Why integrating EMRs and digital images is an ethical and practical imperative

We've all been there. Following an injury, you or a family member gets an X-ray or MRI but when you follow up with a specialist a few weeks later, he or she can't access the study (unless, of course, you made a special trip to pick up a CD from the other care provider). In this age of rapid-fast information sharing, it's hard to understand why this still happens.  

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As a radiologist, I’ve closely watched the movement among my colleagues that is being referred to as “accountable imaging.” The term refers to the idea that all those involved in diagnostic imaging should be accountable for both the effect of the study on patient outcome and the cost of imaging services. This began as a response to a steep increase in imaging seen between 2000 and 2006, when Medicare imaging costs doubled, from $5.92 billion to $11.91 billion. Several studies indicated that too much of the testing was done inappropriately, exposing patients to unnecessary radiation and follow-up procedures. Since then, a nationwide effort to educate physicians (Choosing Wisely, a multispecialty initiative) on appropriate use of imaging studies helped drive  a decrease in Medicare imaging spending, dropping to $9.45 billion by 2010.

There are still areas of medicine where imaging use is problematic, but we're seeing signs of improvement.

Lack of access = redundancy

One area of concern, for which there is little hard data, is redundant imaging done because the ordering physician cannot access the original study. This was more common before the use of digital imaging systems, when the only copy of a study was a film residing in a physician or hospital medical record archive. The use of digital imaging made it easier to provide a copy (like the CD cited in the example above), and online access to reports has further reduced the problem. But it can still happen. If a patient loses the CD, or sees multiple physicians who are not part of the same health system, access to prior studies may be difficult. Or when a patient sees a new physician after moving from one city to another and does not have his or her medical records moved to the new physician.

One reason that this matters is that many imaging studies involve radiation – sometimes, a lot of radiation. CT scans are at the center of concern, because they can expose patients to radiation levels that can be as much as 10 times that of a simple chest x-ray. While they can provide critical information, done too often over a lifetime, CT scans can raise the risk of cancer and other complications.

The second reason of concern is cost. While an MRI doesn’t carry the same radiation risk as a CT scan, it may carry a high price tag. If you are concerned about cost as well as quality, unnecessarily repeating an MRI is a problem.

For the welfare of the patient and the financial viability of the healthcare system, solving the access issue is both a practical and an ethical imperative. As physicians, we subscribe to the foundational tenet of “first, do no harm.” So if we have the ability to solve this problem and prevent harm to patients, we have an ethical duty to pursue it.

The question is: Do we have the technology to solve this problem? Yes and no.

Unifying the patient record

The ultimate solution is the creation of a unified, digital patient record, containing the full history of all healthcare encounters, including diagnostic images and reports. Stored in the cloud and quickly accessible over the internet by authorized caregivers, such a record could virtually eliminate the need for redundant imaging studies. It could also give a much better understanding of a patient’s condition, because the image often tells a more complete story than the report that accompanies it.

Ideally, the patient (or guardian) would have an authorization code, which he or she would give to healthcare providers. The doctor (or other authorized professional) could access the complete record, update it as necessary, and send it back to the cloud for storage.

Recent advances in interoperability are making it possible to integrate diagnostic images with electronic medical records (EMRs), and we should see significant growth in this area in the near future. And the use of cloud storage for EMRs is increasing, which will lead to wider access for all authorized healthcare providers.

Work remains to be done, however. While there is a uniform standard for diagnostic image formats (although it is not always precisely applied), there is no uniform standard for EMR applications. So, while you can integrate an image with an EMR, universal sharing is still a ways off.

But we are seeing progress. Vendor-neutral archives, which translate proprietary image formats to a universal format (DICOM), are becoming more widespread, which will make images easier to integrate with EMRs. And EMR developers have begun a project, The CommonWell Health Alliance, to create standards that would allow easy interoperability, though the work is still in the early stages. Cloud-based imaging archives, possibly linked to the patient’s own personal health record, could also help to deal with this issue.

The question of how and where a universal patient record would be stored, and who would pay for that infrastructure, remains to be answered.

So the answer is yes, we have the technology, but no, we don’t yet have an infrastructure to make it work. But based on recent developments, it seems that the practical and ethical imperatives to cut costs and improve health are moving the industry in the right direction.

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