By Elaine Sanchez Wilson
Improved population health at a lower cost and higher quality—in today’s world, these triple aims of healthcare have placed value at the forefront for success, ahead of volume.
Recognizing this systemic shift in the way medicine is delivered, the American College of Radiology recently launched a campaign called Imaging 3.0, a comprehensive road map that aims to provide radiologists with resources on how to make the volume-to-value transition. “The future of radiology is certain. The future of radiologists is less so,” explains Geraldine McGinty, MD, MBA, FACR, quoting the ACR’s 2013 Gold Medal Award recipient Lawrence Muroff, MD. The initiative is a way for those in the specialty to remain ahead of the curve, using existing tools more effectively and redefining their roles in today’s era of integrative, collaborative care.
“We need to demonstrate our value in terms of interacting with patients and the rest of the care team,” continued McGinty, chair of the ACR Commission on Economics. “With the way that reimbursement has been going, running on that hamster wheel trying to catch up and keep your income the same by reading more studies—well, that is not a recipe for success.”
Many of the ideas within this toolkit aren’t new. For example, on the College’s official website, one can access a page that displays all the programs that fall under the Imaging 3.0 umbrella; among these are familiar programs like ACR’s Image Wisely and Image Gently and RSNA Image Share. But by fitting these resources into an organized framework, the College seeks to provide an overarching set of principles that would inform its efforts going forward.
“This is going to be our specialty’s value proposition to our colleagues, to the payors, to the policymakers, and of course to the patients, about how we’re going to do all the great things that we’ve always done, but focus on where we can add value,” said Bibb Allen, MD, FACR, vice chair of the ACR Board of Chancellors. “We want to be sure that everything that we’re doing is not done just because someone ordered it, or just because we can, or just because someone thinks we might need it. We need to really start using evidence-based guidelines of how we can optimize what we do in imaging to provide value.”
A peek inside the toolkit
Imaging 3.0 is all about the point of care. It begins even before a radiologist sees the patient. Rather, it starts when the referring physician contemplates imaging. Under this section of Imaging 3.0, the ACR aims to ensure that the guidelines that it developed are not cumbersome. Clinical decision support places appropriateness guidelines in front of the referring physician at the time of order entry. Radiologists can make themselves available to determine whether medical questions can be answered just as well with an MR scan or ultrasound and possibly save the radiation exposure from a CT scan.
“We want to emphasize that the protocols are safe for the patient, that we’re going to image gently and image wisely on the radiation exposure front, that we’re going to be board certified participating in certification, that we’re doing everything we can do for meaningful use and PQRS that will keep us assured that we are providing the best care that we can at the time of interpretation,” Allen said.
Another component of Imaging 3.0 deals with the imaging acquisition and interpretation phase. This involves how radiologists can report critical results and make them available for patients in the time span that meaningful use requires. The initiative also looks to leverage IT to facilitate standardized recommendations for incidental findings. This can be accomplished one day, for example, through the development of voice recognition software capable of reading reports in real time.”
Moreover, Imaging 3.0 encompasses what is done after the exam, when radiologists make actionable recommendations. It also encourages the measurement of quality through resources like the ACR’s National Radiology Data Registry. “You can input your own practice data and then compare it to other practices to see how you measure up,” said Raym Geis, MD, FACR, chair of the Society for Imaging Informatics in Medicine and a radiologist with Advanced Medical Imaging Consultants, PC, in Fort Collins, Colo. “All of us in practice think we’re doing better than the competition. It is helpful to verify that by comparing to others. We can’t learn from our data until we start to quantify them.”
Ample evidence demonstrates that patients who are more informed and engaged in their care are more compliant with the recommendations of their healthcare providers and experience better health outcomes.
The ACR hopes that in engaging with patients, radiologists can help ensure that patients are more informed about their care. “We know that patients now want to have easier access to their images and reports,” said Geis. “We want to offer them a secure way to have their images and reports available for anyone who needs to see them.”
Geis pointed out that radiologists have an opportunity to support and empower primary care providers as well. “By encouraging peer-to-peer consultations and developing strong relationships with our fellow clinicians, we can empower the other providers in the healthcare delivery system,” he said.
In particular, the communication arm of Imaging 3.0 touches upon something that many radiologists find challenging.
“If someone has acute bleeding in their head or a large pneumothorax in their chest where their lung has collapsed, you need to pick up the phone and make the call personally,” Geis said. “But if you find something in the patient’s preoperative chest x-ray, for example, a lung nodule that was unexpected, you need to alert the patient’s primary care physician or surgeon, but you don’t need to do it right then. That’s something that radiologists have struggled with for years. Are there ways, using an IT tool, to do that more efficiently?”
At the heart of it, Imaging 3.0 explores how radiologists can make contributions to healthcare delivery apart from the professional fee for interpreting studies. “One of the things that we have promoted is that radiologists need to get some credit—however you define that—for their noninterpretive professional role,” said David E. Avrin, MD, PhD, chair of the Education Committee for the Radiological Society of North America and a professor of Clinical Radiology at University of California-San Francisco School of Medicine. “This can include their consultations for what study should be done, their involvement in the clinical decision support system, tumor board participation, and their role in talking to the patient.”
The shifting landscape
Now that the country is heading toward a different compensation system, radiologists cannot bury their heads in the sand and hope it all goes away, Avrin cautioned. “The total imaging effort needs to be reduced. We need to stop doing repeat studies for patients who are transported because we can’t load the images,” he said. “We need to think more carefully about the studies we are doing and what the clinical decision support guidelines are. We need to establish our value, the value of medical imaging, at the crucial points of the patient care process and what we bring to the table beyond the purely interpretive function of reading a study.”
From the medical home concept to the accountable care organization (ACO), the model of medical care in the United States is changing from individual silos of private practice for every specialty to more of an integrative, interactive system with more patient involvement. In these coordinated care plans, value is demonstrated by one’s contribution to overall patient health and efficiency of the entire plan.
“Over the recent past, radiology has become even more integral to medical care on all levels, from more screening programs, to being used by many specialties for primary diagnosis, to treatment,” Geis said. “Imaging 3.0 supports radiologists to be more involved in new coordinated care models. It will help to describe and measure a radiologist’s value in these new plans and describe that value to the patient.”
Barriers to change
With any shift to the status quo, there are bound to be persons resistant to change. Radiologists are no different, and for good reason. The current market still is fee for service, and as a result, there are no financial incentives to do less. “For many radiologists, the traditional way of doing things has been extremely successful,” Geis said. “Radiologists have contributed enormously to better and more efficient healthcare. So it takes foresight and courage to change now while the traditional model still works quite well.”
This timing is the biggest challenge for radiologists in making the transition to value-based care, according to Geis. “You don’t want to wait until things have fallen apart and reimbursement has gone way down before you make these changes,” he said. “Deciding that you’re going to make these significant investments, both in terms of IT projects and in terms of how you manage radiologists’ manpower, while the old system is working pretty well—that’s tricky. You should do it while you are still in a position of strength.”
In the last 30 years, the profession has seen cascading cuts to reimbursement; as a result, when one has concerns about paying staff or rent, “it is more difficult to feel very enthusiastic about this change,” McGinty admitted. “But to our members’ credit, most people understand that healthcare is changing, and they want to be in the middle of that.”
State-of-the-art IT tools like PACS and voice recognition, image sharing solutions, clinical decision support, and more, not only require financial investment, they also require radiologists’ resources in order to be successful. Direct radiologists’ time is expensive, because if a radiologist is involved in the planning and implementing of IT tools, that is time they cannot read imaging studies and generate RVUs. However, if a radiologist is not deeply involved in optimizing radiologist-centric IT, efficiency gains will be compromised. “Watching many radiology groups, those that have a true radiologist IT champion who is given the time to do it are moving ahead and see a good ROI out of it,” Geis said. “IT done well will improve radiology efficiency dramatically.”
To pay for the healthcare that the country needs, radiologists must figure out how to do more for less, according to Allen. “It goes down to why we chose to be radiologists and what we’re trying to do,” he said. “I don’t think that every motivation has to be financial to make this work. I think a lot of is we know it’s the right thing to do; we just need to get the incentives in line correctly.
“I think all of us have times when we’ve seen some exams that were on our list to interpret that could’ve been done some other way,” Allen continued. “What we’re trying to do is provide a course of action that will let that happen. I don’t think there’ll be that many people who will be opposed to providing appropriate care by having referring physicians use our decision support criteria. I think that if they will embrace it, they will have the opportunity down the line to potentially convert what they’ve seen with radiology benefit management companies in the private arena.”
Avrin emphasized that radiologists must be involved with the ACO medical leadership efforts at their institutions. “They need to be able to verbalize radiology’s contribution,” he pressed. “The only reason to be opposed to it is to hope the world isn’t going to change. You need to have your eyes on the future.”
Elaine Sanchez Wilson is a contributing writer for Axis Imaging News.