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.

Advertisements

The Evolution of Bone Density Reporting

Introduction
In this article we’ll examine bone density reporting and how it has evolved over the years.  Bone density testing is a relatively new test.  Reimbursement for bone density tests wasn’t approved until the mid 1990s.  DXA machines became the primary method used to measure bone mineral density.   Initially, there was little to aid physicians who reviewed bone density scans, as the process was largely manual.  Now there is a cloud based solution.

We’ll take a brief trip, chronologically, through the advances in bone density reporting.   Improvements in reporting will be discussed.  Quality, convenience, and cost improvements will also be noted.

We break down the evolution of bone density reporting into three stages:

  • Manual reporting makes use of pencil and paper or word processors to generate reports.
  • Desktop solutions are first generation software package produced by the DXA equipment manufacturers.
  • Cloud (web) based solutions, such as BoneStation.

Radiologists often use another method to review bone density scans.  This involves the use of PACS with  dictation or transcription.  We’ll look at this option in more detail in a future article.

Background
A bone density scan is a somewhat unusual test.  It has the qualities of both an imaging procedure and lab test.  The scan consists of an image plus numerical data, such as bone mineral density (BMD), t-score, and z-score.

The process of evaluating bone density scans is referred to as reading, reviewing or interpreting bone density scans.  Physicians are specially trained to read bone densitys scans.  A reviewing physician typically looks at both the scan image and numerical data.  It is common to compare current scans with a patient’s prior scans.  A typical report  may include the numerical scan data, an assessment (for example, osteoporosis, osteopenia, or normal), recommendations, and a statement about change in bone mineral density (BMD) – assuming the patient had prior scans.

The Evolution
Manual Reporting
In the beginning, bone density reports were created manually.  DXA machines produce printouts of scans.  A printout contains a scan image and tables of numbers, including bone mineral density (BMD), t-score, and z-score.   The data was typically re-entered into a word processor and an assessment was typed in.  The scan image was usually omitted, since it was difficult to get the scan image into the report.

The disadvantages to this method are quite obvious:

  • Data entry of the bone density quantitative data (BMD, t-score, z-score) is error prone.
  • The only way to compare a scan with prior scans is to have the printouts of the prior scans, and this involves manual labor to pull old charts.
  • Storage of paper scans and reports can be costly.
  • To calculate change in BMD, during review, is also be labor intensive.
  • It was difficult to include images in a report.

Desktop Solutions
Eventually the DXA manufacturers implemented the DICOM standard.  DXA machines could then transmit bone density scans to other computers.  Soon after, the DXA manufacturers provided desktop software applications that could communicate DICOM and receive bone density scans.  A physician could install the desktop software on his office PC and have bone density scans transmitted to it.  Using the software, he could then create a bone density report.  The report could be stored in an electronic format – a data file.

This software was an advancement and addressed issues with the manual method:

  • Quality was improved mainly due to elimination of data entry.  The software could extract the quantitative data from the DICOM transmission and place it in the report.
  • Reports could contain images.
  • Reports took an electronic form and could be stored that way.

Desktop reporting also introduced new problems.

  • Where are electronic reports stored?  Would they remain on the PC of the reading physician?  What if there are multiple reading physicians?
  • How could one recall an old report easily?  Even though reports were stored electronically, the desktop applications offer no easy way to access an old report.
  • What about privacy or security issues with storing scans (in DICOM format) and reports on a PC hard disk?
  • How are reports backed up?

The desktop software also represented an additional cost – both direct and hidden.  The main direct cost was the software itself.  The DXA manufacturers offered the software for purchase.  Hidden costs included addressing the problems described above.  Additional tools and infrastructure are need to backup electronic data, store reports on a network, organize reports (in a database) to be easily searchable, and provide security and privacy of electronic data.

The side effects of introducing desktop software vary depending on the number of bone density tests performed.  A high volume provider may have an IT department in place and the infrastructure for addressing storage, backup, and security may exist.  A low volume provider may have to hire expertise in these areas.

Cloud
The “cloud” solution is BoneStation.  The term “cloud” is today’s common lingo for storing data out on the Internet.  Scans are transmitted, via DICOM, to BoneStation.  Reviewing physicians log into BoneStation’s web application and can view scans – images and data – and create reports.

BoneStation solves the problems of the manual and desktop methods.   Scan data (BMD, t-score, z-score, etc) is automatically extracted and made available on the report.  No data entry is needed.  BoneStation also makes prior scan images and reports available during the review process, which was a shortcoming of the desktop solutions.

New problems introduced by the desktop software are also addressed.

  • Reports are stored centrally, in an enterprise class database.
  • The database is backed up, which prevents data loss.
  • An easy to use search mechanism provides the ability to easily search for and view old reports.
  • Access to BoneStation is secure.  One must be granted authorization to access BoneStation in order to see bone density data.
  • Data transmitted to and from BoneStation is encrypted, which maintains privacy.

In addition, there are additional clinical advantages:

  • Prior scan images and data are available – even during review.
  • Old medical history questionnaires are also available, which is useful with FRAX.

Cloud based solutions often solve a wider spectrum of problems while also being more cost effective.  BoneStation addresses issues of quality, security, data integrity, and privacy.  It is easy to install and use, requiring simply a web browser and internet access.

Costs are typically lower with cloud based solutions.  Startup costs are low and cloud solutions are typically offered on a per usage basis.  BoneStation is offered on a cost per report basis.  In addition, BoneStation addresses hidden IT costs, such as storage, backup, and privacy and there are no upgrade and maintenance fees.

Summary
While bone density testing is relatively new, there are modern solutions available for reporting.  The initial desktop solutions addressed quality issues related to data re-entry.  The most recent solutions are more comprehensive and address clinical, quality, and information technology problems while keeping costs low.

Additional links:

BoneStation – cloud-based bone density report for DXA.

Reading bone density scans on a mobile device with BoneStation.