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.

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.

Bone Density Report Distribution: the last mile

The physician has interpreted the bone mineral density (BMD) test and generated the report.  Now what?

Obviously it needs to be sent or “distributed” to the interested parties.  In this article we look at this distribution phase, which is sort of the “last mile” in the reporting process.

So what happens to the BMD report once it has been created? Having worked with a variety of hospitals, we know that… it depends! There is no standard answer to that question because it depends on several key factors including:

  • Who will be the final “consumers” of the report?
  • Does the facility have an Electronic Medical Records system (EMR)?  Who has access to the EMR?

Let’s dive a little more into these questions.

The final consumer of the report is typically the ordering physician i.e. the physician who prescribed a bone mineral density test for his/her patient. Usually it is the primary care physician, although other doctors treating the patient may also need to see the report.

Today, most healthcare providers have a functional EMR in place.  It is generally accessible to all physicians, and usually the appropriate place to store bone density reports. (There may be a radiology information system (RIS) and/or a PACS in place too;  often though these systems are available only to radiologists.)

The EMR, however, may not be available to all physicians who need to access test results.  If the ordering doctor is located in the hospital where the BMD test occurs, he/she is then connected to the EMR. But the ordering doctor could be external to that hospital or even located in a remote office with limited access to the EMR.

What is then the best way to distribute exam results, such as bone density reports?

BoneStation offers the flexibility required to handle most situations as explained below. There are three methods available to distribute reports:

  1. Printing – which typically means the report is sent via mail to the consumer
  2. Faxing
  3. Transmission to an EMR –  through a digital interface (typically an HL7 interface)

In addition, BoneStation allows the distribution method to vary for each primary care physician (ie. the consumer).  A couple examples:

  • A physician with access to the EMR may simply receive reports via the EMR
  • A physician with access to the EMR may receive reports via the EMR, fax, and a printed report via mail
  • Physicians with access to the EMR may receive reports via EMR and physicians without access to the EMR may receive faxes

As mentioned above, other doctors than the ordering physician may need to receive the patient’s report.  This is very easy to set up with BoneStation thanks to its distribution list functionality.

For the sake of traceability, the complete history of each report, recipient, distribution method, and distribution date/time is stored in BoneStation. The hospital staff can quickly and easily review that historical data.

BoneStation offers the necessary flexibility for distributing BMD reports.  It support traditional methods, such as print/mail and fax, which are still needed today, in addition to the modern solution of interfacing to Electronic Medical Records systems.

In today’s fragmented healthcare landscape it is important for vendors to offer flexible solutions to accommodate different situations, not only within the medical office or hospital, but also at the interfaces between stakeholders. We have learnt that even in the very specific case of the distribution of BMD reports, there can be many scenarios that need to be resolved, and we will continue to address the constantly evolving landscape.

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.

Recommendations

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.

The Cloud and Bone Density Reporting

The current trend in software is “The Cloud“.  Maybe you’ve heard of it?  What does it mean for bone density providers?  In this posting, we’ll provide an overview of the cloud.  Future postings will assume this very basic understanding of The Cloud.

In short, The Cloud reflects storing of data on the Internet.  Some examples are online banking and email (such as gmail).  In these cases, the checking and savings account info and email may not reside on your PC.  Instead, the data is on a “server” somewhere out on the internet (“The Cloud”).

Access to data is typically provided through an application that is usually a web browser, but not always.  For example, banks typically provide a web based application to log in and manage checking and savings accounts.  Google provides email access through http://www.gmail.com.  You may also access gmail through an email client, such as Thunderbird or Outlook.  Mobile access to your email is via a phone app.

In understanding cloud-based computing, it may be useful to contrast it with the old way of doing things – desktop computing.  With desktop applications, one worked in a more isolated manner, on a PC.  Data is stored in files on the PC’s hard drive.  While it is possible to share and collaborate with others, it requires more work than cloud based applications.

In terms of business applications, including bone density practices, cloud based applications are likely to be classified as “enterprise class” applications.  Enterprise class applications are characterized by making entire teams work better and more efficiently.

  • Information is more easily shared among team members
  • A workflow can be instituted which improves team efficiency and reduces errors
  • Data is robust, it is backed up

The next few blog postings will highlight some benefits and touch upon how Cardea Technology‘s BoneStation realizes the benefits of the cloud via as an enterprise class application.

Structured BMD Data Permits Easy Query and Data Analysis

The two prior posts, Bone Density Reporting and PACS and The Evolution of Bone Density Reporting, prompted feedback from readers and BoneStation users.  The articles mentioned that quantitative bone mineral density data (BMD, t-score, z-score, etc.) is available in a structured form in the DICOM format.  Apparently this is quite appealing to physicians and researchers who would like to analyze and mine bone density data.

In this posting we will provide more information the bone density data in DICOM files.  We will describe where the data is stored, how it may be accessed, and the types of things that can be done with it.

Bone density data is available in the DICOM transmissions of bone density scans.  Specifically, BMD data is available in two forms – a raw image and a structured form.  The raw image is of little use in terms of analysis because the numerical information (area, BMC, BMD, t-score, and z-score) can not be extracted out of the image.  However, the structured form may be of considerable value because it can be parsed.

The structured BMD data is not visible when looking at a DICOM image.  The data is stored in private DICOM elements.  GE/Lunar and Hologic use their own proprietary formats.  Fortunately, each DXA manufacturer documents their format.  We have seen very few systems that utilize the structured BMD data stored in DICOM and have yet to encounter a PACS that makes use of the private data.

The DICOM standard supports many modalities – CT, Ultrasound, etc.  Unfortunately, DXA is not one of them.  This is the reason the DXA manufacturers have created their own private DICOM fields for storing BMD data.

BoneStation depends heavily on the structured BMD data.  It parses the data and stores it in its database.  From there, BoneStation can display the data in ways that are useful to physicians.  It can:

  • Perform calculations, such as change in BMD between arbitrary scans
  • Highlight scans performed on different DXA machines or with different scan modes
  • Highlight questionable scan values
  • Assist the physician in assessing an exam – for example, an interpretation may be provided based on t-score

Of course, more than just scan data is available.  BoneStation captures additional information, some of which is customized per user.  Some of this information is entered during the review process and some via an online patient history questionnaire.  A sample of data that may be available:

  • Treatments, current and past
  • FRAX risk factors
  • ICD9 codes
  • Vertebral Fracture Assessment (VFA) fractures, including severity and type
  • Etc…

All of this information is stored in a standard relational database and may be queried using Structured Query Language (SQL).  Tools such as Microsoft Excel and Crystal Reports may be used to access the database. A wide variety of queries may be performed.  Here is a very small sample of the types of queries that may be of interest.

  • How many bone density scans were performed by month for the past year.
  • Find all patients with a t-score within a range – say t-score <= -2.5.
  • Find all male patients under 65 with a t-score below -2.5.
  • Find all patients being treated for osteoporosis who are osteopenic.
  • How many patients are being treated with a specific ICD9 code for each of the past 3 years.
  • Find patients with a moderate or worse VFA fracture.
  • How many scans is each physician reviewing.
  • How many scans have poor quality.
  • How much time does each physician take to interpret scans.

Some astute readers picked up on the value of structured BMD data in DXA DICOM transmissions.  Structured data can be stored in an organized fashion and easily queried and mined for clinical, quality, research, and financial purposes.

Bone Density Reporting and PACS

In our last post, The Evolution of Bone Density Reporting, we looked at how reporting for DXA progressed from manual reporting to cloud based solutions.  We skipped a method of reporting that utilizes Picture Archiving and Computer Systems (PACS).  Many radiologists use PACS for a variety of modalities, including DXA.  We’ll examine bone density reporting with PACS and make comparisons with DXA specific reporting solutions that were discussed in the prior post.

PACS is a key tool used by modern radiology departments.  A typical system consists of a large amount of digital storage, high fidelity DICOM display terminals, and software.  A variety of modalities (digital x-ray, CT, MRI, DXA, etc…) transmit scans to PACS utilizing DICOM.  The images are stored in PACS and can be viewed via DICOM displays.  The amount of storage determines how long images can be recalled and viewed.  After a period of time, images are typically archived and may not be immediately available.

Bone density reporting is often performed with PACS and dictation software.  Typically a radiologist will view a bone density scan on a DICOM display while also dictating or transcribing a report.  This process is consistent with how radiologists create reports for other modalities.

One disadvantage to dictation/transcription is quality.  In our last post we noted quality was addressed with the DXA manufacturer provided reporting software as well as BoneStation.  Bone density scans contain images plus quantitative data, such as BMD, t-score, and z-score.  DXA specific software extracts the data and places it in a report.  With dictation, the radiologist must speak these values in order to transfer them into the report.  This method of transferring numeric data into a report is reminiscent of manual reporting – errors may occur.

It is important to note that the bone density quantitative data is available in two ways within the DICOM transmission.  First, the data is burned into the bone density scan image.  When a radiologist views a bone density image in PACS, it is these values that are transcribed.  There is very little else that can be done with data burned into an image.  Second, and more importantly, bone density data (BMD, t-score, z-score, etc) is also available as values in private DICOM elements.  These values may be extracted, parsed, and placed in a report. Software may read these values and perhaps even aid in decision making.  Calculations, such as change in BMD may be performed in software.  A FRAX risk factor may also be calculated.

We have seen few systems that utilize the values in the private DICOM elements.  PACS is largely used for storing and displaying of images and while it works well with many modalities, it typically ignores BMD data in DXA scans.  The process of dictation/transcription represents a somewhat manual method of transferring the values from the scan into a report.

Another important capability of reading DXA scans is to follow a patient’s progress.  A reader of bone density scans typically compares a current scan with historical scans – by viewing scans side-by-side. Regions of interest (ROIs) are compared for consistency over time.  PACS usually retains images for a certain amount of time.  Historical scans may not readily be available, however.

In summary, PACS is a great tool for modalities that produce images only.  For DXA scans, however, there is a gap in handling of quantitative data that is available in the bone density scans.  In actuality, it lacks the capabilities of even the first generation of bone density software reporting tools.