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.

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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.