COVID-19 Both Shifts Focus Away From and Highlights Need for Interoperability

Rapid, safe digital image exchange has been a growing priority for the past several years, but progress toward the goal has been relatively slow. Recent moves from the Department of Health & Human Services (HHS) have pushed this effort further down the road, but the continued spread of COVID-19 infection has added new urgency to setting up a system that allows for greater interoperability and image exchange.

There’s already been a growing need, according to industry experts, for patient-care environments to be seamlessly connected, able to near-instantaneously share patient images. Greater interoperability between facilities – having a system that allows for images to be transferred from one system to another even between differing PACS systems – can make this vital image exchange possible.

And, in a time where imaging will continue to play a significant role in managing disease, as well as likely be integral in follow-up care, image exchange could be a clinical plus.

“During this time, hospitals have to be ready to, potentially, share patients with one another,” said David Mendelson, M.D., vice chair of radiology information technology at Mount Sinai Health and co-chair of Integrating the Healthcare Enterprise (IHE) International. “We need ways to expediate image exchange.”

Overall Efforts to Expand Interoperability

Before COVID-19 hit the healthcare system, the HHS Office of the National Coordinator (ONC) for Health Information Technology had already released regulations calling for imaging interoperability throughout the industry. In March, the agency published its final rule, with a January 2021 deadline, detailing that all images, imaging information, and imaging elements that can be considered electronic health information must be stored and made available for transfer between medical facilities - a move that would also facilitate patient access to personal health information.

In addition, the rule took a firm stance against information blocking, said Mike Peters, director of legislative and regulatory affairs for the American College of Radiology (ACR).

“The ACR’s focus is mostly on the information blocking provision,” he said. “It will eventually have a positive impact on image sharing, as well as help advance the goals of Ditch the Disk.”

This provision, he said, is intended to break down non-technical barriers to health information exchange, enabling image exchange between PACS systems from different manufacturers. It discouraged anti-competitive behaviors, such as referral trapping, opportunities and rent-seeking fees, as well as prevented dominant actors from not enabling connectivity or exchange between referring physicians and unaffiliated imaging providers.

There are exceptions to the information-blocking provision, but the specifics of those instances are still unclear. Overall, vendors that make both electronic health records, as well as radiology information technology products must be sure they abide by this provision, Peters said. Failure to do so could result in penalties as high as $1 million per violation.

“For radiology, the hope is that referring providers and unaffiliated radiology providers will be able to exchange together and use electronic health information for the betterment of patient care without running into arbitrary barriers, rent-seeking schemes, artificially exorbitant costs, dominant actors ignoring their requests for connectivity, or other anti-competitive behaviors meant to deter bi-directional exchange and competition,” Peters explained. “If well implemented and enforced, this could make a big difference for radiology practices and their patients in terms of breaking down non-technical barriers to the exchange and the use of electronic health information.”

The COVID-19 Impact

But, when COVID-19 began to spread, the rising patient volume impacted the mission for interoperability. Not only did the industry see its attention pivot away from focusing on making images more easily transferable, but it also saw some heightened fear about virus transmission from physical media, such as the CDs currently used to transfer patient images.

“The biggest impact that the outbreak has had is a re-focus on what we can do with the tools that we have deployed on the ground right now,” said Dave Cassel, executive director of Carequality, an interoperability framework designed to enable this type of system nationwide. “We’re looking at how we can have an impact right now when things in health information technology interoperability already tend to move a little slower. We’re having to think about what we can do in a week or in two weeks.”

To date, Carequality has been one of the biggest initiatives pushing toward image interoperability. It connects 600,000 providers, 50,000 clinics, and more than 200,000 hospitals. It’s also partnered with the Radiologist Society of North America to improve the technical standards of image exchange.

To keep the effort moving, he said, Carequality is working to expediate HL7 FHIR (Fast Healthcare Interoperability Resources), a standard for exchanging images electronically, to make interoperability more feasible for public healthcare settings. Accomplishing this goal could be particularly helpful during a viral outbreak, he said, so it’s critical to take steps like these to make continued strides toward greater image exchange.

“We need to speed up our piece and make sure that we’re never the barrier, that we’re adopting the rules as quickly as possible so that the Carequality framework is available to folks to use them,” he said. “They can come at it more at their own pace, and that may or may not be expedited.”

In that vein, he added, Carequality has taken steps to help practices participate more in image exchange efforts. For instance, under normal circumstances, the initiative requires bilateral exchange – giving information to get information. However, this rule has been relaxed, giving people who might not be able to currently provide data in return the opportunity to receive critical details about patients.

Care quality is also encouraging facilities that have not yet flipped the switch on activating an image exchange solution to take that step, he said.

“We’re encouraging organizations that are Carequality-enabled, but that have, for whatever reason, not prioritized getting it turned on yet to go ahead and make that move,” he said. “And, we’re seeing some response to that.”

According to Matthew Michela, president and chief executive officer of medical image exchange company Life Image, the continued spread of COVID-19 has, indeed, revealed to many radiology departments the importance of digital image exchange. Those that have not viewed it as a critical priority are nervous about the impact of handling physical media over the long term.

“We’re hearing a lot from our customers that patients are coming in who may or may not have been diagnosed with COVID-19, and they’re bringing images in on a CD or a disk,” he said. “And, the offices are concerned about exposing their clinicians to additional risk, and there’s added concern about the virus sustainability on physical media.”

While this scenario applies to a small number of patients, the concern will become more important, Michela said, as the industry moves into the recovery and follow-up phase with COVID-19. Because the virus is respiratory in nature, there is likely to be a significant volume of follow-up CT scans and X-rays to monitor changes over time.

To limit or side-step this physical media problem, he recommended practices and departments that may have already started down the path for interoperability contact their vendor to authorize activation. In many instances, achieving functional digital image exchange can be accomplished within a few hours.

“In most cases, it’s as simple as having your PACS administrators make it a priority and saying ‘hurry up and go do it,’” he said.

He did caution practices looking to pursue interoperability to extensively research vendor partners. Making a quick decision could not only put your patient health information at risk, but it could cost a significant amount of money to correct the problem.

But, even as Carequality and vendors work more closely with their customer facilities to help them ramp up to greater interoperability and image exchange, Michela said, the continued spread of COVID-19 means facilities will likely need more time to be truly prepared to meet the ONC’s January deadline.

“We should delay these rules and implementation until post-January,” he said. “I wouldn’t let the healthcare technology companies off the hook for having interoperability solutions in place by January, but I don’t think it’s practical for us to hold the hospital systems to that timeline any longer.”

Right now, these facilities are overwhelmed with growing patient volume, and they will likely remain that way for three-to-six months. If they try to make concrete interoperability decisions now, they might make mistakes and waste resources, he said.

What Can Your Facility Do?

Even though the industry is still in the middle of the COVID-19 outbreak, there is something you and your colleagues can do as providers to help facilitate more streamlined image exchange and interoperability, said Didi Davis, vice president for informatics, conformance, and interoperability for The Sequoia Project, an independent advocacy organization focused on health information exchange.

Typically, she said, radiology offices don’t capture enough patient demographic data, stopping with just a name and date of birth.

“When you look at this model of exchanging data across enterprises and across different systems, you need to make sure you identify that patient properly,” she said. “I would advise radiologists and radiology departments to think about making sure their employees, perhaps their scheduling clerks, capture as much information as possible from the patient identification and matching.”

In addition, Mendelson advised that you query potential vendor partners about internet transfer capabilities to ensure it corresponds to your needs.

Ultimately, Cassel said, he hopes radiologists see the impact of COVID-19 as a reason to actively pursue more seamless and interoperable image transfer.

“The capability for greater interoperability is coming, and I encourage radiologists in the community to continue to ask for it,” he said.