Give it up, buy in and figure it out. In short, that was the message from Kevin McEnery, MD, to his fellow informaticists at the recent meeting of the Society for Imaging Informatics in Medicine (SIIM), Inner Harbor, Maryland.
Let go of past practice patterns, embrace ACR’s Imaging 3.0 vision of the future, roll up your sleeves and help create radiology’s IT value platform, urged the director of innovation in imaging informatics, department of radiology, MD Anderson Cancer Center, Houston, Texas. “It is not SIIM’s role to set policy, but it is SIIM’s role to implement and change radiology through IT systems,” he asserted.
To date, everything that informaticists have done is to create “more stuff,” McEnery contended, but the game is changing and so must imaging informatics. “Radiologists are not going to be asking how fast you can get images from the scanner, they are going to be asking, ‘How can I add value to our practice?’” he noted. “That is our charge, that is what we need to be working on.”
In an unsettling analogy, McEnery compared radiology and its transition to value-based payment models to the Apollo 13 mission—one in which failure is not an option. “I would argue that Apollo 13 has left the Launchpad, and something catastrophic is going to happen,” he said. “This is going to be a very stressful time, but stress is an opportunity to move things along, predict where the puck is going to be and actually thrive in this environment. I think we can thrive, but we have to do this together.”
Moving the puck
Reciting Michael Porter’s by-now-familiar equation for creating value in healthcare, McEnery said that achieving outcomes at the lowest possible cost is the yardstick by which all innovation heretofore will be measured. “It’s a really difficult process to determine the outcomes (in radiology), but I think this is our charter,” he advised. “We have to stop worrying about metrics of volume and revenue focus, and how how thin the CT slices are—that doesn’t matter if it doesn’t change what the ordering doctor is going to do.”
Apollo 13 Reading List
Kevin McEnery, MD, director, Innovation in Imaging Informatics, MD Anderson Cancer Center, Radiology Department, recommends two must-read publications for imaging informaticists as they leave the Launchpad on the way to value-based payment.
McEnery did not imply that state-of-the-art technology has no place in value creation. “We better be able to prove that those fancy CT scanners and MR scanners add value,” he said. “I think we can, but we have to move the puck.”
Assessing the lay of the land, he attributed the fast pace of consolidation in the hospital market to the need to develop centers of excellence for care delivery. In order for radiology to participate in that activity, its IT systems and infrastructure must be aligned.
“The strategy involves, at its baseline, informatics,” he said. “We’ve thrived in this environment, we moved radiology from film to filmless; we did that, it’s done. But we have to keep on moving the puck.”
The value IT platform
What will radiology’s new value IT platform look like? Radiology must work with IT vendors to create a new IT platform that is centered on the patient and provides radiologists access to all of the patient data that drives the care process.
The platform must be built on common data definitions, templates and structured reporting. While building this platform, IT professionals must ask themselves the following questions:
- Are you providing the IT systems that allow radiologists to be consultants?
- Are they patient centric?
- Do your IT systems improve the patient experience?
- Are your IT systems integral to the patient’s care?
- Are they accountable?
“It’s about the entire process of taking care of the patient,” he said. “It’s the order, the protocols we create, the acquisition that’s done at the scanners, the interpretation which leads to the report, which leads to another order or a better outcome for the patient.”
Above all, the patient must become the central concern. Orders must be appropriate for the patient’s presentation and optimized to inform the clinical decision process. Acquisitions must be optimized to deliver a dose that is adequate for the diagnosis and the age and condition of the patient. Reports must focus on findings that are pertinent to the patient and provide context for the clinician.
“Just because I have a template that allows me to expand my report to 48,000 lines, doesn’t mean that it actually increases the value,” McEnery said. “Reports need to be optimized to be efficient.”
The patient-specific order
In developing an extensive digital library of appropriateness criteria (AC), the ACR provided an important toolset for developers—exhibiting great prescience in McEnery’s opinion. “If a person is suspected of appendicitis, and the variant is leukocytosis in classic presentation, the most appropriate scan to order is a CT abdomen according to the ACR criteria,” he said. If the patient is a child or pregnant, then ultrasound is likely more appropriate according to the AC.
“It’s not just the imaging, it’s the context of the patient,” he said.
Rendering this toolset even more pertinent is the upcoming clinical decision support (CDS) mandate, McEnery said. “Beginning in 2017, CMS will not reimburse for claims for the technical and professional components unless approved decision support is utilized,” he warned. “Come 18 months from now, if your referring physicians don’t go through some sort of approved CDS, you’re just not going to get paid for the study.”
Clinicians can ignore the recommendations, but in 2020, the 10% to 15% of physicians who are outliers will be required to contact CMS for every MR, CT and head CT that they order. This will change how things happen, McEnery said.
CCR: The Trojan horse
Nonetheless, he believes our current understanding and implementation of CDS can be characterized as version 1.0. “It’s important to realize that once the request for an examination comes in, the decision support agent is going to have to be aware of some patient context,” he said. “That is more than likely going to be provided through a continuity of care record (CCR) based on a summary of the EMR. Then the approval agent will inform of the criteria.”
The CCR document will gain even greater importance in radiology because it also provides information that could be used for other purposes downstream, not just for matching the indication with the corresponding appropriateness criteria, but also the interpretation process.
“I think this is a Trojan horse in a positive way that we as a specialty have to leverage,” he suggested. “Not only should that information be available for AC determination, but also for the ability for the radiologist to interpret the study and then move downstream.”
As informaticists seek to implement CDS systems, they should consider a more global approach and be aware that work is underway at the healthcare system level to develop scoring systems based on electronic medical record (EMR) data that lead to clinical informed-care pathways. McEnery cited two recent studies, one in the pediatric population using the Samuels pediatric appendicitis score and one in the adult population using the Alvarado score.
“What’s interesting about both of these studies is that if a patient has a high score, in this opinion, this pathway, they don’t need imaging,” McEnery said. “They go right to the OR, they do not pass go, they do not collect $200 from the ultrasound tech.” Another point of interest is that neither study involved radiologists.
McEnery predicted that more of these pathways where imaging is deemed not necessary will be developed, and that radiology must be involved. “It’s important for us to create the studies that help inform these pathways, so the discrimination is appropriate and inclusive and does not exclude radiology at the detriment of patient outcome.” CDS must not only inform the imaging order but the entire process, he said.
Creating the protocol ‘order’
At MD Anderson Cancer Center, McEnery has helped develop for radiologists what he calls an image order entry—not a protocol—system to manage ~500 CTs per day. In each case, the radiologist is presented instantly with information extracted from the EMR with the indication for the patient. If the radiologist needs more information, it’s available in this system in the context of the EMR.
On the inpatient side, when a protocol is entered, the system fires off an order-set to manage medication administration or hydrate a patient. “It elevates the value of what the radiologist is doing,” McEnery noted. “If one of the metrics in your institution is how many electronic orders you are providing—radiologist, here I am. The radiologist is participating in the value and efficiency of patient care through this system.”
Mistakes can be made if the protocol is informed exclusively by the radiology information system. For instance, at MD Anderson, a melanoma patient with a 1.5 cm area of focus in the pelvis would typically receive a pelvis CT with a musculoskeletal protocol. But if the patient is on chemotherapy and the clinician is following a peri-rectal lesion, then the patient requires an MRI peri-rectal protocol.
The outcome of the former protocol would have been a repeat examination at no charge, and both the clinician and the patient would have been disappointed.
“Informing the protocol process not just from the order information but the context of the patient will lead to better outcomes for the patient moving forward,” he emphasized.
Having changed little in the 100 years since Roentgen discovered the x-ray, the radiology report is overdue for a remake, McEnery said. “The fact that Roentgen could pick up a microphone and dictate a report is not a good thing for radiology,” he stated.
Citing a recent article in the Journal of the American College of Radiology (see Reading List), McEnery listed the following report metrics.
- Is it accurate?
- Is it actionable?
- Does it push the needle/process?
- Is it communicated effectively?
- Is it acted upon?
Ultimately, it must be measured on whether it impacts patient outcomes. “Is appropriate care being delivered—or not being delivered in some cases—to satisfied customers?” he asked, including referring physicians and patients.
Templates and structure will enable radiologists to find a more efficient way of delivering information to its customers, but new tools must be created at the PACS workstation that will allow radiologists to create data and information without requiring referring physicians to “discern” that information while sorting through “the subtle hedges” that radiologists work into their reports.
If Amazon can present a list of related reading to shoppers, why can’t radiology make it easier for clinicians to act on radiologist recommendations? McEnery suggested that it go something like this: “Clinicians receiving this report usually order a CT scan in three months. Click here to order a CT scan in three months.”
Providing one-click options and alternative displays for clinicians and patients enables a more robust experience, substantially increasing the value of radiology and the radiologist in the process.
In conclusion, McEnery reiterated that the rocket has left the Launchpad. “We do have a problem, but I think we as a group, as a society and as a specialty can change,” he said. “The IT systems are going to be crucial.”