Complex role for radiology in the PCEHR

The Australian Diagnostic Imaging Association (ADIA) is urging the federal government not to conflate radiology with pathology when formulating standards and specifications for their involvement in the PCEHR simply because they are both focused on diagnosis.

The challenging question of how to integrate diagnostic imaging with the PCEHR and with Australia's broader eHealth agenda will be discussed at the combined Asian Oceania Society of Radiology (AOCR) and Royal Australian and New Zealand College of Radiologists (RANZCR) annual scientific meeting, currently being held in Sydney.

NEHTA's head of the PCEHR, Andrew Howard, will discuss his organisation's plans to integrate diagnostic imaging with the PCEHR at an eHealth session at the conference tomorrow. He will be joined by Associate Professor Nick Ferris, representing the RANZCR, and Scott Ferrero, representing ADIA.

Well-known medical software expert Vince McCauley will provide the perspective of the Integrating the Healthcare Enterprise (IHE) organisation, which has developed a number of radiology-related standards including the cross-enterprise document sharing for imaging or XDS-I profile.

“Tomorrow's meeting is about trying to align diagnostic imaging with the PCEHR agenda,” Dr Ferris said. “The idea is to have pathology reports able to be uploaded to the PCEHR next year and diagnostic imaging will come after that.”

A member of NEHTA's diagnostic services reference group, Dr Ferris said the majority of its time had been spent on working out how to align the pathology sector with the PCEHR and that the initial idea was to develop a model for pathology and to adapt that to diagnostic imaging.

While there are some similarities between the two sectors in terms of developing standards for electronic referrals, radiology has a number of challenges that it will have to be faced differently, he said.

This was echoed by Mr Ferrero, who said the view that pathology and radiology are similar and therefore what works for pathology will work for radiology is not true.

“Specimens and patients are very different beings and workflows that work for specimens don't work for patients and vice versa,” Mr Ferrero said. “We've suggested pretty strongly that they shouldn't be using pathology templates for diagnostic imaging.”

At this stage attention is focused on uploading radiological reports to an individual’s PCEHR, while the future management of the accompanying images is unclear. Dr Ferris said he understood that pathology reports would be uploaded in a PDF format following the development of an HL7 CDA template.

For diagnostic imaging, however, it is rather more complex. “The PCEHR has been developed very much from the perspective of general practice and the people in the hospital sphere mainly have to deal with hospital IT systems and state health department arrangements, which vary across each state,” Dr Ferris said. “I think the main role in the PCEHR (for public hospital practices) will be provision of reports of outpatient studies, and some inpatient studies after discharge. Some of this information may also be referred to in discharge summaries written by other hospital staff.”

Differing state practices would also be a challenge, he said. While NSW has set up a centralised repository for diagnostic images and reports for use by both the acute and primary healthcare sectors, and there are similar arrangements planned for some other states, Victoria is not likely to go down this path, he said.

“And an important point for discussion is that these repositories are explicitly only for the public system. The problem is that for radiology, a lot of patients go in and out of the public and the private systems. A lot of radiology is done in private practices, so any comprehensive system would have to include both public and private practices.”

Dr Ferris said that for radiology practices, what would greatly assist would be to have all referrals sent electronically and conformant with a NEHTA specification. “That would facilitate the smooth uptake of the healthcare identifiers. There would need to be a similar template or specification for reports, and NEHTA has developed some general specification for referrals.

“The college has released some guidelines on what should be in a report. All of this will then need to be sent as a secure message, and it's not really known what proportion of practices are able to send HL7 messages with the secure messaging protocols that NEHTA and Standards Australia have developed.”

For private radiology providers, Mr Ferrero said there were a number of challenges that had to be overcome before any involvement in the PCEHR. However, some of the foundation technologies that are being developed, such as the National Healthcare Provider Directory, would be "godsends", he said.

In its comments on the draft Concept of Operations (ConOps) for the PCEHR, released last year, ADIA made a number of recommendations, the main one concerning the fact that diagnostic imaging, unlike pathology, has no overarching governance, Mr Ferrero said.

“That's one of the key things we have been recommending to DoHA and NEHTA, to establish governance processes around professional interests and implementation processes for these types of systems. Governance is very important for this discussion and in the absence of that, it will provide some challenges.”

He said ADIA firmly believed that only medical practitioners should be contributing documents to the PCEHR. “And we are concerned, as other people are, that the patient is able to edit their record. They are able to say what goes into different parts of the PCEHR and we don't support that.”

He also said the construction of large imaging repositories that private providers would be expected to populate was not the answer. A centralised index was a better choice.

“There is a whole host of problems with these massive imaging repositories, one of which is cost, and the other one is synchronisation. If you don't know who has pushed your data around, and where they have pushed it to, trying to keep control of that through downstream systems is impossible. The only way you can do it is by being the publisher of your information.

“There is technology called XDS-I which IHE has developed and we are big advocates of that. The Canadian Infoway project is an example. You can store the data once and have indexes to that data and that is the intelligent way of doing it. XDS-I specifically does that.

“Interestingly, the infrastructure partner Accenture has actually got that technology in their offering through a company called Merge Healthcare. Merge Healthcare has delivered some of this technology to the US government and in some of the Canadian projects. The problem in Australia is that not a lot of people understand this technology, and it makes the discussion much harder.”

The cost of working on the project and of integration with workflows also needed to be taken into account, he said. “There are no national orderable catalogues in Australia and terminologies are different between states and from practice to practice. Work on that has to be taken into account.

“And there are image storage costs. There is no legislation for agreement at the moment around image storing. It differs between states and even between state jurisdictions. We need to decide policy on how we are going to store images and reports.”

While these are major challenges to be tackled, Mr Ferrero said there were a number of real opportunities in the foundation services being developed in the eHealth arena.

“By foundation services I mean in relation to the certificate exchange process and a national provider directory and I'll be using examples of how those core infrastructures will help private radiology in Australia. We don't understand the utility of the PCEHR today but these foundation services have real value in the private sector and we should get behind utilisation of those.

“To have a national provider directory is a godsend. We don't then have to manage individual doctors. To have a national security certificate will also be a godsend. At the moment we administer that ourselves and each individual machine has to have a different certificate. To have a national service that people can subscribe to and we can deploy would make it so much easier for us.”

Posted in Australian eHealth

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