RSNA Image Share Foreshadows New Era in Patient Engagement

From apps to telemedicine and beyond, technology has become a linchpin for patient engagement. The RSNA Image Share network represents a prime example. Established in 2009 as a pilot project, with $4.7 million in funding from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) and administered by RSNA, the network enables radiology sites to give patients online access to their images—for their own purposes, as well as to share with any physician or other individual whom they designate.

David S. Mendelson, MD, FACR, senior associate, clinical informatics, and director of radiology information systems at Mount Sinai Medical Center (New York, New York) is and principal investigator for the project. He says, “Giving patients control over their images and promoting patients’ engagement with their health” are the core values around which the Image Share project and the Image Share network revolve. As of mid-January 2014, more than 7,000 patients (with more than 25,000 exams) had signed up to use the network—up from about 2,000 patients in December 2012.

Several community hospitals and private practices recently joined the network. The core mechanics of Image Share have not changed since its inception at Mount Sinai Medical Center, as well as at Mayo Clinic (Rochester, Minnesota); the University of California–San Francisco; the University of Chicago Medical Center in Illinois; and the University of Maryland Medical Center (Baltimore).

Each participating radiology site installs a small edge server. The edge server collects images and reports, placing them in a secure digital package for transmission to the network’s image clearinghouse, a Web-based, password-protected repository. Patients establish a personal health record (PHR) account with one of several vendors; then, they use a randomly assigned eight-digit number and a password to download their images to their PHRs and access them on any device (computer, smartphone, or tablet) via any Web browser. In addition to sharing images with physicians and others by showing them their devices, patients can grant access to any designated physician by sending him or her an email link to the information.

Just as the number of patients enrolled in Image Share has increased, so has the involvement of health-care providers and vendors of PHR systems and services. Several community sites—among them Barnabas Health (West Orange, New Jersey); Gillette Children's Specialty Healthcare (Duluth, Minnesota); and Advanced Radiology Consultants (Shelton, Connecticut)—signed on with the network in late 2013 and early 2014. The addition of other sites to the roster is expected to occur shortly. In January 2014, four PHR vendors were participating.

Recent developments on the technology front also are propelling participation. For example, the RSNA will be providing a Web service that in combination with the Integrating the Healthcare Enterprise (IHE) Cross-community Access (or XCA) profile would allow an independent IHE Cross-enterprise Document Sharing for Imaging (or XDS-I) image exchange to use Image Share's patient-engagement PHRs.

Patients will soon have the additional option of using their email addresses, in lieu of the eight-digit code, to access the system. The email-address option was vetted by the DHHS Office for Civil Rights, which determined that it afforded network users as high a degree of data security as the eight-digit code did, when used in conjunction with a password.

Tip of the Iceberg

At Mount Sinai Medical Center, the level of patient engagement sparked by Image Share has “surpassed all expectations,” Mendelson says. In a survey of patients employing this service, more than 75% indicated that they looked at their images—not just their reports. Mendelson is surprised at the large number of patients who want to see the exams (not just have them for their records and for the use of their health-care providers).

“Patients have said not only that they enjoy having control over the way in which their images are shared, but also that they like the ability to sit down, look at exams, ask questions, and more easily get a second opinion by showing clinicians images (on their own devices or through a link),”/+ Mendelson says. Use is most prevalent among patients with an immediate medical need—for example, individuals who have been diagnosed with cancer and must visit multiple sites and specialists in the course of their treatment.

Currently, Mount Sinai Medical Center patients in all age groups harness the image-sharing capability. “The largest group is that of users between 50 and 70 years old,” Mendelson reports. “A younger age group seems to be spontaneously interested, however, even when relatively well. The older patients often have more complex problems and imaging exams, with a greater immediate need for the service.”

He adds, “To date, we have not seen much of an impact on the radiologist–patient relationship, but I think meaningful use is about to change that. In the wake of it, radiologists are going to make themselves more visible and accessible to patients, who may call them from home and ask questions like, ‘I’ve seen my exam, and it says there’s a nodule on my left lung. What does it mean? Can we look at this together?’”

Mendelson attributes a portion of Mount Sinai Medical Center’s success in getting patients on board with Image Share to the organized manner in which enrollment is handled. Designated clerks handle telephone inquiries about enrollment, and a few trained hospital employees are responsible for accepting registrations on-site.

For security purposes, patients who choose to sign up via telephone must provide the employee assisting them with the telephone number used during their last visit to the hospital. “We have them hang up, and we call them back to verify their identity,” Mendelson explains. “Then, they fax in a consent form. It’s a cumbersome (but necessary) measure, if they don’t sign up when they are present at our site.”

Patient education, too, has had (and continues to have) a positive effect on patient participation in Image Share. Literature about the program and its benefits is available at the hospital, along with collateral materials from the participating vendors. Staff members also are responsible for directing interested parties to RSNA resources, including patient-centered information on the association’s website—and a link for downloading a brochure. An email address and telephone number for the Image Share network’s help desk appear on the site.

Next Steps

The Image Share network clearly has come a long way since its inception and, based on enrollment and feedback, is a strong catalyst for engaging patients in their own care. There are further steps to be taken and issues to be resolved, however.

One next step entails the integration of image-sharing services with electronic medical records and health-care providers’ portals. Mendelson says that he and his colleagues are in the early stages of discussing with vendors how to get the job done. He adds that although Mount Sinai Medical Center does have a patient portal, it is not currently handling images. Establishing a portal with image access and creating interfaces for image exchange would help patients by facilitating their involvement in their own care.

Recruiting additional radiology sites also remains a key priority. This, Mendelson notes, is especially true because of a recent request by the Office of the National Coordinator for Health IT to obtain recommendations from the RSNA, as well as other interested parties, on how image exchange might be handled in stage 3 of meaningful use (under the Medicare and Medicaid Electronic Health Record Incentive Programs). At least one state health-care group—the Healthcare Association of New York State (HANYS)—is actively pushing recruitment.

In January 2014, the HANYS HIT Strategy Group, which Mendelson chairs, presented a webcast designed to encourage hospital and health system CIOs and health IT professionals to investigate the benefits of image sharing. The webcast’s content centered on how image sharing, as a whole, can help providers to attain their health IT goals by improving the quality, safety, and efficiency of patient care—while simultaneously giving patients more control over the care they receive.

The question of how to finance the project, once all available funds have been depleted, remains. In late 2012, the NIBIB granted the RSNA a contract for two years’ support of the Image Share network at $5.3 million, plus two additional option years (at a total of $5.5 million).

“Exactly who will pay, after that, remains unclear,” Mendelson says. “We are hoping to continue at a reasonable cost—for patients, maybe $10 per year, or $25 for lifetime use.” Another model would have imaging providers pay a small fee for offering the service to patients; potentially, this would be less costly than it now is to produce and exchange image CDs, he notes.

“If activities such as RSNA Image Share achieve a critical mass and reduce inappropriate redundant imaging, with the attendant, unnecessary additional irradiation of the patient, payors may see the wisdom of underwriting the expense, as it may well substantially drive down their costs,” Mendelson speculates. “It seems a small price for what everyone—especially the patient—gets in return.”

Julie Ritzer Ross is a contributing writer for Radinformatics.com.