Fast Forward: Reimagining the Radiology Department

Twenty years. That’s the time it took for hospital radiology departments in the United States to fully convert from film-based to digital operations. These years spanned an era that witnessed the introduction of RIS, PACS, archival silos and cloud storage, electronic image exchange, digital dictation and an onslaught of advanced 3D, 4D and quantitative informatics software innovations. Radiologists and their departments adapted, adopted and survived.

Now the challenge is value-based healthcare: healthcare provider services that positively impact patient outcomes and the purse strings of payors. How will this impact the radiology department of the future? Radiology Business Journal asked leaders in four healthcare organizations with reputations for innovative thinking to discuss the major forces reshaping healthcare and their implications for the hospital radiology department as it exists today and then to do some crystal ball-gazing into the future five to 10 years hence.

It’s not just the Affordable Care Act that is impacting healthcare. Jonathan S. Lewin, MD, identified three overriding forces reshaping healthcare within the United States that exist in parallel with the mandates of healthcare reform from the Obama Administration. These are:

• The financial necessity to reduce the healthcare expense burden on individuals, companies and other payors, and the society at large;
• The increasing rise of consumerism in healthcare; and
• The steady evolution and expansion of instant communications, particularly mobile technology, resulting in heightened patient expectations.

Lewin should know. In addition to being a professor of radiology and chair of the department of radiology and radiological science at Johns Hopkins University and radiologist-in-chief at Johns Hopkins Hospital in Baltimore, he also is the healthcare enterprise’s co-chair for strategic planning and senior vice president for integrated healthcare delivery at Johns Hopkins Medicine.

“These forces are converging on healthcare, all striking at the same time,” he says. “They represent huge challenges for healthcare delivery systems. We as a country are running out of money to pay for escalating healthcare costs and so is a typical family’s budget. Now that most individuals have a direct stake in keeping healthcare costs down because they pay a higher proportion of them, they are becoming better educated and demanding transparency.”

Lewin believes that decades of escalating healthcare costs are in great part attributed to the rise of Medicare and commercial health insurance negotiations with providers that separated patients from any price consideration. Dieter R. Enzmann, MD, professor and chair of radiology at the UCLA David Geffen School of Medicine in Los Angeles, agrees, pointing out that because third parties negotiate fees for healthcare services, most healthcare providers and radiology departments have evolved into service departments whose practice innovations have concentrated on increasing service volume rather than service value. Only recently have patients questioned the types of radiology exams being ordered, and asked why they were ordered and how they would help, what they cost and why costs differ among providers.

Internet technologies have had a hand in this transition by revolutionizing access to information. Mobile technology, particularly smartphones, has personalized it. The opportunity to use mobile technology to monitor a person’s state of health and to provide interactive feedback is expected to have a huge impact on how healthcare is delivered. Lewin predicts that apps will raise the expectations of patients, and that the healthcare delivery systems that address patient/consumer expectations will be the ones that survive in ensuing decades.

The value-discipline approach

Addressing expectations represents value. The value-discipline approach, as explained by Enzmann, uses three market-based categorical positions: delivering operational excellence/or low-cost services, being a product leader and offering customer intimacy. He believes that most large healthcare systems will adopt a low-cost service provider value discipline that will push radiology practices to conform by offering the lowest price for their services at an acceptable quality. This will require radiology departments to adopt or improve upon strategies for high-capacity utilization of department resources, high labor efficiency, shortened production time, standardization, and reduction of variation; all based on real data.

He foresees that radiology departments will become more like conventional businesses, adding administrative managers to optimize modality, facility and staff resources—a “fleet management” perspective that some very large enterprises are now doing.  Inclusion of radiology practitioner assistants will become commonplace as licensing restrictions change. Radiology facilities will be dispersed, providing services at locations and at times that are most convenient for consumer patients. Says Enzmann: “Departments will evolve into imaging networks that will provide actionable diagnostic information and image-guided therapy as one choice of action.”

Some radiology departments, including NYU Langone Medical Center (NYULMC), with 34 geographically dispersed radiology facilities, anticipated this. “Radiology departments can no longer represent a single static entity; they need to be dynamic and very flexible,” Robert Grossman, MD, comments. Grossman was the chair of NYU’s radiology department before becoming CEO of NYULMC and dean of the NYU School of Medicine.

For the past seven years, NYULMC has implemented a strategy of expanding its reach to local communities. The radiology department operates facilities throughout the five boroughs of New York City and on Long Island. Grossman explains that the organization specifically deployed this strategy so that no one event could wipe out healthcare services being offered.

“Hurricane Sandy flooded basement floors of Langone Center, and we did have to close the main hospital. But we came back in 59 days to full strength, enabled by all the processes that we put in place well before the hurricane struck,” he says. In fact, the radiology department made the loss of four MRI scanners a benefit, putting replacement modalities in locations that were much more appropriate to the radiology-enterprise needs.

Managing this 34-location entity requires a highly coordinated, efficient workflow oriented management team driven by data and by margins. Grossman says that the department is very data driven, and has the ability to see in real-time what is happening at every location and to analyze this data efficiently.

“Our IT strength and the analytic software we use enables us to make good decisions, optimize processes and appropriately allocate all of our resources,” he says. “It’s critical to be very careful when considering how to allocate resources and maximize efficiencies. You need to be able to do more with less. That is the key. If a healthcare organization—or a radiology department—can consistently achieve this, it will thrive,” he believes.

NYULMC initiated a value-based management program in the spring of 2014. The first phase of the program is focusing on the development of evidence-based delivery protocols, the management of high-cost outlier patients, and improved efficiency within operational and corporate services. But the program is intended to evaluate every type of service provider to identify ways to deliver hospital services better at less cost. 

The consolidation impact

As vice president of hospital operations, Lahey Health, Richard J. Guarino is intimately involved with the creation of a regional healthcare enterprise that can address and survive current and impending healthcare changes. Headquartered in Burlington, Mass., Lahey Health is the new configuration of what formerly was Lahey Hospital and Medical Center (best known as Lahey Clinic), Northeast Health System (affiliated in May 2012) and Winchester Hospital (affiliated in July 2014).

“The impetus for consolidation from every aspect is to be more efficient with respect to care,” Guarino explains. “Single community hospitals cannot survive with risk-based contracts, because the size of the population needed to pay for services is greater than what a single community hospital can serve. In the era before the Accountable Care Act, radiology departments generated up to one-third of a hospital’s income, but this is no longer the case. Radiology departments need to implement utilization management to prevent inappropriate or unnecessary exams from being ordered.”

Change is coming gradually to Lahey’s collective radiology departments, which includes a longstanding employee-physician model and the radiology private practice models of the hospitals within the system. Patricia A. Doyle, director of radiology, explains that the foundation of the departments’ plans rest on information technology.

“To cite one example, robust IT systems are essential to support image sharing, because the hospitals within our organization are sharing patients based on their clinical strengths and the acuity of care required,” she explains. “The radiology departments need to support our centers of excellence, such as those for breast care, cardiac centers and the liver transplant center, which happens to be one of the largest in the nation. Imaging protocols are being standardized. Our individual hospital radiology departments are working together to create a unified radiology module for a new enterprise-wide EMR that is going to be installed in 2015. The new system also will include radiology clinical decision support functionality to support physicians ordering exams.”

Offering added value through utilization management, being proactive clinical consultants in radiology and changing patient interaction with radiology departments to reflect smartphone era expectations, are anticipated and fit neatly within Enzmann’s new value-discipline approach. It also reflects a return to pre-PACS days when ordering physicians would feel comfortable and motivated to visit reading rooms to discuss their patients with radiologists.

Embedded radiologists

Johns Hopkins has already made this happen, by placing specialist radiology reading rooms in strategic locations outside the main radiology department to encourage consultation. “It is not as important to embed radiology technology near specialist departments, unless there is enough use to justify it,” he says. “In fact, from an operational efficiency perspective, a better choice is to keep high-end instrumentation centrally located. But embedding specialist radiologists in locations where they will be visible and accessible is helping to maximize the value of an integrated practice unit. This strategy has been facilitating communication for years. We’re doing it wherever it’s feasible.”

Johns Hopkins’ reading room of musculoskeletal radiology specialists is located in the middle of the orthopedic clinic. Orthopedic surgeons walk by the reading room door, located between their offices and the examination rooms. Pediatric radiologists are adjacent to the pediatric operating rooms. Reading rooms are strategically positioned near general operating suites. Mammographers are embedded in breast centers, co-located with breast surgeons.

Lahey is considering assigning a daily-rotational radiologist liaison whose responsibilities for the day are to consult with clinicians about their patients’ cases and to recommend the best diagnostic imaging procedures for clinical diagnoses. Guarino observes: “When a patient presenting to a general practitioner with blurred vision or headaches is referred to a specialist, this doctor doesn’t give orders to the specialist. I have always thought that radiologists have not been treated like the specialists they are: Their expertise merits consultation, especially with the complexity of imaging today. While one may argue that providing consultations decreases the productivity of radiologists, this is offset by eliminating unnecessary exams, saving money and increasing the overall efficiency of the radiology department.”

Compensation for those consultations is a work-in-progress. Doyle reports that the radiology department is discussing the value of consultative time, how to measure it and how to capture it. It is working with a California software company that provides automated customized workflow measurements to acquire measurable data with respect to current consultation trends.

NYU is hoping that its value-based management program will address this as well. Grossman said that academic medical centers need to realize that its physicians need to have a better understanding of imaging, and that regular communications with radiologists must be encouraged, but that radiologists do require compensation for this time. Radiologists’ compensation needs to be linked to more than just interpreting exams and producing reports. It needs to also be based on value, he emphasizes.

Technology can help. Johns Hopkins’ radiologist and informaticist John Eng, MD, developed customizable software to extract pertinent clinical data from an EMR that would be helpful to a radiologist interpreting an exam and display it with a single click command. A tablet app also that splits a tablet to enable two-way videoconferencing on one half and diagnostic images being discussed on the other half is in its final stages of being piloted by radiologists and residents. Lewin hopes that it will be used soon by referring physicians and radiologists for consultations. 

Tackling the radiology report

Technology also can play a role in helping radiology meet the expectations of patients, sources say.  Consumerism, particularly as expressed in young patients, will drive real-time, online scheduling, electronic communications with patients and delivery of radiology reports to patients, requiring a patient-friendly, coherent summary of findings.

Referring physicians are key consumers, as well, and it’s time that radiologists address well-documented frustrations with the radiology report, Enzmann says. Radiology departments are going to need analytics tools that will efficiently extract more information from images that extend beyond the radiologist’s well-trained visual system. The use of more sophisticated informatics skills, structured reports and standardized language will become commonplace, he says. Most important of all, he believes, is the addition of a structured feedback loop from recipients of reports. All of this will minimize the risk to radiology of commoditization.

Radiology reports are disseminated in a broadcast mode, without an easy method for two-way communication, Enzmann says. “Radiologists get very little feedback on the quality of the diagnostic information they provide or the impact this information has on patient care,” he says.”They really need to know if the exam and their advice has any impact on patient management. If the exam isn’t diagnostically valuable, why perform it? If the exam is valuable but the radiologist’s information isn’t useful to patient management, what does the radiologist need to do to make it so? As a business, radiology departments will need to establish methods by which a patient’s physician and the patient himself can provide feedback in a manner designed for impartial analysis. The feedback loop will enable radiologists to adjust their product—the report—to the point where customers consistently say it is valuable.”

Radiologists, in general, also need to be more engaged in image-information-guided treatment, Enzmann says. Interventional radiology set the precedent for radiologists to treat patients, but the expansion of image-guided surgeries and treatments offer even greater opportunity to provide hands-on services.  He references the use of image-guided tumor ablation services combined with ultrasound-CT fusion image guidance to create oncologic treatments beyond angiography-based vascular interventional radiology. He suggests that by integrating molecular pathology with imaging, a new domain of service could be provided.

Integrating molecular pathology and radiology

UCLA has developed a Rad-Path Center, which may represent an entirely new business service in American medicine. This is a joint collaboration and venture funded by the radiology and pathology departments of the Ronald Reagan-UCLA Medical Center.

It was established to create a new service in imaging and molecular diagnosis by combining state-of-the-art, minimally invasive image-guided biopsy with rapid cytological review and tissue processing for biological markers.  The service has the capacity to provide combined cyto-histopathological and clinical diagnoses, clinical staging and, ultimately, molecular prognosis and response prediction in patients presenting for biopsy of suspected cancerous lesions in solid organs.

The service is currently being offered for patients with suspected liver, lung and prostate disease. Patients are imaged and biopsied in a one-stop visit to an outpatient center. The long-term goal is for a patient to be biopsied in the morning and by the afternoon—or 24-hour at the most—receive a diagnosis from a specialized pathology lab.

Additionally, the two departments have created a database that provides a single report and source for all the necessary data from imaging and pathologic testing. A module for lung cancer is the first software application that has been developed, which combines diagnostic imaging reports with image-guided biopsy reports and detailed pathology reports that contain pertinent clinical staging information for patients with newly diagnosed tumors.

Scott W. Binder, MD, Pritzker Professor and senior vice chair, director of pathology clinical services, and chief of dermatopathology, is co-director of the project with Enzmann. “Our objective for the report is to consolidate the 10 to 12 reports an oncologist needs to identify, read, and assimilate,” Binder explains. “It incorporates all the test findings, and includes relevant radiological images selected by radiologists and interventional radiologists. It also includes color images of pathology that we believe will be useful for the oncologists.” Molecular profiling and genomics profiling, if performed, are added.

“A report like this is a warehouse of data, and has been designed for datamining, both by researchers and clinicians,” he continues. “It enables patients to be followed prospectively and helps coordinate therapy. Oncologists tell us that this integrated report saves them hours of time, which contributes to lower costs and potentially expedites the beginning of treatment. We’ve received feedback that patients also like this report. They are more  sophisticated now, and the integrated report clarifies information about their diagnosis.”

Enzmann adds that some clinicians are already using the rad/path report as a marketing tool, because they find it very useful to have the actual biopsy information, biopsy localization and images that show where the biopsies are taken. The project was delayed somewhat by implementation of a new EHR for the entire UCLA medical system, but went live in early November with single-click access to the database from the newly installed EHR.

All stakeholders are pleased with the project. “We both saw the need for radiologists and pathologists to partner,” Binder says. “We work together well. And our joint work is valuable because it benefits our doctors, our organization and, most importantly, our patients.”

Value, technological and professional innovation, flexibility, change and collaboration are the traits that will keep radiology viable going forward. Frontline innovators are already hard at work on the radiology department of the future.

Cynthia E. Keen is a contributing writer for Radiology Business Journal.