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.

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

This posting is the first 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 prior posting.

In this posting, we focus on the questionnaire aspect in the context of DXA-based bone density reporting. We specifically examine the benefits of an online questionnaire which is stored in the cloud.

With the advent of FRAX, patient history questionnaires have taken on new significance.  The FRAX algorithm requires knowledge of the patient’s  risk factors and these are typically collected via a questionnaire in one of different ways.  We will show key advantages offered by The Cloud compared to non-cloud based questionnaire solutions.

Today, DXA machine software includes a questionnaire for use with FRAX.  Both Hologic and GE/Lunar have added this capability.  The presumed workflow is that the DXA technologist fills in the questionnaire at the DXA machine, prior to scanning the patient.  The technologist scans the patient, analyzes the scans, and a FRAX score appears on the DXA machine printout.

In a cloud environment, the questionnaire is filled online and therefore easily accessible through a web browser. It is then stored in the cloud. Let’s look at the advantages of such an enterprise class approach:

  • Technologists and physicians can view and/or modify the questionnaire from anywhere as long as they have access to the Internet through a Web browser.
  • Physicians can easily recall the questionnaire corresponding to a specific report,  since the questionnaire is stored centrally. No need to walk to the DXA machine.
  • Busy bone density providers benefit from an improved operational workflow.  For example, with BoneStation, a questionnaire may be entered before the exam takes place.  The questionnaire is stored in a queue.  When the scan is performed, the questionnaire in the queue is associated with the exam.
  • The questionnaire can be modified without disrupting workflow. In a cloud-based solution that incorporates FRAX, such as BoneStation, there would be no need to change a question on the DXA machine in order to recalculate a FRAX score.
  • New opportunities for Quality Assurance and Research are enabled. This is because questionnaires become easily data-mined, as a result of being part of an enterprise class software.  All questions (and associated answers) are stored centrally.  This may be particularly important in multi-DXA operations.
  • One could even envision the patient accessing his or her questionnaire (for example to review its accuracy).

These benefits to the technologists, physicians, researchers, operations managers and ultimately patients, are characteristic of enterprise class software.  Enterprise class software tie teams together in their work environment, making them more productive through collaboration and workflow.

We probably have not exhausted the potential benefits and opportunities offered by online, cloud-stored questionnaires for bone densitometry.

We thank you for reading this blog, and welcome your suggestions and comments.

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  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.