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.

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 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.

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.

BoneStation: The Software Tool for Bone Densitometry

BoneStation automates the preparation, interpretation, creation, distribution and storage of bone density reports using DXA technology. A web-based interface streamlines the review process for bone density practitioners into a single, secure, interconnected system that processes reports in 1/3 of the time. BoneStation enables practices to provide more accurate bone health assessments and increase revenue without adding administrative staff, transcription services or additional practitioners – directly improving quality of care and profit margins.