A Quality Assist
As new informatics challenges arise, radiologists support their referring clinicians and health systems in becoming more efficient.
Michael Jordan is arguably the greatest NBA basketball player of all time. Not because he won the most league titles (Bill Russell won 11 to Jordan’s six), nor because he scored the most points (Kareem Abdul-Jabbar holds that honor).
Jordan tops many experts’ lists because he, more than any other player, made his teammates better. This is precisely what radiologists must do to ensure their value: help make their referring providers better, more efficient stewards of patient care.
One of the most effective ways to do this is to overcome informatics barriers. With both CMS and private payers laying the groundwork for predicating physician reimbursement dollars on the value of care provided, radiologists must identify efficiencies in coordinated workflows. Imaging experts who help their referring clinicians provide better care at a lower cost will be in the best position to avoid downward payment adjustments in the years to come.
Before the advent of PACS, referring clinicians routinely made the trek to the reading room to consult with radiologists. With the interpolation of technology between imaging experts and referrers, however, radiologists have by-and-large been relegated to the sidelines when it comes to patient management. Radiologists must reverse this trend, says Kevin W. McEnery, MD, director of innovation and imaging informatics and professor of radiology at MD Anderson Cancer Center in Houston, if they are to be seen as vital to patient care. And one way to switch gears, notes McEnery, is through the intelligent use of informatics.
“Radiology metrics traditionally have involved how many RVUs the radiologist generates,” explains McEnery. “Somehow, though, we have to come up with new metrics that get at patient outcomes. But that’s a really difficult metric to ascertain.” Radiology is starting to see the beginnings of this transition, however, says McEnery, in imaging appropriateness. “This is the first domino,” McEnery continues. “We’ve got to make sure that the studies being requested by the referring clinicians have a reasonable likelihood of adding valuable clinical information to the care process.”
Electronic health records (EHRs) may hold the key to determining radiology’s value to patient outcomes, predicts Christoph Wald, MD, PhD, MBA, FACR, chair of radiology at Lahey Hospital and Medical Center, professor of radiology at Tufts University in Boston, and vice chair of the ACR Commission on Informatics. “I envision that wider deployment of EHRs and their wealth of information combined with intelligent natural language processing and search engines could empower radiologists to analyze which of their imaging exams actually changed the course of patient management,” says Wald.
Also, notes Wald, radiologists can do a number of things in addition to their interactions with referring clinicians to improve patient outcomes. “Radiologists could also look at how they can decrease the time patients spend in scanners, for MRI in particular,” says Wald. Some questions radiologists can ask themselves from an informatics perspective include, “What is the minimum meaningful number of sequences needed to answer the clinical question at hand?” and “In what order should MR sequences of a particular protocol be performed to minimize scan time and maximize patient comfort while answering the relevant questions?”
Identifying Next Steps
According to J. Raymond Geis, MD, FACR, vice chair of the ACR Commission on Informatics and assistant clinical professor of radiology at the University of Colorado School of Medicine, radiology in the fee-for-service world uses volume metrics because they are easy to measure and they relate to income. “A metric is a measurement, ” notes Geis, “and as soon as one attaches value to that measurement, people manage to it,” altering their behavior to optimize the metric. “Is turnaround time really the most relevant goal? It might be better to develop a metric on the order of, say, ‘How often does the radiologist help the ordering clinician do the right thing?’”
Tessa S. Cook, MD, PhD, assistant professor of radiology at the Hospital of the University of Pennsylvania, agrees that radiologists have to devise better metrics if they are to be seen as equal partners in patient management. “A radiologist can have short turnaround times and be a bad radiologist,” says Cook. “That metric only tells you how long it took to get from an image to a report. It doesn’t tell you how actionable the report was to the clinician who received it, how easy it was to interpret, or how much of an impact it had on the downstream care of a patient.”
McEnery agrees that the radiology report is a major vehicle by which radiologists can have significant downstream effect on patients. Not only should the next generation of reports become clearer, believes McEnery, but radiologists also must assist referring clinicians in moving forward with a patient’s care.
“We have to be almost prescient in assisting the clinician in determining the next steps in a patient’s workup,” asserts McEnery. One way to make this happen, he notes, would be to set up the radiology report to mimic some of Amazon’s functionality. “If, for example, the radiologist creates a chest x-ray report that says there’s a new nodule in the left upper lobe of the lung, the expectation is that the referring clinician is going to be ordering a CT scan,” explains McEnery. “It would be interesting if the report asked referring clinicians if they wanted to order the CT scan. This would allow referring clinicians to be more efficient. In one click the CT scan could be ordered.”
The future of radiology depends on the intelligent use of informatics. Since a semi-autonomous IBM Watson-like system is relatively far off, radiologists must decide how they can impact patient care given the informatics tools at their disposal. Doing so will ensure radiologists are seen as crucial to quality patient care.
By Chris Hobson, Imaging 3.0 senior communications manager