BoneStation and Epic: The first interface

BoneStation’s first Epic integration occurred recently at a major Massachusetts medical center.  This center has six DXA bone density screening locations which report BMD studies. Bone density tests are read via BoneStation, a browser based application with centralized database, and reports are made available to clinicians via Epic.

The main goals of the integration were to:

  • Increase turn-around time of reports for the clinicians
  • Provide fully formatted reports with tables, images, and graphs
  • Have clinicians notified automatically when reports become available

Before integration, the reports, after being reviewed in BoneStation, needed to be printed and scanned into Epic.  This process greatly delayed the availability of bone density reports.

After integration, bone density reports are available in Epic within seconds of being read.

BoneStation provides richly formatted reports with tables, images, and graphs.  It was desirable to have these available to referring physicians.  The BoneStation Portal, which works in conjunction with the HL7 interface, provides fully formatted reports in Epic.epic with bd report - annotated - blog

Clinicians are also notified when a bone density result arrives for one of their patients.  The HL7 interface triggers this mechanism when a bone density report is finalized in BoneStation and transmitted to Epic.  Clinicians are then notified via their “In Basket”.epic inbox - annotated - blog






The first BoneStation interface to Epic was successful in accomplishing the medical center’s three major objectives, thereby increasing both the effectiveness and efficiency of their bone density testing practices.

BoneStation: a summary of advantages

We have been asked recently to present a summary of advantages that BoneStation provides to users. In this blog we first list what we believe are the key advantages our reporting solution brings compared to traditional methods. We then refer the reader to the results of a mini survey we sent to our current power users.

Differences and advantages that we believe BoneStation brings versus traditional reviewing, interpreting, and reporting methods for Bone Density Testing:

  • faster review
  • possibility to view current scan (image & data) and prior scan simultaneously
  • no data errors (no manual entry, no paper, no dictation)
  • possibility to review scans from anywhere (with web access)
  • more efficient workflow
  • faster overall turn-around
  • more efficient storage of the reports (patient exam, and questionnaire and report stored electronically and linked to each other)
  • possibility to interface to EMR
  • ability to do queries (data is structured in database)
  • better-looking reports
  • calculations of BMD changes and FRAX according to ISCD recommendations
  • possibility to scale up & standardize across several DXA machines (because use of centralized database)
  • possibility to customize your patient questionnaire.

We sent out a subset of ten of these points to our current power users (mostly physicians, and a few technologists) and ask them to pick the 3 most important benefits to their practice.

The results are: 1. the availability of prior scan images during review. 2. the possibility to review exams from anywhere. 3. better workflow compared

You can find the full ranking here:  BoneStation Survey


Reviewing DXA Scans on the Web with BoneStation

BoneStation is a web-based reporting solution which increases the productivity of bone density testing providers, including technologists, physicians, and administrators. In this article we focus on physicians who are responsible for the review and interpretation of BMD and VFA scans.  The physician will essentially do the following: select the exam to review, assess the technical quality of each scan, and  generate the report by filling in the various components (Assessment, Recommendations, Fracture Risk, etc). We describe that process in further details below.

The Review List and Initiating the Review Process

The physician starts by looking at The Review List, a list of recently performed BMD scans which need to be read.

BoneStation Review List

Review List shows scans awaiting review. (click for full size)



In this case the system shows 29 exams ready to be reviewed. Notice the drop down menus at the top.  These are particularly useful in situations where there are multiple DXA machines and multiple reviewers.  The Exam Date filters the list to show scans performed on a particular day.  The Location filters the list based on the DXA machine’s geographic location.  The list can also be sorted by Patient, Exam Date, and Referring Physician. In this Review Step 1, the physician  initiates the review process by clicking on Create Report (left button).

Selecting the relevant historical scans

Review Step 2 appears as “Select Comparison Scans”. During this step the current PA spine scan and all historical PA spine scans are displayed in summary fashion.  Prior scans that the physician does not want included can be excluded from the report by clicking the Exclude checkbox.

On Review Step 2 prior scans may be excluded.  (click for full size)

On Review Step 2 prior scans may be excluded. (click for full size)



The screen shows a summary of each prior scan, including scan date, scan mode, serial number of DXA machine, analysis date, and relevant BMD data.  If a prior scan was performed on a different DXA or using a different scan mode, the corresponding data would be highlighted in red.  This alerts the reviewer to the fact that he may want to exclude the scan.  For example:

Scan mode differs and is highlighted.










Looking back at Review Step 2, notice that “OK” appears in the Tech Quality column for the 11/10/2011 scan.  The 2011 scan has a report that was created in BoneStation and its technical quality was evaluated to be OK at the time of review.  Clicking OK pops up that report for immediate viewing.

Assessing Scan Quality

Click the Continue button to move to the next step.  On Review Step 3 one can compare the images of the current scan and the baseline.  Additional images, with scan data, may be viewed by clicking the dates in the Other Historical Scans section.

Specify scan quality

Review Step 3

On Review Step 3 the reviewer indicates the technical quality of the scan as either OK, marginal, or uninterpretable.  When one of the latter two is selected, one or more reasons must be picked in the second column.  If a scan is designated as uninterpretable, it will not be used in the final assessment. It is also during this step that a reviewer may request for a scan to be reanalyzed.  In this case the physician reviewer is prompted to send instructions to the technologist via email.  The scans are retained in BoneStation in a separate “Awaiting Reanalysis” queue.

Summarizing the Report

Clicking the Go To Next Scan button repeats this process for the remaining scans.  When the final scan is viewed, the Go To Next Scan button changes to Add Recommendations.  At this point the content of the various report sections are filled in.


Report sections are filled in, some automatically. (click for full size)

 The Summary screen can show a variety of optional report sections.  In the above example:

  • The Comparison To Prior Studies section gives a verbal description of change.
  • The Assessment section gives the interpretation.
  • The Current and Past Treatments section lists treatments as entered on the electronic questionnaire.  We did not discuss the questionnaire much during this article.  Note that it is available throughout the review process via the Questionnaire link.
  • Next visit is the suggested followup.
  • FRAX Results is the fracture score.  In the above example a FRAX score was not calculated because the patient is osteopenic.
  • Comments provides for general comments.

Note that there are drop down menus with many sections.  These contains macros of frequently used phrases that may be easily entered in to the report. The physician can also manually enter information into any section.

In Summary

This was a brief overview of the review process.  Many features, such as the integration into EMR systems, were not described or were only touched upon to keep the article short. If you would like to learn more, feel free to contact us.  Of course we are happy to hear from you if you have specific topics you’d like covered in future articles. Thank you.

Meaningful Use and DXA Bone Densitometry

The government’s efforts to coerce healthcare providers to meaningfully use electronic health records is in full swing.  Stage 1 of Meaningful Use (MU) focuses on electronic collection of data. Financial incentives have been provided for early adopters. Starting in 2015 penalties will be imposed for CMS related services, starting at 1% in 2015 and increasing by 1% each year up to 5%.  Stage 2 addresses increasing quality, health information exchange, and patient engagement. Stage 3  targeted now for 2017 focuses on improving patient outcomes and population health.

What does Meaningful Use mean for DXA providers?

To participate in Meaningful Use a hospital or provider must comply with mandatory (Core) and elective (Menu) measures.  Many measures define a degree of compliance.  For example, 30% of all orders must be made via computerized provider order entry (CPOE).  There is some flexibility in how compliance may be calculated.  One key aspect for DXA providers is the classification of a patient encounter as “seen by” or an “office visit”.  Patients “seen by” a physician may be excluded from measurements.

DXA providers may be considered specialists and thus be excluded from many aspects of meaningful use (see the Meaningful Use For Specialists Tip Sheet).  If each patient receives a consult, then each visit would likely be counted under meaningful use (an an “office visit”).  If a provider simply scans patients and returns a report to a referring physician, these could be categorized as “outpatient” (or “seen by”) encounters and be excluded.

We have seen flexibility in how MU is calculated and, in particular, which patients are counted. In one case, a radiologist performed thousands of readings in a year with only a handful of consults.  In this case, the radiologist claimed exclusion because so few office visits were performed.  We have also seen cases where an organization decided to include readings.

DXA providers must ask themselves if they want to comply with the letter of the law or truly buy into the spirit of meaningful use.  Of course there are other factors to consider such as one’s ability (financial, technical, logistical) to comply.

It may be difficult to avoid meaningful use, even as a specialist.  Under Stage 1, 10% of all tests results must be provided to patients and this increases to 50% under Stage 2.  DXA providers may be required to supply test results electronically as part of their hospital’s MU compliance.  At the moment it is unclear as to whether images must be provided.

Another MU aspect which may be difficult to avoid is the collection of relevant patient demographics and history.  For example, under Stage 1 patients’ ethnicity, height and weight must be collected as well as their smoking status.  Many specialists may claim exclusion because these items are not relevant for their services.  However, these items are necessary for DXA.

It may be relatively easy for some DXA providers to comply with MU.  If your organization provides an EHR, you may be able to piggyback on them.

MU may also provide benefits for DXA.  For example, a DXA operator doesn’t have to perform data collection if the data was already entered in the EHR (by another department for instance).  There may be future benefits when the EHR can transfer appropriate data to the DXA machine – saving time by eliminating the technologist’s need to perform data re-entry.   This is a perfect example of the spirit of meaningful use in action.

In this short article, we only touched the tip of the iceberg in terms of meaningful use for DXA.  We hope to address related issues in future postings.

Helpful Links:
Stage 1 Core and Menu Measures
State 2 Core and Menu Measures

Can “The Cloud” help with financial pressures on DXA?

DXA bone density testing has been experiencing mounting economic pressures, as has most of healthcare.  Reimbursement cuts have reduced revenue to bone density providers and bone density test volume has at best remained flat.  As a result, DXA operators have had to become more efficient.

The Cloud” has been instrumental in other industries, including government and military, in reducing costs.  Can “The Cloud” help DXA practices similarly?

Cloud-based applications are typically offered on a Software-As-A-Service (SaaS) basis.  The idea behind SaaS is simple: pay for what you use.  The implication is that the initial purchase of software, which can be quite costly, is replaced with a subscription-type model.  The subscription can be based on any number of factors, such as per user, amount of storage, or simply usage.

There are other savings too:

  • SaaS applications typically minimize – or even eliminate – the need for an internal IT department.  There is no on-site hardware or servers and thus no maintenance for those items.  Installation is easy – often times simply requiring a web browser.
  • SaaS applications often time include upgrades and support.  The traditional model for purchasing software involved an initial purchase and occasional upgrades, that had to be purchased.
  • SaaS services are often scalable.  A business can start small and easily add capacity as it grows.

In future articles we will discuss more advantages of the SaaS model.

There is NO need to re-enter your DXA data when reporting!

Recently, we have spoken to many bone densitometry professionals who still enter bone density data manually when creating a report.  Specifically, we are referring to data produced by central DXA machines, such as Area, BMC, BMD,  T-score, and Z-score.

Physicians and their staff often re-enter the data manually from the DXA printout.  Radiologists often look at the (DICOM version of the) DXA report in their PACS and dictate the numbers into a report.

This data re-entry step is completely unnecessary.  DXA machines support DICOM, which is an electronic report that contains BMD data.  The BMD numbers are burned into the DICOM image and can be viewed.  The DICOM also contains the BMD data within private fields.  Software can recognize and extract the BMD numbers automatically!  We have touched upon this point in prior postings such as these: The Evolution of Bone Density Report and Bone Density Reporting and PACS.

The same phenomenon happens with FRAX.  We’ve observed several bone density testing providers working off the printout from the DXA.  Others manually run FRAX from the web site.  If the DXA machine is used to provide FRAX, then the FRAX score is available in the DICOM.

The benefits of bone density specific reporting software become apparent.   The DXA manufacturers’ software as well as BoneStation can read BMD data in the DICOM transmissions.  Unfortunately, we are not aware of a PACS that extracts bone density data.

There are numerous benefits to the automatic acquisition of BMD data.  Providers spend less time on reporting and more time seeing additional patients.  Reports can be stored electronically and be compatible with electronic distribution to EMRs.  If BMD data is stored in a database, then it may be mined and queried, as discussed in this prior blog post.

Workflow for Bone Density Practices

This posting is the second in a series that discusses cloud based computing and benefits to bone density providers.  For a brief description of The Cloud and cloud based computing, see our earlier posting.

In this article we’ll focus on workflow.  A typical bone density department has several participants involved in processing bone density scans.

  • Technologist – interacts with patient and performs scan and analysis
  • Reviewing Physician – interprets scans and creates report
  • Scheduler – in a multi-DXA center, may need to schedule patient on same DXA as prior exam
  • Office Staff – distributes and/or prints reports

A cloud-based system can make an entire team function more efficiently and smoothly.  Each participant interacts at a different phase in the scanning and reporting process and can be prompted to perform their part of the work at the appropriate time.

Here is a screenshot of the workflow process in BoneStation.  The first column is the patient; second column shows the scans, and the third column is the exam status.  Of course, the tasks can be sorted and filtered by the status.

This screen shot demonstrates work to be done and where each exam is in the process.  Each participant can then focus on their tasks in moving the exam through the process.

  • A technologist will be interested in Exam Pending, which means that BoneStation is awaiting for a scan(s) – in this case a hip scan.  When the hip scan arrives the exam goes to Exam Ready.
  • Exam Ready indicates the exam is ready to be reviewed.
  • Being Reanalyzed means the reviewing physician has requested a reanalysis.
  • Reviewed means a report has been created and it needs to be distributed and/or printed.

Cloud based software lends itself to making teams more productive.    Multiple users have access to the same information and processes.  This is difficult to achieve with desktop software, which typically isolates users from each other.