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.

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.

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.

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