Three views: What constitutes quality in radiology?

RSNA, CHICAGO—Judging by the passion of the presenters, measuring quality in radiology is no mere academic pursuit.

A day-ending session on that topic at radiology’s gargantuan annual gathering produced many points of light—and more than a few provocative points to ponder. Here are excerpts from each of the three talks.

Paul E. Berger, MD, chairman, Partners in the Imaging Enterprise, LLC, and former founder/CEO, NightHawk Radiology Services:

The future of radiology is very bright; I don’t think there’s any question about that. What’s in question is the future of radiologists.

Some folks are going to think I’m just a paranoid old guy who feels that the world is coming to an end. We had a great ride and we’re going to ride the horse until it drops. There are major disruptive changes in healthcare on the horizon and unless we understand them and respond, I think personally that our future profession is in jeopardy. That may be scary to some, but I think it’s reality. So although I don’t mean to scare you, I need to scare you.

Despite how much we love what we’re doing and how important it really is, we are no longer the center of the universe. We are no longer the doctors’ doctor. One of our roles [now] is to make certain that we recapture that title, the doctors’ doctor.

Population health turns the economics of healthcare system absolutely on its head. Our current system is basically a sickness system. When somebody gets sick, we benefit. In the world of population health, we’re paid a sum of money and with that money we’ve got to do what’s best for the patient because every resource we use comes out of that pool of money that we get at the beginning of the year. There’s an opportunity for [provider] systems to make a ton of money, because there’s a lot of waste in the system. If we save just 5% of what we’re spending, 5% of [the] $2.67 trillion [in U.S. healthcare spending] is a chunk of change for people to split up.

What is quality? How do you measure it? We need to have standards that are clearly defined, meaningful and measurable. A simple turnaround time is something we’ve been using for a few years now. It’s easy to do; you put in voice recognition and voilà. You’ve improved your turnaround times. But there are so many more things that go into quality. The only true measures of quality are the outcomes that matter to patients. That’s what our focus has to be. With respect to radiology, what does the patient think about quality? The patient would like you to make a rapid and accurate diagnosis. The patient would hope that you did that safely. They would like to know if they had any way of understanding that the radiation dose they got was not too high. Were they treated with compassion and good communications? Were they satisfied with the whole process, and was there a positive outcome?

The future is being defined by a limited number of integrated delivery networks, IDM’s. There is consolidation everywhere. Big-time consolidation. Big, powerful systems are being swooped up by other systems, larger and smaller. Consolidation is massive and the systems will rule the world. They will decide how things are going to go. And it’s going to be up to them to develop this integrated, fully articulated network that really works. And we have the potential to have a major role in that opportunity.

Radiology’s role as I see it in the leadership is to understand how to best align our interests with the success of those IDM’s. If we can demonstrate that we provide quality in a meaningful, measurable way—and the costs to do that are reasonable and appropriate and within the range that they would anticipate—we’re going to be the winners.

Our goal is to again become the doctors’ doctor. If we focus on what our capabilities are, we can do that.

Paul J. Chang, MD, professor and vice chair of radiology informatics, medical director of pathology informatics at the University of Chicago:

Quality—whatever that means—basically is about trying to achieve efficient, measurable improvements in whatever you deem worthy of achieving. Business intelligence analytics, BIA, is the critical, absolutely essential enabling tool. I apologize if this is boring, but it is critical. It’s not enough to do the right thing; you have to prove that you are doing the right thing.

Quality with inefficiency is a nonstarter to my CFO. Efficiency with quality—hey, good days. Got the difference? Don’t throw people at your problems. The widgets, the technical recipe for BIA, are pretty straightforward. The hard part is governance, figuring out what you are and coming up with a business process model.

Unfortunately a lot of [key information] resides in places that don’t want to work well together. I have to get information from my EMR, I have to get information from my RIS, billing and all that. How do I do that? Many quality [experts] I talk to, that’s their biggest frustration. How do I get the data to do my stuff? My frustration with all of you guys is that you want this data to come up with a brain-dead 1990s scorecard. I would rather have data that actually can orchestrate a workflow to make sure your scorecard is always in the green.

All I’m saying is: No more excuses. I hear too many people with quality [concerns] saying “I could do all this wonderful stuff if I could only get IT to cooperate.” Well, I’m IT! This is easy for us. You just don’t ask the right questions. You just ask blithering generalities. I can’t work on generalities. I need specific OBR segments, specific use case. We’re not good at that. In fact that would be a good topic for next year on quality: how to define your language in the way we think [so you can ask] the right kinds of questions. Because it’s not that difficult.

Again, the hard part is not the widget. The hard part is the governance. And that’s the last thing I want to say. This is what we do [at the University of] Chicago for governance. Because remember, it’s not enough to do it once; you have to do it every day. It’s who you are. It’s what you do. I really believe in the Toyota method, Lean, that kind of thing. The big key of the Lean thing, the Toyota method, is that everyone along the assembly line has the right to close the line in case they see something with risk. I’m a big believer in that.

So how we do that in the [radiology] world? My techs, my medical students, my residents can go into our project intake. They use this thing to say “I’ve got a problem with quality.” And anyone can fill this out. They don’t have to indicate whether they want a scorecard, a dashboard or complex event processing. They don’t have to fill that out. We can help them with that. All we want you to do is tell us what your problem is.

You’ve got to start now. Start modestly, but exploit me for opportunities. This is actually pretty straightforward. Remember, BIA is something you do, not something you buy. You have to have an enterprise perspective, not a radiology-centric perspective. RIS-dependent analytics is no longer sufficient. BIA is a team sport. You have to work closely and continuously with everybody—administrators, physicians, managers and IT.

And that’s basically what I have to say. I know I pissed you off, so now let’s go to the next speaker.

Jonathan Berlin, MD, MBA, clinical professor of radiology at NorthShore University HealthSystem in Illinois:

What is quality, really? Is quality oversensitivity, so that somebody never makes a mistake but they’re recommending more tests? Or is quality potentially [when] somebody has the potential to make slightly more mistakes but they’re more definitive and they don’t recommend as many tests? What would the referring clinicians prefer? Something to think about.

I’m not going to tell you that traditional radiology quality metrics don’t matter, but the fact is that there are certain things that we haven’t focused on that we need to be focusing on more. We focus largely on process, access and structure measures, but patient experience measures have to a large extent not been [important] to us to the extent that they could be. And we’ve only addressed the outcomes measures somewhat peripherally.

Increasing costs being shifted onto people, increased scrutiny of healthcare services—all of a sudden we are being shifted into a retail environment. Because when people have to spend their own money, we are looking at being potentially a retail service. How do you assess that? Well, you take a look at the whole environment. When you buy your house or you rent your condominium, you don’t just look at the house. It’s the school, it’s the community; you look at the whole experience that comes with that purchase.

How do we deal with that in medicine? How do we deal with that in radiology? What do people want? A few main things. Personal contact, convenience, reassurance and safety. And how are we doing with that so far? What have radiologists done up to this point? Increased speed, working off-hours to minimize interruptions, working on the way to reading stations, making telephone contact more difficult, changing the reading room numbers so it’s harder to get a hold of the radiologist, [sending calls straight to] voicemail. How happy are we when we try to call someone and go right to their voicemail? Nobody likes that. And yet that’s happening more and more because of the focus on productivity.

I’m not passing a value judgment on that. It’s just about economics. But certainly we all know that we’re reading more cases than we have in the past. And to some extent we have to think about how that translates to customer service. Because really most patients are not going to score you on the fact that their survivability was a week later if you were a jerk or if the facility was dirty or if they waited a long time or if they were treated poorly.

Imagine in healthcare what the opportunities are for differentiation. They are enormous. You start with things like parking and wait times, how clean is the place, how nice are the people? Did somebody discuss my results with me? Did I feel satisfied with how they followed up with me? All of those things—and that’s just the tip of the iceberg.

The bottom line is, [other] industries are way, way, way ahead of healthcare in terms of differentiation. And we can see this as a threat, and it is a threat. But it’s also a tremendous opportunity.