|By Bolan, Cristen
“Today, volume drives success, but how are radiologists going to get to where value drives success?” askedBibb Allen, Jr., MD, Vice Chairman, ACR Board of Chancellors, in his keynote presentation at the 2013 ACR Imaging Informatics Summit.
As radiology pursues a strategy to integrate with health care reform and adopt a valuebased care model, radiologists need to adjust to cost pressures and shifts in payment models, demonstrate their value in the continuum of care, and improve communication with referring physicians and patients.
The American College of Radiology (ACR) has introduced the Imaging 3.0 initiative, a campaign to leverage information technology (IT) solutions, including clinical decision support (CDS), structured reporting and data mining, communication tools, to move radiology from a fee-for-service care model to a valuebased one.
Imaging 3.0: A call to action
In the value-based health care model, radiologists will be expected to provide better care for individuals and the patient population at lower cost. Ensuring that radiologists play a strategic role in the evolution of health care, the ACR is leading a change process with the Imaging 3.0 initiative.
Imaging 3.0 is the blueprint for providing better care (Figure 1). It is designed to address issues with payment systems, radiology relevance, patients, and payors, and leverages IT to meet these change goals.
“The initiative asks radiologists to go beyond interpretation to assure appropriateness, document the quality and patient safety that radiologists provide, provide actionable reporting with evidence-based follow-up recommendations, and empower patients,” explained Dr. Allen. “The ACR and RSNA are going to work together to align payment system incentives. This will be successful if they can get policymaker buy-in and win over physicians and radiologists to help maximize profitability.”
Technology that connects radiologists
The successful transition from a fee-forservice model, which has incentivized volumes and has driven technology that supports maximizing productivity and volume, will require the development of technology that incentivizes quality.
Accordingly, Dr. Allen pointed out in his keynote presentation that “[s]ignificant imaging care occurs prior to and following exam interpretation. However, for a number of reasons, a lot of radiologists are not providing all of that care.” He said, “If radiologists could get involved from the beginning to the end, then they could improve patient safety and outcome, the care delivered would be therefore more cost effective, radiologists’ relevance to the health care system would be improved, there would be a measurable way to show how radiologists are improving population health care, and [you could] calculate it by decreasing capital costs.”
To accomplish this, radiologists need to access the complete clinical picture by integrating radiology information systems (RIS) and picture archive and communication systems (PACS) with the hospital electronic health records (EHR). When interpreting exams, they need to use CDS tools that pop up while dictating the report, reference appropriateness criteria for imaging to code exams and indicate the exam results versus the appropriateness score, and leverage structured reporting templates and dose registry indexes.
PACS plus EHRs equals opportunity
As technology has advanced, it has also isolated radiologists from other physicians. Linking PACS with EHRs is an opportunity for radiologists to improve communication with colleagues and referring physicians. The image-enabled EHR can become the foundation for increasing patient engagement, also in accordance with MU Stage 2 and Stage 3 draft, because it allows healthcare organizations to develop a more patient-centric ecosystem.1
“Face-to-face communication with referring physicians has been lost and radiologists have taken a back seat to decision making on a local and national basis,” said Michael P. Green, MD, Diagnostic Radiologist, Liberty Hospital, MO. “The next step is communication with EHRs and PACS and transferring images. From the radiology standpoint, we can see the total care of the patients.”
Providing medical images and related information in context with patient information is a key consideration in developing EHRs, successful collaborative care solutions and new organizations and reimbursement models – it’s a Menu Objective for meeting the requirements of MU Stage 2 and Stage 3 draft.1
“For radiologists to be part of a truly valuebased practice, you need to know more about the patient. Our ability to provide a better diagnosis and add value to care is much higher. If you are only living in a PACS/RIS environment, there is no access to that information, and, in many cases, there are many options of diagnoses,” noted Khan Siddiqui, MD, Visiting Associate Professor of Radiology at Johns Hopkins University, Co-Founder of higi, a system that enables patients to track and measure important body statistics to better manage their personal health.
Many hospitals have image-enabled their EHRs using a single repository or vendorneutral archive that centralizes access to medical images for all approved providers from anywhere in the health care network. At the Cleveland Clinic, Dr. Cheryl Petersilge explains how the clinic adopted a VNA model to manage its internal and external imaging network consisting of 35 imaging centers. “Our enterprise has taken the Agfa ICIS view 3.0 to bring in images from any different vendor system. That way, if you change vendors, you’re not going to have to roll over all of your storage. We are leveraging that to bring in nonradiology-generated images [too],” said Dr. Petersilge.
Clinical decision support (CDS)
The wide adoption of CDS may present one of the best ways to prevent additional fee-forservice payment cuts while transitioning to a value-based care, indicated Dr. Allen.
There are several benefits of CDS to radiologists over prior authorization programs or unmanaged care. It reduces unnecessary care, accelerates imaging utilization, and has driven decreases in fee-for-service system payments. It provides structured indications to radiologists with real and meaningful reasons for the examination of translatable to correct protocoling of examinations and correct ICD coding, leading to enhanced regulatory compliance.
Furthermore, the use of CDS increases the relevance of radiologists to ordering physicians and the health system. For example, when there are low appropriateness scores, this creates a reason for the ordering physician to engage in a consultation with a radiologist, and these interactions will increase radiologists’ visibility and value. Since CDS provides an appropriateness score for every examination, these data can be the basis for analytics that can help understand causes for inappropriate utilization and radiologists can be associated with the education efforts to improve ordering physician performance. Nationally, policy makers will see radiology as part of the solution – not part of the problem.
An important part of CDS involves ordering appropriate imaging exams. As part of health care reform’s aim to contain costs, e-Ordering is recognized as a cost-effective and datadriven approach to assure clinical best practices are applied to all ordering decisions. The ACR Appropriateness Criteria represents a national standard.
“There can be an overuse of imaging, so going in the direction of doing appropriate imaging based on the concern or diagnosis is the direction we are going and help patient care,” noted Christine Granfield, MD, Partner, Mori Bean and Brooks, Jacksonville, FL, and Medical Director of Breast Imaging at Baptist Health System/Hill Breast Center, Jacksonville, FL.
At Mori Bean and Brooks, a 44-physician practice, adjunct breast images exams are becoming increasingly prevalent, particularly in women with dense breast tissue. Breast imagers consult M-Vu Breast Density software by VuComp. The solution is designed to identify the radiographically dense areas of a mammogram, and then map this finding to a calibrated VuCOMP density category. This kind of technology not only provides decision support to guide patient treatment plans but helps avoid unnecessary follow up images.
“M-Vu Breast Density does analysis of breast density, and indicates what Bi-RADs rating the case falls into-categories 1, 2, 3 or 4. It creates a more reproducible measurement, there are less extraneous marks, and it’s more accurate. The reading time is more streamlined because you’re not looking at unnecessary marks or distracted,” said Dr. Granfield.
Evidence-based guidelines are designed to assist referring physicians and other providers in making the most appropriate imaging or treatment decisions. The ACR partners with the National Decision Support Company(NDSC), which captures clinical data. Through the ACR, an expert panel of diagnostic imaging, interventional radiology, and radiation oncology professionals evaluate the criteria. There are 197 topics with over 900 variants in the November 2013 version.
ACR Select is the complete web service version of the ACR Appropriateness Criteria (AC) solution. By integrating ACR AC with EHR technology on the ACR Select platform, physicians can order imaging examination and reference appropriateness criteria to confirm the validity of ordering the imaging exam. EHR technology platforms powered by ACR Select are designed to improve quality, reduce unnecessary scans, lower imaging costs, minimize false positives, and add value in outpatient, inpatient, and ED settings.
Medical Xrays Consultants, which provides radiological services to 11 different hospitals across rural Wisconsin, is working with its affiliate hospitals to implement the ACR Select in the EHR for appropriate image ordering.
“The hospitals have to use clinical decision support software for other areas, for ordering medication, which is easier to implement than a radiology clinical decision support system. I think ACR Select will decrease volumes of imaging studies at first, but ensure we get right imaging studies ordered for the right patient,” said Wells Mangrum, MD, Diagnostic Radiologist, Medical Xrays Consultants, Eau Claire, WI.
Meeting Meaningful Use criteria
Part of health care reform’s initiative to drive the adoption of EHRs is Meaningful Use (MU), part of theMedicare and Medicaid EHR Incentive Programs, which provides financial incentives for the “meaningful use” of certified HER technology. Providers have to show that they are “meaningfully using” their certified EHR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records.2
Medical Xrays Consultants is working with its group of hospitals to meet Stage 1 and Stage 2 MU criteria by implementing a solution called Imaging Elements, software designed to help radiologists meet Meaningful Use (MU) criteria.
“None of our hospitals have certified EHRs to meet ambulatory care MU criteria, but they all have EHRs certified for in-patient use. We are creating our own EHR with Imaging Elements, which is certified to meet MU requirements for ambulatory care. We send the patient data to Imaging Elements. When we dictate a study and create a report, that report goes into a hospital medical record and stores it in Imaging Elements software, which is on a certified ambulatory EHR. The ideal way to do it is create a HL7 interface between the hospital EHR and the Imaging Elements EHR,” indicated Dr. Mangrum.
Stage 2 of MU is a game changer for hospitals, radiologists, and referring physicians. The hospitals are required to provide referring physicians access to medical images via links in the EHR.
A recent study3 found that referring physicians want multimedia radiological reports with embedded images. The researchers recommended that creating accessible, readable, and automatic multimedia reports should be a high priority to enhance the practice and satisfaction of referring physicians, improve patient care, and emphasize the critical role radiology plays in current medical care.3
“For Stage 2, the menu objective is that if a referring physician orders an imaging study, they have to be able to view the images on their own system. That puts the burden on the hospital because the radiologist doesn’t order the imaging studies. Hospitals will make the images available for the referring physicians. It’s in the hospitals interest to make medical images available to referring physicians,” said Dr. Mangrum.
He added, “In this scenario, both images and reports as inseparable. When there is an abnormality, for example, the referring physician can reference the images. So, letting referring physicians use the images will help with patient care.”
Structured reporting and dose indexes
By combining the reporting and imaging process in a structured reporting template, radiologists are adding true value. Structured reporting allows users to mine data over time and more easily navigate through reports, and it provides a clinically robust multimedia report.
For example, when a radiologist circles a lesion, it is automatically bookmarked as a region of interest, and the measurement is inserted in the report. With a vessel analysis, a radiologist inputs the table of measurements, which automatically populates the report for the surgeon to reference when inserting a stent.
“Clinicians live in the EHR – an encounter- based workflow, but radiologists have a worklist-based workflow. Their reporting system needs to allow me to handle more than one worklist and reads from multiple PACS, RIS, and send to multiple EHRs,” said David Weiss, MD, Associate Professor of Radiology, Virginia Tech Carilion School of Medicine, and on the Applied Radiology Editorial Advisory Board. “What I’m looking for are navigation tools and the ability to build a structured report. I’m looking for a template that fills in the measurements automaticially allowing me to concentrate on the images. The reporting process should never be the distraction.”
The Radiological Society of North America (RSNA) has built a report template library that serves as a starting point for radiology practices wishing to improve the quality of their reports by standardizing format, content, and structure. These new report templates represent best practices that can be adapted and adopted based on local practice patterns. The templates support the use of automated speech recognition or other reporting tools.
Quality control metrics for radiation exposure can also be tracked with the ACR’s National Radiology Data Registry (NRDR), which houses data from several other groups, including the Colonography Registry (CR), the Dose Index Registry (DIR), and the General Radiology Improvement Database (GRID).
Big data with intelligence
Big data presents an opportunity in the clinical arena to bring previously unfathomable amounts of data to life, and transform the data to valuable insights,” said Rasu Shrestha, MD, MBA, vice president, Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.
Applying software intelligence to the enormous amounts of imaging and contextual data makes sense of big data. Analyzing this data provides ways to measure improvements in quality care, patient outcomes, and drive efficiencies in clinical workflow.
“Operational metrics are important to maintaining a viable robust practice and making sure turn around times are within reason,” said William Boonn, MD, President, Montage Healthcare Solutions Inc. MONTAGE(TM) Search & Analytics is a radiology data mining and analytics solution that uses a search-driven approach leverage proprietary natural language processing to extract and visualize, business and clinical understanding, using information in the RIS and EHR.
“As we transition to value-based care, you need to be able to measure or generate metrics focused on quality, safety and outcomes,” said Dr. Boonn. Montage provides business metrics on referral patterns and also on quality data captured in unstructured reporting done during dictation, extracting free text data for quality metrics in the reports.
Montage also offers tools that help practices manage compliance with critical test results policy. “One of those tools is radiology-pathology correlation designed to help radiologists correlate findings to path studies to demonstrate accuracy. To do radiology-pathology correlation you have to do manually and with the amount of studies you have to read, it makes the likeliness of doing radiology-pathology correlation slim to none. Montage helps radiology-pathology correlation to determine if your outcomes are correct. It’s quality feedback system,” said Dr. Boonn.
Siemens Healthcare is also on the cuttingedge of data mining. The syngo Workflow solution’s MicrosoftSQL based database makes it more convenient to perform database queries for business analytics, population health management, and many other data that are important for accountable care organizations (ACO). A module developed for radiation dose management in collaboration with MedInformatics, the module also supports automatic insertion of dose information in the radiology report and automatically forwards dose information to the Dose Index Registry of ACR.
Streamlining workflow adds value
Despite the transition from a volume-based to a value-based care model, technology that supports high-volume caseloads for radiology reporting will still be important in the new value-based care model.
“I think we are going to emphasize more value, but I don’t see volumes coming down; just reimbursement per case coming down,” said Dr. Weiss. “Adding value to volume is daunting. We are going to have to create reports and analyze data quicker and smarter.”
Some of the most widely adopted reporting tools are speech recognition and audio feedback technologies. These solutions can maximize the efficiency of radiology reporting and sharing data in EHRs by allowing clinicians to record information and get audio feedback about patient records without the need for typing.
Speech recognition systems, like Nuance’s Dragon Medical 360|Direct, provide enterprise- class, cloud-based, front-end speech recognition to improve clinical documentation accuracy, enhance patient care, drive productivity, and reduce costs. For radiologists, it enables them to create reports without taking their eyes offof the diagnostic images, and quickly send offreports to referring physicians, thereby adding value to the continuum of care.
“Clinicians are looking for a partner to get that information from in a timely manner that is accurate and in a format that is easily consumuable. I want to increase my perceived value and the present information that is extractable in just a few seconds,” explained Dr. Weiss. “I can dictate a report and make concise, itemized structured reports with existing technology. The new reporting systems really enhance workflow. I’m trying to make it easier for the providers to consume the information and trying to improve turnaround time.” Nuance’s PowerScribe solution also provides critical test results based on the rules and preferences the radiologists set up and includes an audit trail.
At Liberty Hospital, radiologists use speech recognition and audio feedback technology provided by Viztek’s PACS. “Using voice recognition at time of interpretation for creating a final report is helpful, and there is a voice file associated with the exam,” Dr. Green explained. “The voice file is embedded in each study and the referring physician can listen to the radiologist. This helps communication with the referring physicians. We are not exactly sure how to get more involved, but initially it will take improved communication across the [EHR].”
On the syngo Workflow by Siemens Healthcare, a RIS functions as the nerve center for the radiology department. It includes a new version of Powerscribe 360 for higher dictation accuracy and shorter report turnaround times. Similarly, Montage integrates Nuance’s Powerscribe 360 into its system. “You can open up a patient’s timeline and read the pathology reports, used prospectively, and read as part of radiology decision support. It can be used in both scenarios, particularly if you’re trying to track outcomes and used at the point of care at the PACS workstation-it is used at decision support,” said Dr. Boonn.
Increasing patient-radiology interaction
The last tenet of Imaging 3.0 is empowering patients. Radiologists can empower patients by providing them with knowledge about their care.
“Engaging patients is the next big step for radiologists in asserting their role in the continuum of care,” said Dr. Green noted. “Whether it’s verbal or written communication, patient communication is the next big hurdle.”
There is a real risk that if radiologists continue to only read images and write reports rather than provide comprehensive clinical care, other physicians could eventually supplant them in health care. Not surprisingly, the theme of the 2013 Radiological Society of North America annual meeting was “Power of Partnership,” whose message urged radiologists to establish stronger relationships with both referring physicians and patients by stepping outside of the reading room and speaking directly with them.
“We [rarely] interact with the patients because, logistically, interacting with patients is challenging. If there are more complex cases, for example with interventional care, that will lend itself to improving status with referring physicians,” noted Dr. Green. “Radiologists need to take the initiative to get involved with patient care. They need to put the worklists aside and talk with patients, get on the phone with referring physicians and put in their recommendations to referring for follow-up imaging.”
So how can radiologists better connect with patients? This interaction can be built on technology that provides tools to physicians at the point-of-care. In fact, the latest modalities are now designed with Imaging 3.0 in mind, engineered for imaging at the point of care that is reproducible and reliable. Samsung Electronics America, for example, recently introduced a premium ultrasound system, UGEO WS80A, for obstetrics-gynecological patients. The system’s automated technology with 5 segmentation allows myocardium perfusion and reduces variability dramatically. “The concept of the WS80 is that it reduces variability and increases diagnostic confidence. We are heading it in Imaging 3.0. We are looking at how to increase reproducibility in these technologies and add to the quality of care,” explained Doug Ryan, Group Vice President, Health and Medical Equipment, Samsung Electronics America. Any time I can minimize user variability, I can maximize diagnostic confidence.”
Does that mean radiologists should provide bedside care? Not necessarily. The value of the radiologist is in consultative care, but consulting in a way that is not just automated but in a way that is personal.
“Radiology practices need to demonstrate how they provide value for the referring physician and the patient too. In mammography, the radiologists call the patient with the results,” said Dr. Siddiqui. “Each practice needs to design its own plan of engagement – and engage with the patient directly.”
1. Enterprise Imaging 20/20. Navigating the “New Normal”: Agfa Healthcare’s vision for enabling the EHR.Agfa Healthcare Corporation. 2013.
2. Health IT Regulations. Meaningful Use Regulations. Health IT. http://www.healthit.gov/policy-researchers-implementers/ meaningful-use-regulations. Accessed April 7, 2014.
3. Nayak L, Beaulieu CN Rubin DL, Lipson JA. A picture is worth a thousand words: Needs assessment for multimediaradiology reports in a large tertiary care medical center. Acad Radiol. 2013;20:1577-83. doi: 10.1016/j.acra.2013.09.002.
Cristen Bolan, MS