Digging the Ditch
By Beth W. Orenstein
Radiology Today
Vol. 21 No. 2 P. 18

Radiology is making a push to get rid of CDs.

Over the past two decades, when patients wanted to share their medical images with other providers—whether for a second opinion or some other reason—they’d routinely request that the files be put on compact discs (CDs). This scenario requires the facility with the original images to burn the CD. Then, either the patient has to pick it up and hand deliver it or the facility has to send it by mail or messenger service, incurring additional charges.

Once most radiology departments went digital in the 1990s, “CDs became the primary method of sharing medical images, replacing the large, bulky images that were traditionally provided on film,” says David GrandPre, director of product management at Novarad, a health care IT and imaging solutions company.

But, while CDs “are much better than film,” they are less than ideal, says David S. Mendelson, MD, FACR, associate chief medical information officer at Mount Sinai Doctors Faculty Practice and vice chair of radiology IT at the Mount Sinai Health System in New York. In fact, the list of issues regarding the use of CDs to transfer images is quite long, he says; they include dependability, accessibility, mobility, and security.

No More CD Drives
Perhaps one of the most obvious and critical issues is that “no one has CD drives on their computers anymore,” says Alexander Towbin, MD, Johnson Chair of Radiology Informatics and associate chief of radiology, clinical operations, and radiology informatics at Cincinnati Children’s Hospital Medical Center. Indeed, the national electronics retailer Best Buy announced in 2018 that it would no longer sell CDs as a storage medium, writes Geraldine McGinty, MD, MBA, FACR, chair of the ACR’s board of chancellors, in an article titled, “#DitchtheDisk,” which appeared in the Journal of the American College of Radiology in March 2019. “Apple, too, eliminated optical drives on its computers more than a decade ago,” Towbin says. “You still can buy peripheral drives to view CDs, but most people don’t.”

The CDs that patients bring to their providers usually end up in radiology because that’s the one place in the health care system that may still have the capability to read them. “There are likely only one or two places in the hospital that can still upload CDs, and they’re usually within the radiology department,” Towbin says.

GrandPre adds, “Just finding equipment with CD burners and readers is becoming increasingly difficult.”

Even if a radiology department or imaging facility has a CD drive, the CDs may sit for days until someone is able to take the time to upload the images to the health care system’s PACS. “Getting the images into the local PACS viewer can take extensive and unnecessary manual effort,” GrandPre says. And there’s no guarantee that the CD viewer at the sending and receiving facilities are compatible. “Often the viewer attached to the study does not work on the hardware the viewing facility uses,” he says.

Mendelson agrees that loading CDs to the local PACS is a cumbersome process and “can be a pain in the neck” for those who are asked to do it.

Cost is yet another issue. Burning a single CD usually costs between $3 and $5. That doesn’t include packaging and shipping; it has to be sent via mail or courier, GrandPre points out. And, if patients transport the CDs themselves, the discs can get damaged along the way—CDs have to be protected from heat and scratches—or lost in transit.

Why CDs Remain
When CDs first emerged as a replacement for film, they helped patients take ownership of their medical information, which was something they wanted, Towbin says. At the time, everyone had CD drives on their computers and could see their images on their desktops, if they wanted. But, as the world has moved to streaming technology and downloading, discs have gone away everywhere but in radiology, Towbin says. The question is, why?

“There’s no reluctance on the part of the professional provider or the radiology community at all,” Mendelson says. Mendelson believes radiologists would be happy if all images could be shared via secure, cloud-based file sharing.

GrandPre sees a few issues preventing the elimination of CDs. One is that providers are concerned about patient privacy and compliance with HIPAA. “CDs have been an easy and proven way to avoid liability concerns,” he says. Many in health care also fear exposure of images and patient information to cyberattacks and data breaches, GrandPre says. “There’s also the worry about the cost and time of implementing another new IT solution,” he says. However, GrandPre adds, that last worry may be more perception than reality.

Mendelson says that vendors share some of the blame because they have been reluctant to make their images compatible with one another. “Vendors, first and foremost, want to be the sole provider for the entire country, if not the world,” he says. “That’s why you will always have proprietary solutions. If you want to exchange images, you have to be on their network.”

McGinty writes that “some argue that health systems are not incentivized to make it easy for patients to use other imaging facilities” and regard “the lack of an easy way to transmit images [as] a competitive advantage.” However, she continues, “this hypothesis obviously ignores the very real imperative to make images easily available to support emergency imaging care as well as the fact that we need to earn our patients’ trust and choice of our facility, not use their data as a restraining device.”

Movement Toward Alternatives
Recently, some good news has emerged for those who won’t be sorry to see radiology CDs become obsolete. In 2018, the ACR Informatics Commission, in collaboration with the ACR Data Science Institute and RSNA, formed a task force to #DitchTheDisk. The task force is charged with determining what radiologists can do to encourage their institutions to transition from cumbersome, unsecured CDs to digital, secure, cloud-based file sharing. McGinty is concerned that patients undergo unnecessary repeat exams when they can’t share the results of their prior studies. That’s why, she says, the task force “has made it a priority to ensure that we put our patients at the center and help break down the barriers to them receiving the very best care.”

Some recent developments will help enable internet-based image exchange, Mendelson says. First, two organizations, CommonWell Health Alliance and Carequality, announced an agreement to increase health IT connectivity nationwide. CommonWell Health Alliance, a not-for-profit trade association of health IT companies, operates a health data–sharing network that enables interoperability using a suite of services to simplify cross-vendor nationwide data exchange. Carequality is an initiative of The Sequoia Project, a national, consensus built, common interoperability framework to enable exchange between and among health data–sharing networks. The agreement has the following three parts:

• CommonWell will become a Carequality implementer on behalf of its members and their clients, enabling CommonWell subscribers to engage in health information exchange through directed queries with any Carequality participant.

• Carequality will work with CommonWell to make a Carequality-compliant version of the CommonWell record locator service available to any provider organization participating in Carequality.

• CommonWell and The Sequoia Project have agreed to these initial connectivity efforts and will explore additional collaboration opportunities in the future.

Also, the RSNA Image Share program now will be incorporated into the Carequality Implementation Guide, Mendelson says. While future collaboration could touch on many different areas within health care IT, the immediate focus of the work between Carequality and CommonWell will be on extending providers’ ability to request and retrieve medical records electronically from other providers, the groups say.

“What this means,” Mendelson says, “is that if you’re a member of either organization, you can begin to share information across both networks.”

Three vendors—Philips, Ambra Health, and Life Image—have agreed to join this exchange. “That’s a big deal because it means you will be able to exchange images with any of the other two,” Mendelson says. He expects others to participate in this program as well. “These are significant vendors,” he says. “And, if this is successful, which it is likely to be, others will hop on, no doubt.”

Morris Panner, CEO of Ambra Health, says, “The group is pushing for even more participation,” and he expects to see “real public pressure on who’s in and who’s out on this.”

The 21st Century Cures Act, which was signed into law in December 2016, requires the government to draft an agreement that defines standards for interoperability of patient health information. In 2018, a task force was formed to draft an agreement, known as the Trusted Exchange Framework and Common Agreement (TEFCA). TEFCA is not yet “fully baked,” Panner says, but the idea of full interoperability of health information exchange has bipartisan support. “There’s not a person on either side who would disagree with it,” Panner says. And so, he expects, it could be a powerful tool for helping providers to retire the CD.

File-Sharing Emergence
Other vendors are already proposing solutions, such as Novarad’s CryptoChart, which consists of a small, networked router and a compact QR code printer. Patients and other health care providers are given a time-sensitive QR code that allows them to view the patient’s studies on the cloud. GrandPre says the advantage to the system is that it’s “plug and play” and HIPAA compliant. He says it can be set up in minutes, requires no special training, and offers “over 3,000-bit encrypted passwords with no patient health information left behind.” He adds that it’s considerably cheaper than burning CDs. The fee for printing a QR code is less than $1—approximately one-third of the cost of burning a CD. “There’s a small monthly fee for the equipment and an additional per-study fee for long-term storage,” GrandPre adds.

Mendelson describes himself as a pragmatist, so he does not expect that, despite the many promising developments, CDs are going away anytime soon. He expects it could take another four or five years until health care providers are completely comfortable exchanging patient images electronically or by other means. However, he says, “The recent willingness of vendors to move from proprietary solutions to standard-based solutions supported by both Carequality and CommonWell is a major enabler for all networks to securely exchange data, no matter the underlying vendor.”

At Cincinnati Children’s, “We just let you send your patient’s information however you send it, and we have a way to bring it all into one place,” Towbin says. “We have worked with our preferred vendor to help us do it. We let people send the way they like, and we make sure the data passes automatically into our holding pen so we can normalize it the way we need it.” Towbin says Cincinnati’s system is working fairly well, and he suspects that many hospitals are capable of implementing similar programs for file sharing.

Ideally, Towbin says, he’d like to see patients take complete control over their medical information, including their images. Patients could have vaults where they keep their images and allow access to providers as they see fit. Some countries already use such a configuration, but not the United States, he says. “I’m not sure the US patients are ready for that, but there are some who may be.”

Even if providers have not, the patient community has clearly moved on from CDs, Towbin says. “When you give patients CDs, they realize they’re getting coasters—things they can’t do anything with—and that they have to act as the courier taking them from place to place. It’s not fair to them anymore. It was one thing 30 years ago when we had to do it with film. It was another thing 20 years ago when we couldn’t do it any other way. But, now, we can.”

The radiology community should have some urgency about solving the ongoing CDs issue, Towbin says. “We can’t keep going down this path for much longer. With only one or two places in a health care system having a disc drive and disc burner, eventually, it will become impossible to find drives; as an industry, if we’re not preparing for this eventuality, we’re going to have problems.”

Could 2020 be the year when CDs disappear and other file sharing solutions take their place? Panner says Ambra is telling its customers, “Demand interoperability from all of your vendors because you’re the one with the power. If we all start using that leverage, we will see more and more commitments.”

Is radiology there yet? “No, not yet,” Panner says. “But we are hopeful, and we are working on it.”

— Beth W. Orenstein, a freelance medical writer based in Northampton, Pennsylvania, is a regular contributor to Radiology Today.