A Conversation With Mark Alfonso, MD: What Is Patient-centered Radiology?

If the triple aim—improved access to better-quality health care at a lower cost—is the goal of health-care reform, then patient-centered care is its soul. Throughout the Patient Protection and Affordable Care Act, the authors took precautions to protect patients from the abuses of 1990s-era managed care, when profits appeared to trump patient care. What, then, is patient-centered radiology? For the RSNA, which made patient-centered radiology the theme of its 2012 annual meeting in Chicago, Illinois, it meant inviting patients to give keynote talks at the opening session, even though some of what they said was hard to hear. Radinformatics.com puts that question (and more) to Mark Alfonso, MD, president of one of the nation’s most successful, respected, and tech-savvy practices, Riverside Radiology and Interventional Associates (Columbus, Ohio), and an early adopter of FUJIFILM Synapse® PACS. Alfonso details a vision and pathway in which imaging informatics is central. RADINFORMATICS: What is patient-centered radiology, and how is it different from what we are doing now? ALFONSO: Patients seem to be affiliated with either a site of service or a health-care system. When they come into the system, all of their information is available, but only to that specific site or health-care system. If they go from one hospital system to another, none of that information transfers over, and there is not a tremendous incentive, at this time, for the hospital to share that information. That will change with the accountable-care era that we are rapidly approaching. Patient-centered radiology takes all of the image information, reports, and data and puts them into one repository, so that regardless of where the patient is being treated, you have access to that entire history of radiological exams. RADINFORMATICS: How is patient-centered radiology different from customer service? ALFONSO: It’s not completely different from customer service; it’s part of customer service. Any patient who has a radiological exam performed is relying on the quality of the equipment, the experience of the technologist, the facility’s cleanliness, and interactions with the technical staff and clerical staff—and, most importantly, the qualification of the radiologist interpreting the exam. Part of the interpretation is the ability to access any of the patient’s prior studies. This is paramount in providing a definitive diagnosis. We need to know whether someone has an abnormality that is new or that has been stable for many years (because the treatment and prognosis can be substantially different). Tying that all together, patient-centered radiology is part of the customer service that the patient experiences. It complements customer service. RADINFORMATICS: Will changes in practice patterns be required for the transition to a patient-centered model? ALFONSO: Yes, they will, because you must have several things: First, you have to have a robust IT infrastructure to be able to access all of this information. Second, you have to have the appropriate subspecialization to ensure the most qualified radiologist is intereting the exam. Third, you need that radiologist’s expertise at all times of the day, which requires a 24/7 presence. This three-pronged approach to providing high-quality, consistent, 24-hour service. When patients are ill, they deserve to have the same quality and standard of care whether they present at 2 pm or 2 am. RADINFORMATICS: How will this affect radiology’s business model? ALFONSO: First, it will change the way you do your staffing. In our practice, we look at all of our data, and we staff according to our volumes. We tend to shift more radiologists to the early evening and at night because that is when the emergency departments tend to be busier. We try to mirror the number of cases with the number of radiologists available to interpret those cases. Second, the complement of appropriate physicians in respective subspecialized fields is also important. The third impact is having access to the patient’s prior imaging studies—which goes back to having the infrastructure in place to be able to visualize prior studies, in real time, when you are interpreting the exam. RADINFORMATICS: Will new tools be necessary to help radiology achieve those objectives? ALFONSO: Yes; one of the tools we are using is a workflow software called RadAssist™, which basically is a software solution designed for patient-centered workflow. It takes all of the information and organizes it in such a way that it sets priorities based on the rule sets that you put in: Patients are prioritized based on their clinical urgency and the chronology involved. In other words, whether you are a patient at a 1,000-bed tertiary center or in a 20-bed community hospital, you are prioritized based on arrival time. He or she is considered just as much a priority at one hospital as at another. The guessing game (based on the radiologist picking and choosing what to read) is over. That’s a distinct difference from what has traditionally been done, which is trying to organize and prioritize among disparate PACS. This enhances patient outcomes, because a quicker turnaround time enables the physician to treat the patient appropriately. What we are doing in radiology will be a prelude to what is going to have to happen in health care in this country: You must have access to all of the patient’s medical history. That includes prior admissions, physical exams, and laboratory and pathological results. Providing access to all of the data allows you to expedite patient care. It saves time, and it also saves money, because you are minimizing duplication of services that occurs, quite frequently, because of lack of access to prior studies. It is like a unified medical record, but it is specific to radiology procedures. RADINFORMATICS: What role will the patient play in patient-centered radiology? ALFONSO: Patients will choose where they would like to have their studies performed, preferably with the knowledge beforehand that a particular institution uses a program that will give the radiologist and referring physician the most information available at the time. It also serves as a method to record patient radiation exposure. Allowing patients (or referring physicians, for that matter) to have access to that information—so that when someone comes to the emergency department, it is apparent that this person had 20 or 30 CT scans in the past six months—might make physicians more reluctant to order additional studies that expose patients to ionizing radiation. RADINFORMATICS: What is the long-range vision for patient-centered care at Riverside Radiology? Is a shift in culture needed? ALFONSO: Our culture is what is creating the change. I think we all agree that we need to do this because it provides better patient care. It makes a lot of sense: practicing better and higher-quality medicine with a reduction in unnecessary exams. We are on our way to developing very robust, patient-centered archiving of imaging data. This hopefully will be a prelude to other health-care organizations allowing access to their databases for imaging, regardless of whether you are the radiology providing services at their institution. RADINFORMATICS: Is interoperability the limiting factor, or are there other issues that are preventing institutions from sharing information? ALFONSO: The technology exists to permit access to the data, but you need health-care providers and institutions to permit sharing this information. Through the nature of our contractual relationships, we are able to create a large database of imaging procedures. Regardless of whether you are providing clinical services or have privileges at that hospital, it’s still very important for you to have the information from that facility if you are going to treat that patient. There needs to be a change in thinking regarding a health-care system viewing a patient as proprietary. I think the system that is willing to share information will probably be the one that succeeds in the future. It is a unique paradigm, but once the mentality shifts—patients aren’t necessarily ours, but we are privileged to have them in our system and willing to share that information so that they get the best care—patients will naturally migrate toward such a system. It provides a much better value proposition for them. Cheryl Proval is the editor of Radiology Business Journal.