gone back to using legacy methods to transport orders and results, which has essentially rendered the bidirectional interface useless. Leadership at Adventure Health is now hesitant to invest more money in integration strategies and is looking for other ways to satisfy the referring community and increase imaging referrals.

Most of the radiologists at Adventure Health are burned out from having to utilize multiple disparate systems to get through their already demanding days. In some cases, radiologists must physically move to different workstations if they wish to review a study within a specialized viewing module. In other cases, they can minimize the current study desktop, load the specialized viewing module, and search for the patient/study within the third-party system. Essentially, the radiologists themselves are serving as the integration engine among the multitude of systems in their reading room. Radiologists must manually search for a given patient/study record in up to three different systems to get their job done, depending on the nature of the exam. Patient safety issues arise when radiologists accidentally dictate content into a patient's report template while reviewing images from a completely different patient. When one radiology team member brings up the idea of implementing a new AI application that can help the radiologists identify brain aneurysms more effectively, the radiologists quickly dismiss it due to their past experience with new third-party tools that have historically created rather than reduced their workloads.

When Adventure Health patients ask any questions about gaining access to their images or delivering the images to their referring physician, the staff has been trained to do the same thing they've been doing for years: offer to burn the patient a CD! Storing and transporting imaging discs is not a new concept for most patients; however, that doesn't make it any less frustrating for them. Patients are commonly required to make additional trips to the imaging facility to pick up CDs. Worse, patients often complain that their CDs do not work or that their current computers don't have disc drives. Adventure Health is even experiencing some concerning HIPAA security issues related to mix-ups, in which a patient's images are burned to a CD and then given to the wrong patient. Because Adventure Health doesn't have the resources to solve its interoperability challenges, its patients will just have to continue doing what they have been doing for years -- waiting for change.

What were Adventure Health's financial losses from taking the non-CIIP path in the first year?

  • Opportunity cost of 20% increase in outside referrals (adjusted for interface setup fees): $235,000
  • Bidirectional integration that is not being utilized: $15,000
  • Opportunity cost of 14% radiologist efficiency gain: $106,000

Total: $356,000

Running total of one-year costs from parts 1 through 4 of this series: $970,576

Additional outcomes from not using a CIIP include the following:

  • Outside referral-related revenues lost in subsequent years will increase to $465,000 annually due to decrease in integration-related costs from year one
  • Increased radiologist frustration, patient complaints, and HIPAA security issues
  • Reduced adoption rates for new technology, workflow efficiency, and opportunities for future growth

For widespread interoperability to occur in health imaging, organizations must first engage the expertise of professionals who have the correct skill sets to lead them to success. When CIIP resources are engaged to lead impactful interoperability initiatives, the return on investment can be staggering. There is no question that the future of health imaging will be rooted in interoperability. Organizations that flourish will be those with the necessary resources in place to help them grow.