LAS VEGAS - The creation of a health information exchange (HIE) in the Maryland/Washington, DC, region has improved stroke care by giving doctors faster access to medical images, enabling them to triage patients better, according to a Tuesday presentation at the Healthcare Information and Management Systems Society (HIMSS) meeting.
The exchange, called the Chesapeake Regional Information System for our Patients (CRISP), went into full operation in mid-2017 after 18 months of being run as a pilot operation. The network allows images of patients being seen at community hospitals to be sent to the region's specialty stroke center, where a determination can be made as to the type of care they should receive and whether they should be transferred for endovascular therapy.
The experiences with CRISP were described at HIMSS 2018 by Dr. Michael Phipps, director of the Brain Attack Center at the University of Maryland, and Karan Mansukhani, program manager for image exchange at CRISP.
Time is brain
Stroke is the No. 5 cause of death in the U.S. and the No. 1 cause of long-term disability in the country. While multiple therapies have been tried for stroke patients, the recent introduction of clot retrieval devices has improved the outlook for stroke victims -- assuming they can be treated within six hours of the stroke event -- hence the phrase "time is brain."
The challenge is that while 87% of strokes are ischemic, for which clot retrieval is appropriate, 13% of patients have a hemorrhagic stroke, for which the use of clot retrieval would be disastrous. Only medical imaging can provide the information doctors need to determine which is which, and this can help determine which patients should be transferred from a community hospital to the stroke center for clot retrieval and which ones can be treated at their local hospital, Phipps said.
But getting images from the community hospitals to the stroke center can be a challenge. That's where CRISP comes in. The system consists of edge servers that take images from PACS at community hospitals and make them available via a portal to specialists at the stroke center. The images continue to reside at the local hospitals; CRISP has no image storage function, Mansukhani pointed out.
CRISP was launched as a pilot project with federal funding in December 2015, with five hospitals initially participating. It's been rolled out in stages since then, with full operation being achieved in mid-2017. Currently, 21 hospitals in Maryland and Washington, DC, are participating in CRISP.
How well is it working? Phipps and Mansukhani presented early data collected from the hospitals that began participating in the pilot phase. The HIE can get images from community hospitals to specialists at the stroke center in 10 minutes, and CDs are no longer needed for transferring images.
Hospitals in the CRISP network saw an increase in the number of patient referrals, which Phipps and Mansukhani attributed to a growing awareness of the effectiveness of endovascular clot retrieval therapy. But they also saw a decline in the number of repeat imaging scans that had to be performed -- and, perhaps most significantly, a sharp decline in the "door-to-groin time," or the time between when the patient leaves the community hospital and when the interventional treatment begins.
| Effect of CRISP health info exchange on patient outcomes | ||
| 2016 | 2017 | |
| No. of patient transfers | 66 | 91 |
| No. of endovascular therapy procedures | 14 | 17 |
| No. of repeat imaging studies | 8 | 5 |
| Door-to-groin time | 79 minutes | 63 minutes |
But what about the cost of setting up the network? There is some expense, but CRISP received federal funding to establish the project (funding that is due to expire soon). Mansukhani provided a return-on-investment (ROI) analysis indicating that CRISP hospitals would save $5 for every $1 invested in the project after five years.
Phipps and Mansukhani will continue to collect data on outcomes from the additional hospitals that have joined the network. But they offered some points of advice for HIMSS attendees who may want to set up their own HIE:
- Find PACS vendors that have already worked with a health information exchange (CRISP is working with software from 10 PACS vendors, Mansukhani noted).
- Pick a flat fee for managing images rather than a per-click model to avoid giving vendors an incentive for trying to boost volume.
- Keep specialists engaged.
- Identify champions who can promote the project.
- Work closely with PACS administrators and radiologic technologists, as a project like an HIE really needs their support, Mansukhani said.
