Cloud-Based Medical Data Exchange at Virtual HIMSS

Exchanging medical information in the cloud is getting more attention these days, as its patient-safety and economic advantages become more apparent.

Among the leaders in this field is eMix, a client of ours. Florent Saint-Clair, eMix general manager, recently led an On-Demand Education Session of Virtual HIMSS12 titled “Cloud-Based Medical Data Exchange: What We’ve Learned So Far.” Virtual HIMSS 12 was held online from Feb. 20-24. To see Saint-Clair’s post on the HIMMS blog, click here.

HIMSS provided the virtual sessions as a way to take part in activities related to the HIMSS 2012 Annual Conference & Exhibition, other than attending the event in person. Attendees were able to participate from any location in the world. Virtual HIMSS12 included both interactive activities and on-demand sessions such as the one on cloud-based medical data exchange.

Saint-Clair’s session described the evolution of cloud-based medical data exchange from its introduction in 2010 to its increasingly wide use today. He discussed why the technology is a giant leap forward from such troublesome, limited workaround solutions as exchanging files on CDs and sending them via virtual private networks (VPNs).

CD and VPN file exchanges are plagued by such issues as time delays, reliability, and security. Cloud-based medical data exchange has created a sharp, and welcome, break with this troubled past. Thanks to the new technology, a hospital can now securely send an imaging or other medical file to a radiologist’s EHR, PACS, or mobile device – indeed, any computer with a broadband connection – in just minutes.

The technology is similar to using email and just as reliable. It is also vender-neutral, which means it neatly hurdles the fact that medical information technology systems are often proprietary and don’t easily “talk to” each other. This was the problem that created workarounds such as CD- and VPN-mediated file exchanges in the first place.

Saint Clair’s presentation detailed the various ways that patient care has been improved by the increased reliability and speed brought about by services like eMix. He also noted the adjustments that adopters of the services face with respect to their workflow, protocols for handling images, and business processes. For those who couldn’t make it to HIMSS, the session provided an opportunity to get updated on an important new advance in medical data exchange with the depth and sophistication that HIMSS attendees expect.

Breast Cancer Media Teleconference

Shortcomings of the New Study on Breast Cancer Brachytherapy (APBI): What Women Need to Know Now

On December 13, 2011, four of the world’s leading clinical researchers in breast brachytherapy gathered to provide statements and discuss a controversial new study on APBI presented at the 2011 San Antonio Breast Cancer Symposium.

Featuring:
• Robert Kuske, MD, (Scottsdale, AZ) Co-Principal Investigator, NSABP B-39 study comparing five-day APBI to six-week whole breast irradiation
• Peter D. Beitsch, MD, FACS, (Dallas, TX) Co-Principal Investigator of the American Society of Breast Surgeons’ MammoSite Registry
• Jayant Vaidya, MD, (London, U.K.), pioneer of targeted intraoperative radiotherapy (IORT)
• Rakesh Patel, MD, (Pleasanton, CA), Chairman, American Brachytherapy Society

Stream audio of teleconference

Background:
The study was based on Medicare billing claims for more than 130,000 patients over the age of 66 who were diagnosed with early stage breast cancer between 2000 and 2007 and received a lumpectomy and radiation.

Many members of the medical community have spoken out against the study since it was presented. In particular, many physicians object to mastectomy being considered a validated surrogate for local failure, contending that there are many indications for mastectomy unrelated to APBI, such as a new primary cancer or elsewhere failure, and that claims data do not provide sufficient clinical information to draw such conclusions. In addition, the study claimed brachytherapy was associated with higher rates of infection and increased toxicity which is contrary to results of several published clinical trials on brachytherapy.

Read statements of concern from the major medical societies involved in the research and use of APBI – American Society of Breast Surgeons, American Brachytherapy Society (PDF) and American Society of Radiation Oncology.

MD’s Criticize Breast Brachytherapy Study

A controversial study on breast brachytherapy (APBI) presented last week at the San Antionio Breast Cancer Symposium has prompted deep concern among APBI experts. They worry that breast cancer patients who are good candidates for APBI modalities such as SAVI, MammoSite and IORT will be scared off the therapy, by what the experts say is an inaccurate and misleading study.

Below are statements by three of these internationally know experts, prepared for a Dec. 13, 2011 teleconference they organized to challenge the study findings.

“Shortcomings of the New Study on Breast Cancer

Brachytherapy (APBI): What Women Need to Know Now”

  Robert Kuske, MD, FAACE:

 — Co-Principal Investigator, NSABP B-39 study comparing five-day APBI to six-week whole breast irradiation.

Partial breast irradiation (PBI) was begun in New Orleans in 1991 by myself and colleagues at the Ochsner Clinic, and has been one of the most studied treatments for breast cancer over the past 20 years.  Numerous publications have shown PBI to be safe and effective for select early stage breast cancer patients. As a result of promising phase 2 clinical trials and two favorable randomized prospective clinical trials (scientifically the “Gold Standard”), there has been growing interest in using PBI. Accelerated PBI (APBI) treats only the part of the breast affected by cancer and the treatment time is decreased from several weeks to four or five days. For decades, whole-breast irradiation (WBI), where radiation is delivered every day for five to eight weeks, has been the standard treatment for patients with early breast cancer treated with breast conserving surgery.

APBI has several benefits, including a decreased overall treatment time and a decrease in the radiation delivered to healthy tissue and adjacent organs.  To document its long-term safety and effectiveness compared to WBI, we await the results of the other 7 randomized trials comparing APBI with WBI.

I am concerned about the potential misinterpretation of data presented last week at the 2011 CTRC-AACR San Antonio Breast Cancer Symposium regarding breast cancer patients who received brachytherapy, or accelerated partial breast irradiation (APBI). These data have serious limitations, and should not influence current treatment recommendations for women with early stage breast cancer fitting current eligibility criteria for PBI.

This study, based on Medicare claims data, demonstrated a small 1.8% increase in the rate of mastectomies in patients treated with APBI compared with those treated with conventional whole breast external beam irradiation. Note that the rate of documented recurrences of breast cancer after treatment is not reported.  In either case the rate of mastectomy is still very low (2.2 to 4%), and should be contrasted with the 35 to 40% recurrence rate after lumpectomy without any radiotherapy.

The data presented in San Antonio was drawn from records of patients varying risk factors and stage treated between 2000 and 2007. Doctors choose treatments for their patients based on cancer extent, grade, surgical margins, and other factors such as obesity, diabetes, and age.  This study failed to take these important tumor and patient issues into account, and is therefore biased. This study is a good example of why it is important to be selective in choosing which patients receive the accelerated treatment.

The PBI treatment given in this study is an antiquated balloon catheter with a single channel. Since that time, technology has dramatically improved including the use of newer multichannel applicators with tighter dose constraints. The side effects and toxicity seen with these modern technological advances are far better than the results presented in this study.

This study should encourage enrollment in clinical trials, especially NSABP B-39/RTOG 0413, a National Cancer Institute-sponsored, randomized prospective phase 3 trial. In the meantime, doctors and patients should not limit their options, and should continue to consider a 5-day alternative to conventional 6-7 weeks of whole breast irradiation to conserve the breast.

Peter Beitsch, MD, FACS:

Co-Principal Investigator of the American Society of Breast Surgeons’ MammoSite Registry.

The study presented by at the San Antonio Breast Cancer Symposium has garnered a tremendous amount of print and Internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in breast surgery and radiation oncology, I want to try to clarify the data on APBI, and discuss the “information” in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, accelerated partial breast irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early-stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer.  Numerous retrospective studies and two prospective randomized studies (the gold standard) have shown no difference in survival, local-regional cancer recurrence rates and complications between APBI and whole breast irradiation (WBI).  The American Society of Breast Surgeons’ MammoSite Registry has published more than 16 papers showing the safety and efficacy (comparable to WBI) of MammoSite APBI.

The San Antonio abstract and presentation were drawn from the Medicare claims-SEER database, which is a large database with cancer-patient data linked to Medicare claims data.  The database is managed by the National Cancer Institute and sold to institutions to do research.  The linked database has information about cancer type and treatments, but it has no specific data on margin status, prognostic factors such as estrogen receptor/progesterone receptor (ER/PR) and HER2/Neu receptor — or even local, regional or distant recurrence.

The study stated that “subsequent mastectomy” is a “validated surrogate for local failure,” but I am unaware of any literature that states this.  The “two-fold increased risk for subsequent mastectomy” is misleading and inaccurate. (It s 4.0% for APBI vs. 2.2% for WBI in their study).  Both of these rates are quite small, and it is questionable whether there is any clinical significance between the two.  Not emphasized but equally important are the overall survival rates for APBI vs. WBI, which were equivalent.

The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast), but there is no statement regarding severity (were the APBI patients just placed on prophylactic antibiotics and is that how an infection was defined?).  Fat necrosis and breast pain were also significantly higher in the APBI group, although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity of the fat necrosis or breast pain.

Lastly, the researchers state there was a 9.6% hospitalization rate for APBI patients vs. 5.7% for WBI patients.  This is puzzling since no diagnosis was given for hospitalization nor was there information on the time period over which patients were hospitalized. Was hospitalization APBI-related (doubtful) or related to first chemotherapy cycle (perhaps) or other unrelated health issues? (It’s worth noting that APBI is often used in older, sicker patients who may not be candidates for six to seven weeks of WBI).

In summary, this retrospective study of an inherently inaccurate database (no data on tumor characteristics and margin status — both known to be significant determiners of local recurrence), with questionable outcomes (admission rate) and non-validated “surrogate endpoints” (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and two prospective randomized trials to the contrary.

Jayant Vaidya, MD:

— Pioneer of targeted intraoperative radiotherapy (IORT).

We have performed a prospective randomized phase III trial, which is considered the highest level of scientific evidence.

We have shown with the TARGIT approach (risk-adapted partial breast radiotherapy with a single dose of radiotherapy during breast conserving surgery) that the local recurrence rate is very low (about 1% after 4 years). This rate is non-inferior to the standard approach, which was used in half of the more than 2000 patients.

This supports the concept of PBI in selected (e.g., older) patients with small tumors.

Also important was that the toxicity was not higher with the new approach. The rates of clinically relevant toxicity were about 3% in both treatment arms.  Toxicity is highly dependent on how radiation is delivered, i.e. treatment device, dose, dose rate, fractionation and target volume concept.

– End –

eMix a Radiology Success in Montana

Healthcare Informatics magazine reports in its new issue on eMix and the Montana consortium known as IMOM. Using eMix (Electronic Medical Information Exchange — http://www.emix.com) IMOM facilities are sharing radiology images and reports.

See the full article at http://tinyurl.com/29b35db.

Montana facilities use eMix to share radiology images and reports much more quickly and at less expense — realizing a key goal for many of the state’s rural healthcare facilities.

The article puts it this way:

“eMix uses cloud-based technology to house images after they are encrypted and pass through eight layers of security that include a physically secure data center and member and user authentication. The uploaded images are then accessible to the intended recipient through a simple download following an e-mail notification.

“Beginning in November 2009, three Montana health providers-Great Falls Clinic, St. Luke Community Hospital in Ronan, and Kalispell Regional Medical Center in Kalispell, all with different PACS, started beta testing the eMix service. No significant problems were encountered, and three additional facilities-Benefis Health System in Great Falls, St. Vincent Healthcare in Billings, and Glendive Medical Center in Glendive, were added as beta sites. In March 2010 beta testing concluded and the facilities signed up with eMix to continue sharing images.”

eMix is a venture of DR Systems (www.dominator.com), a client of Dowling & Dennis PR.

eMix Radiology Cloud Computing Expands

Radiology is in a transition phase when it comes to sharing radiology data between various users. We’re moving from sharing files on old technology such as CDs to sharing images and reports using cloud computing– that is, sharing the files in electronic form using a hosted service on the Internet.

During this transition time, however, hospitals are still getting a lot of radiology files on CDs. How they move those files to hospitals and doctors without the expense, hassle, and time delays of mail or shipping? eMix – created by DR Systems, a client of Dowling & Dennis PR — has found a way.

eMix (“electronic medical information exchange,” http://www.emix.com) is the leading cloud-based system for sharing radiology images and reports. It has just added a terrific new feature: The ability to import data from CDs.

Now when hospitals get radiology data on CDs, they can import it into eMix. From there, the files can be read, moved to another hospital IT system such as a PACS or radiology information system, or sent via the cloud to another hospital or doctor.

The process is as simple as sending email. The new eMix feature enables them editing of the imported exam’s medical record number (MRN) so it corresponds to their own numbering system and also create a radiology order session number.

This new feature also allows users to import data into eMix from a USB thumb drive, external hard disk, and/or other digital storage device. That makes eMix the ideal bridge into the future, from the technology mix we have today.

Cloud Brightens Radiology

While healthcare reform will make immediate changes in the medical landscape, one aspect of care is still evolving only slowly. The problem: Most patient information remains on paper, stored away in files. Even most electronic patient information remains in silos – and is often not readily accessible, with appropriate privacy safeguards, to caregivers who need it.

Radiology, which generates most of the information in an electronic health record, has traditionally relied on proprietary picture archiving and communication systems (PACS) to store and transmit patient info. While PACS will remain central to radiology, much of this information will eventually migrate to the “cloud” of digitalized info that can be uploaded and downloaded remotely – again with privacy safeguards – to and from websites and servers.

This month has seen the official commercial launch of eMix (“electronic medical information exchange,” http://www.emix.com). It’s the leading new application for sharing radiology images and reports, but it certainly won’t be the only one.

eMix solves a problem that has vexed medical imaging: how to securely share radiology data between proprietary PACS and other IT systems that don’t “talk to each other.” The solution: Use cloud computing to make data sharing as easy as sending and receiving email. The service was created by DR Systems, a client of Dowling & Dennis PR.

As RHIO’s (regional health information organizations) evolve into HIE’s (health information exchanges), they’ll have to figure out how HIE members can easily and inexpensively share patient information. Given how hard this is to do institution-by-institution or state-by-state, it seems inevitable that HIE’s will look to the cloud for the solution.

eMix Radiology Sharing Service Debuts

eMix, a groundbreaking new technology for sharing radiology images and reports, has made its debut in Montana health facilities. A number of other health systems are also lined up to use eMix (“electronic medical information exchange”).

For “Healthcare IT” magazine’s coverage of this exciting new service, see http://tinyurl.com/yfo4of7.

The first three institutions to use eMix were Great Falls Clinic,
Kalispell Regional Medical Center, and St. Luke Community Healthcare. The service was created by DR Systems, a client of Dowling & Dennis PR.

eMix solves a problem that has vexed medical imaging: how to securely share radiology data between proprietary PACS and other IT systems that don’t “talk to each other.” The solution: eMix uses “cloud computing” to make data sharing as easy as sending and receiving email.

The three Montana facilities are involved in a grassroots organization called Image Movement of Montana (IMOM), which formed to address the difficulty of sharing radiology images and reports. IMOM approached numerous vendors for possible solutions. DR System’s eMix was by far the most attractive option because it was simple, affordable, and required no new hardware or software.

For more information, visit http://www.emix.com.