Rules of Interpretation with Fractures

In last week’s post we talked about how BoneStation automatically generates an assessment. A couple of sample sets of rules were provided for BMD. This week we’ll extend those rules to include fractures.

As a review, BoneStation’s rules engine takes inputs from three sources: BMD scan data, patient data, and online questionnaire. It generates output, which is an assessment.

When adding fractures an additional input is needed: the VFA scan. More specifically, vertebral fractures as noted by the reading physician (using BoneStation) are used.

Here is an updated diagram depicting the rules engine.

Before we show the updated rules for VFA, it is important to note:

  • In BoneStation there are four choices for indicating the presence of a fracture on VFA: Yes, Maybe, No, and Indeterminate.
  • Fractures may be indicated on the questionnaire – as patient reported. See sample questionnaires below for examples of how fractures may appear in questionnaire form.

Only the rules for normal bone density (T-score ≥1.0) are displayed below. Showing all the assessment categories will be too lengthy. The rules for the other categories would be similar.

The original BMD rules used these inputs:

  • Age
  • T-score
  • Z-score

For fractures we added:

  • QN Fx = Fracture indicated on the questionnaire
  • VFA Performed = Yes/No – if a VFA was performed
  • VFA FX = Fracture indicated on VFA

The sample rules above represent one way to automate the assessment of bone density scans. There are many variations.

BoneStation’s rules engine is very flexible. Rules, questionnaire, and output (assessment) text may all be customized.

Here are some sample questionnaires.

Rules of Interpretation

BoneStation is a web-based reporting system for DXA based bone densitometry. In many of our blog posts we mention that BoneStation requires no transcription and no dictation. That is because BoneStation automatically generates a suggested assessment.

What is meant by that? How does it work?

BoneStation combines three inputs:

  • DXA Scan Data – The bone mineral data from the DXA scan
  • Patient Data – Information about the patient
  • Questionnaire – Online questionnaire that is built into BoneStation

The scan data, patient info, and questionnaire answers are fed into a rules engine. The engine output the assessment text, which is displayed to the reading physician as a suggested assessment. The reading physician can accept the assessment or alter it.

A simple set of rules may look like this, where the T-score and Z-score are the lowest values for all measured sites:

The above rules make use of information that is available from just the DXA scans (T-score and Z-score) and patient (age). One common variation on this set of rules is to incorporate the gender and menopausal status of women. The rules can be adjusted to look like this, where the menopausal status is indicated on the questionnaire.

BoneStation is very flexible. The questionnaire, rules, and (output) assessment text are all customizable. Some BoneStation customers’ rules consist of more than 30 rules when factoring in fractures (VFA) and other patient conditions.

Here are some sample questionnaires:

In our next blog post we’ll look at how fractures and VFA can be factored into the above rules.

Bone Density Reporting and SaaS?

What is SaaS and what is its relevance to bone density reporting?

SaaS stands for Software As A Service. The financial model and logistics behind SaaS may be compelling for bone densitometry given low reimbursement rates.

A key characteristic of SaaS is that users pay for only what they use. Also startup costs are typically minimal.

With SaaS software the same fully featured software is available regardless of the size of the company using the software. BoneStation, for example, is a SaaS software package for reading bone density scans. The set of features is the same for all customers regardless of size of the practice. Practices performing 200 scans a month are using the same software as those performing 1000 scans a month.

There are other cost savings to SaaS. For example, SaaS software packages usually include support and upgrades. With the traditional model, software packages frequently have costly annual maintenance fees (typically priced at 10% to 20% of the original software). And upgrades are an extra cost too.

There are other benefits to SaaS.

Software based on the SaaS model is often times “cloud based”, meaning it runs in a web browser. There is no special client software to install on each user’s computer. This implies convenience, in that the software can be used on any computer with a browser. Installation and support are easier and less costly also.

Software As A Service is a newer model for offering technology and software. It provides many advantages, in terms of price and convenience – appealing characteristics for bone density practices running on tights budgets.

There is No Need to Re-Enter DXA Data When Reporting

Many bone densitometry practices re-enter patient and DXA scan data when creating reports.  Accuracy is critical because interpretation is based on this data.  Key patient information includes gender, date of birth, and ethnicity.  Important bone mineral density data includes BMD, T-Scores, and Z-Scores. 

Physicians and their staff often re-enter the data manually from the DXA printout into templates.  Sometimes reports are transcribed.  Radiologists typically dictate the numbers into a report.  All of these are error prone.

This data re-entry step is completely unnecessary.  DXA machines support DICOM, which is an electronic format that contains all the patient and BMD data.  While BMD numbers are burned into the DICOM image and can be viewed.  The DICOM format also contains the BMD data within discrete fields.  Software can recognize and extract this information!  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 benefits of bone density specific reporting software, such as BoneStation, become apparent with electronic availability of DXA data.  Software can calculate change in BMD, highlight if change is significant, calculate a FRAX score, and even suggest an interpretation. In addition, the data can be displayed on a report in a way that is desirable and visually appealing.

Computerizing the handling of DXA data not only reduces errors, but it increases efficiency, and shortens turn-around time of reports.

Advantages of an online Questionnaire for DXA-based bone density reporting

BoneStation is an enterprise class bone density reporting solution.  It makes bone densitometry practices more productive by streamlining the workflow of technologists, physicians and administrators.

The assessment for osteoporosis and fracture risk became more complicated when FRAX was introduced about ten years ago.  In addition to the DXA measurements, the patient’s medical history had to be considered when interpreting bone density scans.

FRAX is built into BoneStation’s web-based interface.  When using BoneStation, the DXA machine’s questionnaire is not used.  Instead BoneStation’s online questionnaire is used and BoneStation calculates a FRAX score.

This provides many advantages over using the DXA for FRAX.

  • Technologists and physicians can view and/or modify the questionnaire from anywhere as long as they have access to BoneStation.
  • The FRAX score appears on the report along with the indicated risk factors (from the questionnaire).
  • The questionnaire is readily available to the reading physician during review.  The reading physician can even modify the questionnaire.  The FRAX score generated by BoneStation will be adjusted.  There is no need to have the technologist modify the questionnaire at the DXA and regenerate the FRAX score.
  • Questionnaire’s are saved with each bone density report and can be recalled at any later time.
  • BoneStation has the ability to provide a warning if a questionnaire has not been filled out for a patient.

The workflow for questionnaires is straight-forward in BoneStation.

  • The technologist typically fills out the questionnaire (but this is not always the case).  The questionnaire is stored in a Questionnaire Queue and assigned to the scans when they are transmitted to BoneStation.
  • During review, the reading physician has access to the questionnaire and can even modify answers on the questionnaire.
  • When the reading physician finalizes the study, the questionnaire is saved in BoneStation along with the report.
  • Both the report and questionnaire are available to be recalled at a later time.

Click here for more about bone density imaging workflow.

Next time the patient has a bone density test, answers from the prior questionnaire pre-populate the new questionnaire that is used for the visit.

BoneStation includes a standard questionnaire, which is sufficient for FRAX.  Questionnaires may be customized for a bone density practice.

An online questionnaire has an additional advantage in research environments.  With all data being stored centrally in BoneStation, it is easy to perform data mining.

BoneStation and ISCD Recommendations For Bone Density Reporting

The International Society for Clinical Densitometry (ISCD) publishes recommendations for DXA based bone density reporting.  BoneStation makes it easy to create reports that comply with these guidelines.

This quick moving video shows the guidelines, from the ISCD website, along side sample reports created with BoneStation, as each guideline is highlighted.

Click here to watch the video.

Optimizing Bone Densitometry

We have encountered some interesting ways in which bone density specialists want to understand their practices.  The goal is typically to optimize operations, improve quality, and increase business.

While BoneStation is a great tool for creating DXA based bone density reports, it also can be used to understand the operations of a bone density practice.  BoneStation collects a wealth of information regarding the processing of bone density studies, and that information can be used in a variety of ways.

Here are some interesting questions BoneStation users have inquired about:

  • Which physicians refer the most patients for bone density scans?
  • What’s the turnaround time for a bone density test, where “turnaround time” is defined as the duration from scan to report finalization?
  • What’s the turnaround time for each reading physician?
  • How many scans does each technologist perform?
  • What percentage of scans must be reanalyzed per each technologist?

BoneStation is an “enterprise-class” software application.  “Enterprise-class” software is designed to be used by an organization as opposed to an individual.  BoneStation is used by technologists, reading physicians, and administrators.  As such, it captures information about the entire process of DXA based bone densitometry,

Workflow for Quality DXA-based bone density testing

Typical medical imaging workflow, as discussed in our prior post, works well in most radiology practices.  However, bone density testing via DXA is a unique form of medical imaging.  Some ways in which DXA is unique:

  • DXA produces quantitative data in addition to images
  • Accurate patient demographic information is required for an interpretation along with a FRAX score
  • Reading physicians are required to confirm proper and consistent positioning

In this posting, we’ll examine how BoneStation, a web-based bone density reporting system, provides an efficient workflow while simultaneously addressing many of the unique characteristics of DXA.   Many of the features and capabilities described below are based on experiences at high volume bone density practices over the past twelve years and with more than a half million bone density reports created at these practices using BoneStation.

DXA produces numbers, in addition to images.  PACS are not designed to deal with numbers, and dictation is tedious and error prone. BoneStation extracts all BMD data and makes them available during review.  This is described in our post, There is NO need to re-enter your DXA data when reporting.

Bone density also requires accurate patient demographic information for an assessment. If a FRAX score is being calculated, then risk factors are also required.  BoneStation verifies that information is not missing.  It can notify the technologist before an attempt is made at reading the scans.  Some examples of info may be omitted:

  • Height is often used at determining height loss.
  • Height and weight are needed for FRAX, which uses BMI as in input.
  • Ethnicity is important for interpretation.

BoneStation includes FRAX and includes an online questionnaire, which may be customized.  The questionnaire in the DXA software is not used.  There are many advantages to having the FRAX questionnaire online, as described here.  Some examples:

  • The reading physician may make changes to responses to FRAX questions during review.  There is no need to have the technologist change the answer on the DXA to have the FRAX score recalculated there.
  • BoneStation can confirm that a questionnaire has been filled in and notify staff when it is missing – before the scans are read.
  • BoneStation warns staff of inconsistencies in scan and FRAX info.  For example, a 65 year old patient may be designated as pre-menopausal.  This can be significant when menopausal status is used in determining the assessment or reporting of FRAX.

An online questionnaire may be very helpful in research settings too.  All scan and patient history information is easily accessible in real-time, which may be useful for data mining.

Here are some sample questionnaires.

So far we’ve discussed issues that occur early in the process, before scans are read.  BoneStation provides numerous workflow and quality benefits during the reading process too:

  • Images and BMD data for prior scans are available quickly and easily during review.
  • Generation of the assessment and FRAX is automatic.  This is possible because BoneStation makes decisions based on the extracted BMD data.
  • BoneStation incorporates re-analysis of scans into its workflow.  No more post-it notes or lost scan results because reanalysis of a scan was forgotten about. BoneStation tracks scans being reanalyzed.

This video demonstrates reading of a bone density study in under ninety seconds.

Here is a longer video that describes bone density reporting with BoneStation in high volume practices.

BoneStation builds upon radiology workflows while also supporting DXA specific requirements.  Both a high volume of testing may be maintained as well as quality.

Bone Density Imaging Workflow

In this post, we’ll describe medical imaging workflow as it specifically applies to DXA based bone densitometry.  Radiology departments, imaging centers, and hospitals have implemented efficient processes that maximize the volume of patients, along with revenue, and also minimize errors.

This posting assumes modern technology is in place, such as electronic medical records (EMRs), hospital information systems (HIS), radiology information systems (RIS), DICOM for electronic image transfer, and picture archiving systems (PACS).  For a reporting system, we’ll assume BoneStation is used.  We’ll also assume the EMR, HIS, or RIS provide order entry and results capabilities (where ordering providers view test results).

The following diagram depicts typical workflow, but adapted for DXA based bone densitometry.  The workflow can be thought of as an assembly line, where the patients navigate through the process.  Often times, patient flow may be tracked throughout the day via the EMR/RIS/HIS.

1) An order is placed (scheduled) for a bone density test.  Often times the ordering provider calls the bone density practice to order a test.   The order is entered into the EMR/RIS/HIS.

2) Patient arrives for the exam on the scheduled day.

The receptionist may log into the EMR/RIS/HIS and update a patient’s status to “arrived”.

3) A DXA technologist scans the patient on the bone densitometer, analyzes the scans in the DXA software, and transmits the scans, via DICOM, to BoneStation.  BoneStation extracts all the quantitative data and the images.

If DICOM Modality Worklist (MWL) is available on the DXA, the tech may pull all the patient info (name, DOB, ethnicity, etc) electronically from the EMR/RIS/HIS into the DXA software.  Otherwise the technologist manually enters patient demographics.

The technologist logs on to BoneStation and fills in the patient history questionnaire.  FRAX is built into BoneStation, and the questionnaire is filled out there instead of in the DXA software.  There are advantages to having questionnaires in BoneStation, which are discussed here.

The technologist may update the patient’s status in the EMR to “complete”.

4) A physician, that is specially trained to read DXA scans, logs into BoneStation and reads the bone density scans.  BoneStation automates much of the process of reading scans.  The final output is a bone density report.  This video demonstrates how easily and quickly reading scans is in BoneStation.

5) BoneStation distributes the report to the EMR/RIS/HIS.  BoneStation creates fully formatted reports, with tables, images, and charts.  Click here to see some sample reports.  Depending on the interface between BoneStation and the EMR, only a text report may be available or the fully formatted report in the EMR.

BoneStation supports a variety of ways to distribute reports, including printing and faxing.  This article provides more info about one instance of a BoneStation to Epic interface.

Once the EMR receives the bone density report, the patient’s status is updated to “final”.  This may also trigger events related to billing.  The process for the patient’s scan is now complete.

6) The ordering provider accesses the report in the EMR/RIS/HIS.  Some EMRs may notify the ordering provider that results have been received when the report is received by the EMR/RIS/HIS.

The workflow described here is typical for most hospitals, radiology departments and imaging centers.  There are some unique aspects that are specific to DXA. We will go into more detail regarding DXA in a future posting.

Three Keys to Quality Bone Density Reporting

This posting is the last of a 3-part series about bone density reporting and how BoneStation can make a difference compared to common practices. Part 1 focused on costs reduction and part 2 on time savings.  In this article we discuss three specific areas that BoneStation addresses in regards to quality:

  • The Report – components that comprise a good bone density report
  • Review process – facilitating a sound interpretation
  • Workflow – improving communications between staff

The Report
The International Society for Clinical Densitometry defines the minimum requirements for a bone density report.  Some items that should appear on a report include: patient demographics, BMD values for each site measured, DXA manufacturer/model, and significant change.

BoneStation automates report creation.  Manual data entry is eliminated.  BoneStation extracts all appropriate DXA data and places the data in a report.  In addition, changes in BMD and determination of significant change are automated.  A final bone density assessment is even suggested.

The Review Process
While DXA bone density scan images should not be used for diagnostic purposes, they are instrumental in determining the consistency of serial measurements.  Is the patient positioned properly?  Are the regions of interest (ROIs) consistent with prior scans?  What is the technical quality of the scans?

BoneStation’s review process is designed to highlight key aspects for interpretation.  Prior scans are easily visible. ROIs may be viewed both visually and numerically.  Technical quality of scans must be specified and may also appear on the report.

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Workflow
In most situations, the technologist and reading physicians are in different locations.  Scans are not typically read in real time either.  Improved communications among bone density staff can lead to increased quality.

  • BoneStation allows technologists to pass information to reading physicians via “scan comments”, which are entered on the DXA and appear in BoneStation.
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  • BoneStation may be configured to “validate” patient information for consistency.  Is data missing, is patient demographic info consistent, etc.  For example, if a female patient is 62 years old and is designated as pre-menopausal, BoneStation is able to provide a warning that this information may not be valid.
  • When a reanalysis is required, BoneStation facilitates communications between the reading physician and technologist.  The reason for reanalysis is described to the technologist.  The scan is also tracked as awaiting reanalysis – so staff will not lose track of it.
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Summary
BoneStation is designed specifically for DXA based bone densitometry.  It increases efficiency and quality simultaneously.  Much of the mundane handling of bone density scans is automated. It facilitates a review process designed for bone density, and enables easy communication among bone density staff.

BoneStation has produced more than a half million reports and has proven to be reliable solution for BMD reporting.  Customers such as Mass General Hospital, Swedish Medical Group, Emory and others enjoy higher throughput and quality at lower cost.