Re-visioning Radiology
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Transcript of Re-visioning Radiology
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