Of the thousand daily frustrations I experience as a radiologist, perhaps the most painful is that of the portable patient. You see, patients migrate from hospital to hospital, from clinic to clinic, from office to office. They may be in search of a second opinion, a specialist, the answer they want to hear, convenience, drugs, or some combination of the above. As often as not, they acquire a mountain of imaging studies along the way. When asked why they had a particular study at a particular site, the answer is invariably, "My doctor told me to have it there." Add to that the dependence on our ER's for emergent (or subemergent, or impatient care, as I like to call it), and the ER's love of imaging studies. Put it together and what have you got? No, Cinderella, not Bippity Boppity Boo (my daughter made us watch that tape about a thousand times, and it stuck), but rather a collection of the patient's imaging studies spread across a city or even a state.
Americans place a tremendous amount of trust in their physicians. I think it is well-deserved, for the most part. But I must editorialize for a moment. You are all aware of the huge number of imaging devices being placed in clinicians' offices. With declining revenues, the docs had to turn somewhere to keep their incomes steady, and imaging is nothing short of a cash cow. Now, every last one of these installations is placed solely for the benefit of the patients, or so I'm told. It is just so much more convenient for them to have their scan right there in the doctor's office, rather than trudge down the block to the cold, impersonal hospital where parking is at a premium and the waiting room smells funny. It should not be shocking to learn that utilization of imaging resources doubles, triples, or even quadruples if it is in the physician's office. This is simple human nature. Mrs. Jones has a pain. To scan her or not to scan her. Hmmmmm. To generate technical revenue or not to generate revenue. Well, OK, maybe the thought process isn't so blatant as that, and most likely every single scan on an individual basis is justified. Still, the statistics bear out that the coin in this case lands on "heads" significantly more often than "tails". Here is a quote from our literature:
As shown in this article, the empiric literature reveals that self-referral constitutes approximately 60-90% of nonhospital radiography and sonography and smaller percentages of imaging in other modalities and settings. Nonradiologists performing their own imaging are at least 1.7-7.7 times as likely to order imaging as non—self-referring physicians in the same specialty who see patients with the same problems. When self-referral consists of referral to an outside facility in which the referring physician has a financial interest, imaging is increased by as much as 54%, depending on the modality. Nonradiologists' interpretation of images is usually less accurate than that of radiologists; the practical significance of this difference in some instances is debated. Other important deficiencies, such as in image quality or patient safety, are up to 10 times as common among nonradiologists as among radiologists, although a very few specialties, particularly cardiology and orthopedics, have records approximating those of radiologists. The limited evidence available generally indicates that increased financial incentives, such as those in self-referral, lead to more imaging and that self-referral involves overutilization.
B. E. Kouri, R. G. Parsons, and H. R. Alpert. Physician Self-Referral for Diagnostic Imaging: Review of the Empiric Literature. Am. J. Roentgenol., October 1, 2002; 179(4): 843 - 850.
There is great debate amongst the radiological community about this sort of thing. We are really upset when clinicians install scanners in their offices and read the output themselves. Now, what about the situation of clinician-owned scanners feeding scans to radiology groups that contract to read them, or even participate in the scanner equity? Well, whatever your opinion about all of this, two factors are evident: First, the insurance companies, our sometime friends, are hemorrhaging money over this issue, and will likely be the ones to put a stop to anything smacking of self-referral. Second, it is here for the time being, so, add to the list of patient exams those performed in their physicians' offices.
Back to things technical. Mrs. Jones, our patient with abominable, I mean abdominal pain, has undergone the following imaging studies within the last week (and whilst this patient is fictional, the list is shorter than some in the real world):
- Abdominal and Pelvic CT, SestaMIBI myocardial perfusion scan, and Gastric Emptying Study at County General
- Barium Enema at Baptist Memorial
- Gallbladder Ultrasound done in the ER at East Methodist
- HIDA scan at University Hospital
- Repeat CT at her internist's office machine
- Corpora Cavernosagram inadvertently ordered by intern at University Hospital
Obviously, she didn't get #6. Still, this is quite a bit of imaging, not to mention radiation. I'll avoid the obvious controversy as to why Mrs. Jones had the repeat CT. Let's assume her pain got worse and her internist wanted to monitor her progress. To accomplish this, it is critical to have the old scan available to compare to the new. I deal with this scenario several times a day. The ideal situation would, of course, have the patient get all her studies at one location, which somehow never happens. Sometimes the patient brings old studies on a CD-ROM or even on (yucch) film. Others have studies on varying other PACS systems in town. At last count, we use the following systems which we may have to access for comparison studies:
- Agfa Impax 4.5 at our two largest hospitals
- Amicas LightBeam 126.96.36.199 at our two next largest hospitals
- GE Centricity 2.0 at an Oncology clinic we cover
- ScImage PicomOnline for remote reading of studies from a 64-channel CT at a Cardiology clinic
- GE Centricity Web 2.0 for comparisons at the Oncology clinic from the one hospital in town we don't cover
- MedView 5.0 from StorComm for remote viewing of musculoskeletal MRI from an Orthopedic clinic.
- Amicas LightBeam for importing imaging from various physician-owned scanners (MRI, CT, etc.) scattered around the state (work in progress...still need a guru!)
The Oncology clinic seems to be the nexus of this mess at the moment, and our viewing rooms there each have 7 monitors and three computers. Looks rather like the bridge of the Enterprise, but somehow my phasers won't blast the clinicians no matter how hard I squeeze the trigger. Comparing CTs slice by slice between the study on the monitors in front of me and those behind me is a real pain, and this is certainly a set-up for disaster. It would be a terrific advantage to be able to pull up the comparison within the PACS I am currently using to read today's study.
You see the problem. So, what to do? I propose a rather bold solution: a city-wide, a state-wide, or even a national PACS system. Before you fall off your chair laughing, keep in mind that even Cuba has a national PACS, IMAGIS. On a smaller scale, Austin Radiology had wired up their 9 hospitals and imaging centers together with one unified Fuji Synapse system as of a couple of years ago. (Their web-page mentions 14 sites today.) They specified that studies had to arrive at point B from point A within 3 seconds, and at that point they were paying quite dearly for the communication network to accomplish this. But the important thing to remember is that they did indeed network the town together.
I proposed this radical idea of a city-wide PACS to the powers-that-be, and was told, "You can't expect us to work with that other hospital that's suing us..." referring to the acrimony generated by a competing hospital's challenge of a certificate of need. Petty politics scuttled a potential savings of several million dollars, and compromised patient care. This sort of stuff has to be overcome somehow. All I can do is to point out the economy of scale, that a big PACS might be cheaper than two smaller PACS, and more importantly, that mobile patients need to have their imaging studies equally transportable.
I've been dealing on a small scale with the problem of networking widespread scanners and disparate PACS systems. I am not well versed in DICOM, and I could probably express myself better in this venue if I studied this more. (Someday, I would like to have even a tenth of the respect DICOM guru David Clunie enjoys in this field.) My simplistic view of connectivity is that you have to establish some sort of TCP/IP connection, usually via VPN, and you must know the AE titles, ports, and IP addresses of the origin and destination systems. I find myself trying to remember IP addresses from a dozen sites, and if I'm off by one digit, we accidentally send Mrs. Jones' scan to the ChiComms or someone equally distasteful. There has to be a better way.
I've been looking for ideas for another AuntMinnie article, and my friend Mark (I know at least three Mark's in the PACS business, by the way, but this Mark knows who he is...) suggested the intriguing idea of "Napster PACS": Let the network figure out who is where and what is what, like the old Napster peer-to-peer network. This is the better way. But, we have more security issues than Napster ever did due to patient confidentiality and HIPAA. But here's the solution to that: an automatically-tunneling network on the order of LogMeIn.com. In their white paper, the LogMeIn.com approach is compared to a more standard VPN. Since LogMeIn folks wrote it, they win, but look over their arguments and you will agree. Basically, with proper ID and password authorization, you can tunnel into another computer. I've been using their system to maintain all the computers under my domain (about 20 or so), and it works like a charm for remote control, file transfer,maintenance, and the like.
Now, I assume this approch would require at least minor, and possibly major revisions to the way we do things, possibly some surgery to DICOM itself. But in my simplistic world, wouldn't it be nice to "LogMeIn" at the remote site, scanner, etc., and have the receiving PACS system instantly recognize you as a friendly source of data?
The final piece of the puzzle requires matching patients. Is today's Mrs. Jones at the Oncology clinic the same Mrs. Jones that was scanned at University Hospital last month? There are a number of ways to figure this out, but sooner or later we are going to have to have some sort of universal identifier for all of us. The Social Security number is probably the best bet for this, although we have to deal with the situation of multiple people using the same number, something that happens a lot, I'm told, among immigrants whose legal status in this country is questionable. Perhaps we could append the patient's initials and/or date of birth onto the SSN ('Social as it's called here in the South) to individualize it further.
I think this idea has the potential to markedly simplify the way we connect, and to solve the problem of the portable patient. I await the bashing of the experts.