Re-Visioning Radiology

Jonathan Breslau, MD, FACRPresident, RAS

ACR, Council Steering Committee@jonathanbreslau

So where are we today?

There is a tide in the affairs of men,Which, taken at the flood, leads on to fortune;Omitted, all the voyage of their lifeIs bound in shallows and in miseries.On such a full sea are we now afloat,And we must take the current when it serves,Or lose our ventures.

−William ShakespeareJulius Caesar

What is happening at topline health care level that radiologists need to know about and respond to?

National Health Expenditures per Capita, 1960-2010

Per Capita Total Current Health Care Expenditures, 2009

http://www.oecd-ilibrary.org

Putting Off Care Because of CostPercent who say they or another family member living in their household have done each of the following in the past 12 months because of the cost:

Not filled a prescription for a medicine

Cut pills in half or skipped doses of medicine

Skipped dental care or checkups

Put off or postponed getting health care needed

Had problems getting mental health care

Relied on home remedies or over-the-counter drugs instead of going to see a doctor

Skipped a recommended medical test or treatment

Source: Kaiser Family Foundation Health Tracking Poll (conducted August 10-15, 2011).

‘Yes’ to any of the above

Life expectancy by country (years)

US not in top group for life expectancy

Population Health

Care for Individuals

Per Capita Costs

Radiology will be valued by its role in enabling primary care to manage population health

Radiology’s first attempt at achieving Triple Aim

Imaging Triple Aim

1. Right test, right time

2. Right images, right interpretation

3. Patient-focused

Ordering the right test – 1

EHR first lineCDSImaging pretest reviewD2D consultation

Ordering the right test – 2“Batphone”

Use old ideas from capitation e.g., tracking ordering MDs

Radiation safetyDose reduction and tracking

ProtocolsPatient dose registry

Build department infrastructurePart of qualityWork with vendors

Educate stakeholders with enhanced role for med physicistPatientsMD consult

Right images, Right interpretation – 1

MOC and subspecializationwe’re talking dollars here

QualityOptimal readsOptimal clinical interaction

Efficiency

Leverage size of groups

Breslau J, JACR 2012; 9:535-536. http://download.journals.elsevierhealth.com/pdfs/journals/1546-1440/PIIS1546144012002001.pdf

Right images, Right interpretation – 2

Image exchange

RSNA Image Share Network Reaches First Patients

September 01, 2011

Designed to help patients take control of their medical images and reports, the RSNA Image Share network has entered into clinical practice as patients across the country begin to use the system as part of their routine care.

http://rsna.org/NewsDetail.aspx?id=2409

Right images, Right interpretation – 3

Actionable reportingCritical resultsFollow-upManage incidentalManage surveillance of known disease

Another health system buzzword: variation reduction – imaging report can help

Examples of variation reduction

IncidentalomasStandard descriptionStandard recommendations for biopsy and

surveillanceRadiologists do not need to memorizePopulate reports using macros from literature,

such as Fleischner Society, JACR papers, etc.

Known diseaseCancer surveillance protocols – automate

scheduling of F/U exams

ACR member response to incidental findings

JACR 2014; 11:30-35

Survey on incidental abdominal CT findings

89% respondents used the content in clinical practice

51% recommended follow-up imaging less often

Clinical decision support tool in lung nodules

MGH – point of care for radiologists

Guidelines based on Fleischner Society

Analyzed only incidental nodules picked up on abdominal CT

Concordance 50% pre

Went up to 96% post

Communication – Health Affairs, 2013; 32:1368-1375. Analysis of RCAs in VA system involving delays in treatment and diagnosis in outpatient setting. Process breakdowns frequently involved tracking of diagnostic information and performance and interpretation of diagnostic tests: inadequate followup, delayed scheduling, inadequate tracking system for results and followup. Also miscommunication of urgency between providers.

EHRs “need to better support “shared” thinking processes for timely and safe patient care across a team.”

Patient Focused

“Patient Centered” can be a useless termExcuse for not doing anything

The point is to make the system work for the patient – reduce the time spent in the health care system

Patient-centric Imaging Awards

Cincinnati Childrens’ – instituted “difficult news” process – radiologists meet with families

UCSF/Univ of Maryland – Image Share – about 350 new patients per month sign up

Radiology Ltd. In TucsonComprehensive prescreening and exam review at

time of schedulingExam protocol in advance and entered into report

shellPatient portal – includes preregistration

http://www.healthimaging.com/topics/practice-management/2013-patient-centric-imaging-awards

"Sixty-five percent of ... patients signed into their system to look at their images," [David] Mendelson, MD told FierceMedicalImaging. "What this says to me is that we have grossly underestimated the interest patients have in their own care.”

Connected patient tools

Scheduling – like airline seat selection

Exam details – prep, location

Images and reports – system-level

Interact with radiologist – chat client within EHR?

Price TransparencyMore patients paying more out of pocket

Wide variation

Huge opportunity

Uwe Reinhardt http://jama.jamanetwork.com/article.aspx?articleID=1769895

https://healthcarebluebook.com/page_Default.aspx

Zip code 92093Healthcarebluebook.com

Abdomen And Pelvis CT (No Contrast)

Total Fair Price:$793

Includes printable pricing agreement to take with you

Includes signature page

• Reproducible• Predictable• High outcome per dollar

of health care cost

What do health system executives want?

Can Imaging influence key performance measures?

1. LOS?2. ED throughput?3. Patient satisfaction?4. …others

HowOwn all aspects of imaging

Better care

No extra imaging

Evidence-based

Empower patients

IT

Take some (data-based) risk

At all points

Look for D2D opportunities

D2P opportunities

We’re here

Scared yet?

Could vRVU be the answer?

Adding Value to Relative-Value Units

Eric C. Stecker, M.D., M.P.H., and Steven A. Schroeder, M.D.

N Engl J Med 2013; 369:2176-2179

Current RVU-based – proven, potent, and efficient MD motivators

Could assign evidence-based values proportional to influence on patient outcomes and clinical efficiency

Example of Cardiology20 vRVUs for certain population management

activities, per 50 pts

Double value of office visits

Stent value doubles if DTB <60 min

Decrease value of stent procedure as less appropriate

N Engl J Med 2013; 369:2176-2179

Challenges for imaging enterprise with vRVUs

Don’t order tests that are unlikely to add info

Radiologists evolved as passive participant in care team

Would be a positive change in radiologists’ role to be on the hook for inappropriate overimaging

What’s holding us back?

Trying to chase the money in new system

Need to chase the patients and meet the system’s goals

November 19, 2013Sutter Health acquires RAS, region's largest radiological group

November 12, 2009Sutter zaps pact with radiologists

March to the beat…

Don’t get distracted by imperfect messaging!

www.coveredca.com

Hot Chocolate Boy

“If you don’t like change,

you’ll like irrelevance even less”

Eric Shinseki