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Going beyond health information exchange as a replacement for the fax machine, Children's Hospital of Philadelphia and Virtua, a Southern New Jersey health system, have unified their radiology operations across electronic health records systems and state lines.

By deeply integrating imaging systems and EHRs, the two systems have made it possible to create an integrated health record that includes images captured at a Virtua facility and read by pediatric diagnostic imaging specialists at the Children's Hospital of Philadelphia. Even though CHOP, as it's known for short, is an Epic shop, and Virtua uses EHR software from Siemens, patient records are then synchronized across the two systems, with access to radiology reports and diagnostic images available from either one.

The two health systems are just across the Delaware River from each other, meaning that New Jersey children needing specialized care often are sent to CHOP. Yet there was also an opportunity to cut down on that travel when it was unnecessary.

"One of our guiding principles for the partnership was that when the patient family needs radiology services, they could be done either at CHOP or done at Virtua," says Gayle Stidsen-Smith, the CHOP IT director who oversees support for its picture archiving system and served as CHOP's project lead. "We wanted to make it so New Jersey patients could have images done in their own backyard. Those images would reside in both the Virtua electronic medical record as well as the CHOP medical record, even though they're completely different systems with different database structures."

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Although health information exchange (HIE) technologies are important to many of the federal government's initiatives to promote better coordinated care based on digital patient records, the records exchanged often are treated as supplemental information, appended to, rather than integrated with, the patient record. Moreover, radiology image sharing typically is outside the scope of services HIEs provide. Last week, Nuance announced a diagnostic image sharing cloud service that integrates with Nuance software for automatically transcribing radiology reports. Nuance promised deeper EHR integration to follow.

CHOP and Virtua went further by creating an integrated business process, where records of patients registered as part of the diagnostic imaging partnership are matched between the two EHRs, if possible. If no record for a given child exists in CHOP's Epic EHR, a new record is created containing a reference to the patient identification number from Virtua. This record key makes it possible to keep patient records synchronized between the two EHRs going forward.

When the CHOP and Virtua IT teams went looking for examples of integration at that level, including cross-registration of patients, they couldn't find any, Stidsen-Smith says. "We're probably the only people that have done it, at least that we're aware of."

Virtua's project lead, director of integration Julia Staas, says her organization is an active participant in building the New Jersey Health Information Network community HIE, but she agrees the CHOP partnership represents a deeper level of integration than most healthcare organizations have achieved between institutions. More typically, HIEs aggregate information and make it available to view with a portal. Routing of information such as lab results is another popular application, which is sometimes more deeply integrated with EHRs.

"What hasn't been done much is sharing care across organizations," says Staas. "If for some reason the child needed to be transferred to CHOP, because of this partnership we're not re-imaging the patient -- so we're not including the radiation exposure."

That's an important clinical benefit, given concerns about unnecessary medical imaging leading to an increased risk of cancer. Even while these diagnostic images can be life-saving, unnecessary scans have become a medical safety issue.

The middleware for the CHOP-Virtua integration is the Alere Accountable Care Solutions enterprise HIE, which assists with patient identity matching as well as data exchange. The CHOP and Virtua IT teams did additional work to make the data flow into their respective EHRs with the correct diagnostic codes. In addition, they integrated the records exchange with the medical image management system ScImage, which serves as the image broker, enabling images to be matched and available as part of the patient medical record in both EHRs. CHOP had already purchased the ScImage system, and Virtua bought and installed it as part of the integration project.

Radiologic data integration means clinicians at each location can work with the software they are most familiar with, rather than having to refer to an external portal for information on shared patients. "Radiologists really have a need to stay in their own systems and not have to go to multiple foreign systems," says Stidsen-Smith. There was nothing "out of the box" about this integration, she notes, given the need for both database records and images to be exchanged.

Chris Adair, radiology systems manager at CHOP, tells us reliable image data transmission requires particular attention, given that a radiology study of a single individual can generate thousands of images, each weighing in at 20 megabytes or more. "We wanted to be able to meet our service-level agreements for imaging and results within an hour, so a lot of thought went into that." The IT team created custom monitoring tools to detect when an image transfer fails and then retry it, he says.

The two organizations also operate a jointly owned medical imaging center, located at Virtua's Voorhees hospital, where CHOP personnel contribute their expertise in pediatric sedation -- important because safely rendering a child unconscious can be the only way to get younger patients to lie still.

CHOP and Virtua aren't synchronizing data for every patient, only for those who are tagged as part of the joint medical imaging program. "That's the trigger to say the patient also needs to be registered in CHOP's systems," Stidsen-Smith says. Registrations do not yet flow the other way, from CHOP to Virtua, she tells us, although that is one of the goals for the next phase of the program.

CHOP has done some radiology integration work, although not quite as extensive, with Cincinnati Children's Hospital as well, and it is working on a potential partnership with Boston Children's Hospital, says Adair. With these more-distant partners, patients aren't as likely to be shared between the two systems, so EHR integration isn't as important. However, the idea is to allow radiologists to retrieve and interpret images shared across the network, providing remote access to specialized expertise, while "allowing patients to stay close to home," he says. Remote reading of diagnostic images could also be a way of augmenting the staff at each facility, providing better coverage on overnight shifts or during periods of peak demand.

Though the online exchange of medical records is central to the government's Meaningful Use program, the effort to make such transactions routine has just begun. Also in the Barriers to Health Information Exchange issue of InformationWeek Healthcare: why cloud startups favor Direct Protocol as a simpler alternative to centralized HIEs. (Free registration required.)