Re-Visioning Radiology
Jonathan Breslau, MD, FACR
President, RAS
ACR, Council Steering Committee
@jonathanbreslau
There is a tide in the affairs of men,
Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their li...
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 Cost
Percent who say they or another family member living in their household have done each of...
US not in top group for life expectancy

Life expectancy by
country (years)
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 line
CDS
Imaging pretest review
D2D consultation
Ordering the right test – 2
 “Batphone”

Use old ideas
from capitation
e.g., tracking
ordering MDs
Radiation safety
 Dose reduction and tracking
 Protocols
 Patient dose registry

 Build department infrastructure
 Pa...
Right images, Right
interpretation – 1
 MOC and subspecialization
 we’re talking dollars here

 Quality
 Optimal reads...
Right images, Right
interpretation – 2
 Image exchange

RSNA Image Share Network Reaches First Patients
September 01, 201...
Right images, Right
interpretation – 3
 Actionable reporting





Critical results
Follow-up
Manage incidental
Manage...
Examples of variation
reduction
 Incidentalomas





Standard description
Standard recommendations for biopsy and sur...
ACR member response to
incidental findings
 JACR 2014; 11:30-35
 Survey on incidental abdominal CT findings
 89% respon...
Clinical decision support tool
in lung nodules
 MGH – point of care for radiologists

 Guidelines based on Fleischner So...
 Communication – Health Affairs, 2013; 32:1368-1375.
Analysis of RCAs in VA system involving delays in
treatment and diag...
Patient Focused
 “Patient Centered” can be a useless term
 Excuse for not doing anything
 The point is to make the syst...
Patient-centric Imaging Awards
 Cincinnati Childrens’ – instituted “difficult news”
process – radiologists meet with fami...
"Sixty-five percent of ... patients signed into their system
to look at their images," [David] Mendelson, MD told
FierceMe...
Connected patient tools
 Scheduling – like airline seat
selection

 Exam details – prep, location

 Images and reports ...
Price Transparency

More patients paying more
out of pocket

Wide variation
Huge opportunity
https://healthcarebluebook...
Zip code 92093
 Healthcarebluebook.com

 Abdomen And Pelvis CT (No
Contrast)

 Total Fair Price:$793
 Includes printab...
Healthcare Provider / Facility (hereinafter “Provider”): ____________________________
Patient (hereinafter “Patient”): ___...
What do health system executives
want?

• Reproducible
• Predictable
• High outcome per dollar of
health care cost
Can Imaging influence key
performance measures?

1.
2.
3.
4.

LOS?
ED throughput?
Patient satisfaction?
…others
How
 Own all aspects of imaging
 Better care
 No extra imaging
 Evidence-based

 Empower patients
 IT

 Take some (...
At all points
 Look for D2D opportunities
 D2P opportunities
We’re
here
Could vRVU be the answer?
 Adding Value to Relative-Value Units

 Eric C. Stecker, M.D., M.P.H., and Steven A.
Schroeder...
Example of Cardiology
 20 vRVUs for certain population management
activities, per 50 pts

 Double value of office visits...
Challenges for imaging
enterprise with vRVUs
 Don’t order tests that are unlikely to add info

 Radiologists evolved as ...
Trying to chase the
money in new system

Need to chase the
patients and meet the
system’s goals
November 12, 2009
Sutter zaps pact with radiologists

November 19, 2013
Sutter Health acquires RAS, region's largest
radio...
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
Re-visioning Radiology
Re-visioning Radiology
Re-visioning Radiology
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Re-visioning Radiology

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Focus the Imaging Enterprise on health, quality, and most importantly, patients. Radiologists need to help advance the Health Care Triple Aim.

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Re-visioning Radiology

  1. 1. Re-Visioning Radiology Jonathan Breslau, MD, FACR President, RAS ACR, Council Steering Committee @jonathanbreslau
  2. 2. There is a tide in the affairs of men, Which, taken at the flood, leads on to fortune; Omitted, all the voyage of their life Is 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 Shakespeare Julius Caesar
  3. 3. What is happening at topline health care level that radiologists need to know about and respond to?
  4. 4. National Health Expenditures per Capita, 1960-2010
  5. 5. Per Capita Total Current Health Care Expenditures, 2009 http://www.oecd-ilibrary.org
  6. 6. Putting Off Care Because of Cost Percent 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: Relied on home remedies or over-the-counter drugs instead of going to see a doctor Skipped dental care or checkups Put off or postponed getting health care needed Not filled a prescription for a medicine Skipped a recommended medical test or treatment Cut pills in half or skipped doses of medicine Had problems getting mental health care ‘Yes’ to any of the above Source: Kaiser Family Foundation Health Tracking Poll (conducted August 10-15, 2011).
  7. 7. US not in top group for life expectancy Life expectancy by country (years)
  8. 8. Population Health Care for Individuals Per Capita Costs
  9. 9. Radiology will be valued by its role in enabling primary care to manage population health
  10. 10. Radiology’s first attempt at achieving Triple Aim
  11. 11. Imaging Triple Aim 1. Right test, right time 2. Right images, right interpretation 3. Patient-focused
  12. 12. Ordering the right test – 1 EHR first line CDS Imaging pretest review D2D consultation
  13. 13. Ordering the right test – 2  “Batphone” Use old ideas from capitation e.g., tracking ordering MDs
  14. 14. Radiation safety  Dose reduction and tracking  Protocols  Patient dose registry  Build department infrastructure  Part of quality  Work with vendors  Educate stakeholders with enhanced role for med physicist  Patients  MD consult
  15. 15. Right images, Right interpretation – 1  MOC and subspecialization  we’re talking dollars here  Quality  Optimal reads  Optimal clinical interaction  Efficiency  Leverage size of groups Breslau J, JACR 2012; 9:535-536. http://download.journals.elsevierhealth.com/pdfs/journals/15 46-1440/PIIS1546144012002001.pdf
  16. 16. 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
  17. 17. Right images, Right interpretation – 3  Actionable reporting     Critical results Follow-up Manage incidental Manage surveillance of known disease  Another health system buzzword: variation reduction – imaging report can help
  18. 18. Examples of variation reduction  Incidentalomas     Standard description Standard recommendations for biopsy and surveillance Radiologists do not need to memorize Populate reports using macros from literature, such as Fleischner Society, JACR papers, etc.  Known disease  Cancer surveillance protocols – automate scheduling of F/U exams
  19. 19. 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
  20. 20. 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
  21. 21.  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.”
  22. 22. Patient Focused  “Patient Centered” can be a useless term  Excuse for not doing anything  The point is to make the system work for the patient – reduce the time spent in the health care system
  23. 23. 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 Tucson  Comprehensive prescreening and exam review at time of scheduling  Exam protocol in advance and entered into report shell  Patient portal – includes preregistration http://www.healthimaging.com/topics/practice-management/2013-patient-centricimaging-awards
  24. 24. "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.”
  25. 25. Connected patient tools  Scheduling – like airline seat selection  Exam details – prep, location  Images and reports – systemlevel  Interact with radiologist – chat client within EHR?
  26. 26. Price Transparency More patients paying more out of pocket Wide variation Huge opportunity https://healthcarebluebook.com/page_Default.aspx Uwe Reinhardt http://jama.jamanetwork.com/article.aspx?articleID=1769895
  27. 27. Zip code 92093  Healthcarebluebook.com  Abdomen And Pelvis CT (No Contrast)  Total Fair Price:$793  Includes printable pricing agreement to take with you
  28. 28. Healthcare Provider / Facility (hereinafter “Provider”): ____________________________ Patient (hereinafter “Patient”): _______________________________________ Service/Product: Abdomen and Pelvis CT (no contrast) According to the Healthcare Blue Book, the Fair Price for consumers who pay healthcare providers with cash at the time of service or product delivery is ____$793______. Price includes the total amount for both physician (interpretation) and technical (imaging) fees. Sometimes the test will be billed in two parts but they should add up to the listed price. The Provider agrees to provide Abdomen and Pelvis CT (no contrast) to the Patient for a total price of (please complete and check agreed upon price): $793 or _________, subject to the terms below: 1. Price includes the total amount for both physician (interpretation) and technical (imaging) fees. Sometimes the test will be billed in two parts but they should add up to the listed price. 2. If the actual service or product required to treat the patient is different from that listed above, then Provider will make a reasonable effort to inform Patient what the new service or product is and what the price will be before treatment. 3. Other terms or conditions: __________________________________________ __________________________________________________________________ __________________________________________________________________ Includes signature page Patient agrees to pay Provider in full at the time of service or in the manner that is agreed to in advance and
  29. 29. What do health system executives want? • Reproducible • Predictable • High outcome per dollar of health care cost
  30. 30. Can Imaging influence key performance measures? 1. 2. 3. 4. LOS? ED throughput? Patient satisfaction? …others
  31. 31. How  Own all aspects of imaging  Better care  No extra imaging  Evidence-based  Empower patients  IT  Take some (data-based) risk
  32. 32. At all points  Look for D2D opportunities  D2P opportunities
  33. 33. We’re here
  34. 34. 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
  35. 35. Example of Cardiology  20 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
  36. 36. 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?
  37. 37. Trying to chase the money in new system Need to chase the patients and meet the system’s goals
  38. 38. November 12, 2009 Sutter zaps pact with radiologists November 19, 2013 Sutter Health acquires RAS, region's largest radiological group
  39. 39. March to the beat…
  40. 40. Don’t get distracted by imperfect messaging!
  41. 41. www.coveredca.com
  42. 42. Hot Chocolate Boy
  43. 43. “If you don’t like change, you’ll like irrelevance even less” Eric Shinseki
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