HIE Image Sharing for a Statewide Stroke Network Session #68, March 6, 2018 Karan Mansukhani, MPH, MBA, Program Manager, Chesapeake Regional

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1 HIE Image Sharing for a Statewide Stroke Network Session #68, March 6, 2018 Karan Mansukhani, MPH, MBA, Program Manager, Chesapeake Regional Information System for our Patients (CRISP) Dr. Michael Phipps, MD, MHS, Director, Brain Attack Center, University of Maryland Medical Center 1

2 Conflict of Interest Karan Mansukhani, MPH, MBA Michael Phipps, MD, MHS Have no real or apparent conflicts of interest to report. 2

3 Agenda Learning Objectives Problem Statement Our approach Stroke Time is Brain Why HIE-enabled image exchange is a game changer for stroke care Outcomes Barriers Recommendations Questions 3

4 Karan Mansukhani MPH, MBA Program Manager, Chesapeake Regional Information System for our Patients, Baltimore, Maryland 4

5 Learning Objectives Demonstrate how an HIE with an image exchange service can improve triage and assist in clinical decision making, leading to improved patient outcomes Illustrate the value of decreasing time to treatment for acute ischemic stroke and intracerebral hemorrhage patients through an HIE image exchange service Quantify the potential savings of time and costs based on ROI studies conducted at participating sites as well as reduction of radiation exposure to patients Contrast sharing images through HIEs with stand-alone image sharing networks 5

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7 Problem / Issue: How do we make stroke images available from multiple community hospitals to a specialist at a Comprehensive Stroke Center? Ideal State: At the point of care, we enable an ED provider at a community hospital with the ability to publish an image and collaborate in real time with a stroke specialist at an external location to jointly view, triage, and make treatment / transfer decisions 7

8 Step 1: Identify the technology CRISP - Chesapeake Regional Information System for our Patients Non-profit state-designated Health Information Exchange (HIE) that has real-time clinical feeds from All 48 acute care hospitals in Maryland and 8 hospitals in Washington D.C. Growing connectivity to ambulatory practices, skilled nursing facilities and long term care 12,000+ users 17 million unique patients data 8

9 Health Information Exchange Edge Device Community Hospital 5. New patient created (as required) 6. Emergent deep link sent to Interface engine 3. Patient, Study & Facility information extracted from DICOM header Data Center 2. Study forwarded as Emergent Exam Emergent Destination 1. DICOM send PACS / Modality 7. Link published on dedicated Stroke Worklist 4a. ADT Patient Registration 4b. ORU Message Exam Creation Emergent Image Cache 2. Study forwarded as Emergent Exam Community Hospital Edge Device Neuro Radiologist Stroke Stroke Resident Specialist 8. Launches CT/CTA 9 Emergent Destination 1. DICOM send PACS / Modality

10 Step 2: Engage specialist groups Maryland Institute for Emergency Medicine Systems Services (MIEMSS) Stroke Consortium Representation for all 48 hospitals Responsible for Quality Improvement Activity Define Stroke Protocols Auto-route defined studies 10

11 Step 3: Get connected 11

12 Dr. Michael Phipps MD, MHS, Director, Brain Attack Center, University of Maryland Medical Center, Baltimore, Maryland 12

13 Stroke #5 cause of death in the US #3 cause of death in Maryland #1 cause of serious, long-term disability in the US On average, every 40 seconds someone has a stroke Types of strokes: Ischemic Stroke: 87% Hemorrhagic Stroke: 13% Distinctly different treatment protocols 13

14 Time is Brain The only way to determine the type of stroke as well as the appropriate course of treatment is emergency brain imaging, interpreted by a neurologist/ neuro-radiologist Many community hospitals do not have a neurologist / neuro-radiologist on staff Treatment must occur within six hours* of symptoms Certain treatments, such as endovascular clot retrieval, are ONLY available at JCAHO certified Comprehensive Stroke Centers (CSC) in the state of Maryland 14

15 Time Trend for Scientific evidence 1990 s/2000 s: Angioplasty +/- stenting Early 2000 s: Merci retrieval device Late 2000 s: Penumbra Suction/Fragmentation devices 2012: Stent retrieval devices (USA): Solitaire and Trevo 2013: Advanced suction catheters (USA) 15

16 Time Trend for Scientific evidence 2015: 5 trials demonstrating dramatic improvement with endovascular therapy for large vessel occlusions 2017/2018: DAWN/DEFUSE trials 16

17 CTA of a Large Vessel Occlusion Courtesy Dr. Timothy Miller, University of Maryland 17

18 Stent Retriever 18

19 Stent Retriever Case Courtesy Dr. Timothy Miller, University of Maryland 19

20 Stent Retriever Case 20

21 Time to Reperfusion and Outcome: IA Trials (Prabhakaran et al. JAMA, 2015) Reperfusion at 5.5 hrs Reperfusion at hrs 21

22 DAWN/DEFUSE trials: Extend the possible treatment window to hours However, this is only based on IMAGING characteristics Using imaging, we need to know: The irreversibly damaged area of brain The brain area at risk, but not irreversibly damaged Due to limited bed availability, we cannot accept every patient with stroke symptoms who present within 24 hours Therefore we need access to brain imaging at community hospitals that is fast and accurate 22

23 User Experience: 23

24 View Radiology and Clinical data side by side 24

25 Toggle and Collaborate in real-time 25

26 HIE-enabled image exchange is a game changer for stroke care Single point of entry: Stroke specialists can access images from all sources connected to the HIE Critical clinical information is readily available: Patient history of stroke, INR lab values, medication lists, known contraindications Appropriate and Faster triage: Real time image sharing makes transfer decisions faster Avoid Importing and Exporting studies from physical media: Real time image sharing makes treatment decision faster 26

27 Patient stroke symptom start Image Sharing without an HIE : Patient presents at ED CT/A Study Triage (Treat or Transfer) Treat Transfer Burn a CD tpa Repeat/First CTA Study Read Endovascular Clot Removal Supportive treatment 27

28 Patient stroke symptom start Image Sharing through an HIE : Patient presents at ED CT/A Study Image pushed to EDGE device No Repeat studies Transfer IR prepped Endovascular Clot Removal Image published on HIE = Faster triage Treat tpa Avoid unnecessary transfers Saves critical beds Stroke Specialist / ED doc consult 28

29 Outcomes Number of stroke transfers Number of Endovascular therapies Number of repeat images Reduced Radiation Exposure Door to groin time With and without advanced imaging 90 day disability score (modified Rankin) Return on Investment Net Present Value 29

30 Metrics Jan Dec 15 Jan Dec 16 Jan-Dec 17 # Acute Stroke calls # Transfers # Endovascular therapy # of repeat imaging Door to Groin time * 79 mins 63 mins w advanced imaging w/o advanced imaging * * 61 mins 40 mins Modified Rankin <2 * 38% 40% (9 mo) 30

31 Return on Investment 5 hospitals identified and reported: Costs savings factors Import/Export costs Discontinued local image sharing interface costs Costs avoidances factors Avoided licensing costs for stand alone image sharing vendors 31

32 Return on Investment ROI Y0 ROI Y1 ROI Y2 ROI Y3 ROI Y4 A B C D E

33 Net Present Value Hospital Net Present Value A $792,391 B $72,949 C $131,020 D $106,738 E $176,400 Average $255,900 33

34 Reduce System Total Cost of Care Avoided duplicate imaging Avoided inpatient admissions Avoided critical care days Avoided pharmacy costs Avoided ambulance transfer costs 34

35 Barriers Existing local sharing networks Interfaces Independent image sharing platforms Change management User Interface Cost Setup Maintenance Storage 35

36 Recommendations For HIEs - Identify vendors with HIE experience - Flat fee vs Per-click fee - Engage specialist groups - Identify Champions - Subsidize upfront costs - Maintain contact with PACS admins, Radiology techs - Reach out to us! 36

37 Questions? Contact: Karan Mansukhani, MHA, MPH, MBA, Program Manager, Chesapeake Regional Information System for our Patients (CRISP) Dr. Michael Phipps, MD, MHS, Director, Brain Attack Center, University of Maryland Medical Center (UMMC) @UMBaltimore Please complete the online session evaluation! 37