Rules of Interpretation

BoneStation is a web-based reporting system for DXA based bone densitometry. In many of our blog posts we mention that BoneStation requires no transcription and no dictation. That is because BoneStation automatically generates a suggested assessment.

What is meant by that? How does it work?

BoneStation combines three inputs:

  • DXA Scan Data – The bone mineral data from the DXA scan
  • Patient Data – Information about the patient
  • Questionnaire – Online questionnaire that is built into BoneStation

The scan data, patient info, and questionnaire answers are fed into a rules engine. The engine output the assessment text, which is displayed to the reading physician as a suggested assessment. The reading physician can accept the assessment or alter it.

A simple set of rules may look like this, where the T-score and Z-score are the lowest values for all measured sites:

The above rules make use of information that is available from just the DXA scans (T-score and Z-score) and patient (age). One common variation on this set of rules is to incorporate the gender and menopausal status of women. The rules can be adjusted to look like this, where the menopausal status is indicated on the questionnaire.

BoneStation is very flexible. The questionnaire, rules, and (output) assessment text are all customizable. Some BoneStation customers’ rules consist of more than 30 rules when factoring in fractures (VFA) and other patient conditions.

Here are some sample questionnaires:

In our next blog post we’ll look at how fractures and VFA can be factored into the above rules.

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.

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

BoneStation is an enterprise class bone density reporting solution.  It makes bone densitometry practices more productive by streamlining the workflow of technologists, physicians and administrators.

The assessment for osteoporosis and fracture risk became more complicated when FRAX was introduced about ten years ago.  In addition to the DXA measurements, the patient’s medical history had to be considered when interpreting bone density scans.

FRAX is built into BoneStation’s web-based interface.  When using BoneStation, the DXA machine’s questionnaire is not used.  Instead BoneStation’s online questionnaire is used and BoneStation calculates a FRAX score.

This provides many advantages over using the DXA for FRAX.

  • Technologists and physicians can view and/or modify the questionnaire from anywhere as long as they have access to BoneStation.
  • The FRAX score appears on the report along with the indicated risk factors (from the questionnaire).
  • The questionnaire is readily available to the reading physician during review.  The reading physician can even modify the questionnaire.  The FRAX score generated by BoneStation will be adjusted.  There is no need to have the technologist modify the questionnaire at the DXA and regenerate the FRAX score.
  • Questionnaire’s are saved with each bone density report and can be recalled at any later time.
  • BoneStation has the ability to provide a warning if a questionnaire has not been filled out for a patient.

The workflow for questionnaires is straight-forward in BoneStation.

  • The technologist typically fills out the questionnaire (but this is not always the case).  The questionnaire is stored in a Questionnaire Queue and assigned to the scans when they are transmitted to BoneStation.
  • During review, the reading physician has access to the questionnaire and can even modify answers on the questionnaire.
  • When the reading physician finalizes the study, the questionnaire is saved in BoneStation along with the report.
  • Both the report and questionnaire are available to be recalled at a later time.

Click here for more about bone density imaging workflow.

Next time the patient has a bone density test, answers from the prior questionnaire pre-populate the new questionnaire that is used for the visit.

BoneStation includes a standard questionnaire, which is sufficient for FRAX.  Questionnaires may be customized for a bone density practice.

An online questionnaire has an additional advantage in research environments.  With all data being stored centrally in BoneStation, it is easy to perform data mining.

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.