Bridget M. Kuehn

A physician at The Cleveland Clinic can now view  photos of a patient’s hand and an X-ray of the same hand side-by-side within the electronic medical record to determine the best treatment plan, according to Louis Lannum, the director of enterprise imaging at the nine hospital health system, during a session at the HIMSS 2015 annual meeting.

This advance was made possible by the organization’s adoption of an enterprise VNA to facilitate access to images and other unstructured patient data throughout the system. The organization is one of a growing number that have adopted an enterprise-wide imaging strategy. It’s the latest step in the evolution of imaging, explained Richard “Skip” Kennedy, MSC, a radiologist and regional technical director of imaging information at Kaiser Permanente Medical Group.

“We adapted to the idea that the EMR is the fundamental [hub] for all imaging, “ Kennedy said.

Lannum said the Cleveland Clinic was motivated to make the switch to an enterprise-wide image solution when they realized that more than 60% of the data physicians need at the point of care-unstructured data such as images-were missing from the medical record. These data were trapped in silos throughout the organization.

To remedy this, the organization opted to pursue an organization-wide strategy for cataloging and storing images, regardless of which department created them.[[{"type":"media","view_mode":"media_crop","fid":"34497","attributes":{"alt":"Louis Lannum","class":"media-image media-image-right","id":"media_crop_8233973144881","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3671","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 169px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Louis Lannum","typeof":"foaf:Image"}}]]

“It’s more than just storage,” Lannum said. He explained that VNAs initially emerged to extend storage capabilities of radiology departments, however, these systems have evolved to include workflows, central image management, and a single access point.

Previous imaging strategies have been “radiology-centric,” Lannum said, but as more specialties utilize images, it is becoming more important to look at imaging management at the enterprise level. At many organizations, this process has included no longer referring to other specialties using the VNA as  “the ologies.”

“It is time to stop talking about ologies,” Kennedy said. “Now, we have to learn to collaborate (within the enterprise model).”[[{"type":"media","view_mode":"media_crop","fid":"34498","attributes":{"alt":"Richard “Skip” Kennedy, MSC","class":"media-image media-image-right","id":"media_crop_3702769266793","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3672","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 213px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Richard “Skip” Kennedy, MSC","typeof":"foaf:Image"}}]]

So far, 35 of the 45–50 departments that produce images at the Cleveland Clinic have been integrated into the enterprise-wide system.

In addition to solving some of the storage and access problems associated with siloed image management, Lannum said the new system is giving physicians the opportunity to utilize a wider array of image capture devices and provide more efficient care. For example, if a patient sees a dermatologist for a rash, the dermatologist could ask the patient to take “medical selfies” of the rash during treatment and the physician can incorporate these images into the record to assess treatment results.

One of the keys to a successful enterprise image strategy, according to Lannum, is having strong governance. He explained that the Cleveland Clinic has created a governance body, including the chief information officer and representatives from the departments using imaging, that meets regularly. This body helps set image storage policies and helps to ensure that new systems purchased by various departments are compatible with the enterprise system.

Another key to a successful enterprise imaging strategy is to ensure that communication among specialties doesn’t suffer, said Kennedy. He explained that despite the inefficiencies associated with earlier generations of imaging technologies, these older technologies also required one-on-one discussions among clinicians or even physical handoffs of data. It is critical, he said, for enterprise strategies to include good cross-department communication and collaboration.

“For all the inefficiencies, we had a communication and collaboration process build into that,” he said. “We need to maintain that.”

Articles

Experts that have developed enterprise imaging strategies talked about their process at HIMSS 2015.

Successful Execution of Enterprise Imaging

Health system purchases of VNAs are outstripping PACS purchases by 5 times, according to presenters at HIMSS 2015 in Chicago.Presenters Trent Conwell, technical manager at Sentara Healthcare, and Eric Rice, Chief Technology Officer of Mach7 Technologies, a company that sells VNAs, highlighted the factors driving this trend.

Slideshows

7 reasons why it might be time to switch from PACS to VNA.

The Case for Unpacking PACS

Reports that a quarter of New York patients who undergo cardiac catheterization likely received this invasive test 

 have raised concerns for both patients and payers across the country. But when those questions arise, Creagh Milford, DO, MPH, associate medical director at Partners Health Care, and his colleagues are prepared to allay them with data that show that about 90% of catheterizations at Massachusetts General Hospital and its sister hospital Brigham and Women’s Hospital meet criteria for appropriateness.

That data and the confidence it inspires is a product of the hospital’s Queriable Patient Inference Dossier (QPID), which Milford described during a session at the HIMSS 2015 annual meeting. The QPID system is a software program that extracts data from patient records, medical literature, and relevant guidelines to help guide physicians and patients through the process of assessing the treatment options for a particular condition.

The physician still leads the process and makes the final decision, said Michael Zalis, MD, a radiologist and chief medical officer of QPID Health, a company created to commercialize the QPID platform. But the software cuts out some of the labor associated with culling relevant data from the patient’s medical record and highlights for the physician which patient data may be relevant to the decision. With these data in hand, the physician is guided through a decision tree based on the relevant clinical guidelines and professional consensus. At the end of the process, the physician and patient discuss a list of possible options graded based on their appropriateness.[[{"type":"media","view_mode":"media_crop","fid":"34247","attributes":{"alt":"Creagh Milford, DO, MPH","class":"media-image media-image-right","id":"media_crop_5822654009154","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3642","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 190px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Creagh Milford, DO, MPH","typeof":"foaf:Image"}}]]

“We are trying to move us to a system where patient and provider are making decisions based on quantitative evidence,” said Milford.

Once a decision has been made, the system guides the patient through a personalized consent process that includes calculation of the risks of the procedure given their medical background and pictures and descriptions of the procedure, explained Zalis.

“It completely changes the game in terms of the patient’s understanding of what they are getting involved in,” Zalis said.

So far, a pilot of the QPID system for lumbar spine care involved 95 cases; the care selected for 83 of them (87%) was deemed appropriate. Seven cases were deemed rarely appropriate and are currently under review. By the end of the year, the health system plans to have QPID up and running for 9 costly procedures.[[{"type":"media","view_mode":"media_crop","fid":"34248","attributes":{"alt":"Michael Zalis, MD","class":"media-image media-image-right","id":"media_crop_8202817250507","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3643","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 190px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Michael Zalis, MD","typeof":"foaf:Image"}}]]

The hospitals have reaped other benefits as well. The system has helped lower the costs of unnecessary care, Milford said. It can also be used as a selling point to patients and referring physicians who want evidence that the organization’s care is cost-effective. It has also cut the administrative work associated with prior authorizations for both the hospitals and the insurers they work with. Milford explained that some insurers have been willing to forgo preauthorization now that the QPID system is in place. Additionally, the system helps provide data for state and federal registries on appropriate use.

Ultimately, Milford said the system may not reduce the number of procedures, but it helps to improve relationships between patients, payers, and clinicians.

“The goal is not to reduce the number of procedures, but to attest to their appropriateness,” he said.

A program presented at HIMSS 2015 highlights the value of decision support for appropriateness in imaging.

Maximizing Appropriate Use With Smart Decision Support

CHICAGO - Declining reimbursements, commoditization, and preparing radiologists to adapt to health care reform are some of the key issues leaders from the American College of Radiology (ACR) are grappling with, according to ACR leaders who spoke at the Radiological Society of North America’s “Critical Issues Facing the Practice of Radiology” round table discussion.

Bibb Allen Jr., MD, chair of the ACR board of directors, noted that many radiologists are practicing hyper-efficient radiology in which they sit at a work station and try to minimize interruptions from referring physicians and patients, a phenomenon documented in 

. But Allen noted that the model isn’t sustainable and contributes to commoditization.

“If all we have to offer is interpretation, anybody can do it,” he said. “It can be traded on the market based on price.”

To help radiologists stay relevant, ACR has launched the 

 initiative. Allen said the initiative aims to help drive culture change in the specialty by providing radiologists and referring physicians with tools that will help them integrate high-value care into their workflows. The initiative, he said, also aims to better align pay incentives, so that physicians are rewarded for making these changes.

He noted that the organization has created a clinical decision support tool called 

) that makes it easier for referring physicians to integrate the ACR Appropriateness Criteria into their image ordering. The program has a web-based version and can be integrated into an electronic medical record system. Bibb noted that the Appropriateness Criteria have long been widely available in books, guidelines clearing houses, and other formats, but referring physicians haven’t used them. Electronic decision support tools integrate the criteria into the imaging order workflow of an electronic record and automatically set up a radiologist consult if a physician orders a low value test.

The college is also working on developing electronic tools that will help improve radiologists’ performance. For example, the organization is working to help develop programs that will ensure fail-safe reporting of critical patient results. Bibb noted that electronic systems can ensure that critical results are reported in minutes, hours, or days depending on the urgency.

The organization is also developing decision aids for radiologists to help them make more consistent and evidence-based decisions about the tests they order.

“Our goal is to deliver all the imaging care that is beneficial and necessary and none that is not,” said Geraldine B. McGinty, MD, MBA, chair of the ACR Commission on Economics.[[{"type":"media","view_mode":"media_crop","fid":"30615","attributes":{"alt":"ACR","class":"media-image media-image-right","id":"media_crop_1763377234780","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3214","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 104px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

James A. Brink, MD, vice chair of the ACR board, said the ACR is developing dashboards to help radiologists track quality measures. These dashboards, he noted, can help practices demonstrate their value and meet the requirements of accrediting organizations.

While the ACR works to help adapt to health care reform, the organization is continuing to shore up the current fee-for-service reimbursement system most practices operate under, McGinty said.

“We are fighting hard to prevent further cuts,” she said.

She noted that the ACR has had success working with diverse stakeholders to address reimbursement issues. For example, ACR worked with patient groups, physician organizations, and others to support Medicare payments for lung cancer screening of long-time smokers and the Centers for Medicare and Medicaid Services agreed to coverage beginning in 2015.

All of these initiatives create greater opportunities for radiologists and other physicians to track the value of the care they provide. Brink said it is essential to embrace these quality improvement tools going forward. He noted that at Massachusetts General Hospital, where he is radiologist-in-chief, physicians have been able to identify areas where they may not be performing as well as their peers and improve the care they provide while reducing unnecessary imaging.

“If we don’t become our own watchdogs, others will do it for us,” Brink said.

ACR leaders debate reimbursement, commoditization, and health care reform at RSNA 2014.

ACR Leaders Focus on Moving Radiology Forward

CHICAGO - Radiologists must make themselves visible and valuable to their patients and their physician colleagues if they want to secure a bright future for the specialty, said David C. Levin, MD, professor emeritus at Thomas Jefferson University in Philadelphia during the Radiological Society of North America (RSNA) Annual Oration in Diagnostic Radiology.

Levin’s talk challenged radiologists to take a drastically different approach to their practice to stop the commoditization of the field in his talk, “Transitioning from Volume-Based to Value-Based Practice: A Meaningful Goal for All Radiologists or a Meaningless Platitude?” He noted that all physicians are being admonished to focus on value-based care over volume-based care, but that radiologists are truly at a crossroads that may determine the fate of the profession. Radiologists, he said, must either choose apathy and the status quo or “take meaningful action to transform what we do.”

He noted that many people in the medical industry view radiologists as overpaid, and uninterested in patients. He explained that some choices that the profession has made over the years have reinforced these views such as outsourcing night and weekend work and not engaging with patients or referring physicians.

“We have let ourselves become the invisible doctors,” he said.

To counter these perceptions, radiologists must begin acting more like consulting physicians, he said. He recommended that radiologists screen imaging requests for appropriateness and educate referring physicians about ACR’s Appropriateness Criteria and the Choosing Wisely campaign, which was launched by the American Board of Internal Medicine (ABIM) Foundation to identify medical tests and procedures that are often not necessary. The ACR was one of the first groups to partner with ABIM on the project. But, Levin noted, 72 of the unnecessary procedures identified so far are imaging tests done by radiologists.

“That is a huge number and something we all really have to worry about,” Levin said. He said professional radiology organizations should do more to publicize the Appropriateness Criteria to other specialties and that radiologists must do everything they can to eliminate unnecessary imaging.

Radiologists must also take a more active role in supervising technologists. Levin suggested a daily morning huddle, frequent feedback from the radiologist, and that technologists be encouraged to call with questions throughout the day. He also urged radiologists to make themselves available to referring physicians. For example, by creating a “Consultant-of-the-Day” who is available to field calls and handle consultations.  Levin noted that it is particularly important for radiologists to build strong relationships with primary care physicians and their staff because they will play an influential role in Accountable Care Organizations.

Patients must also become central to the radiologist’s work. Levin said radiologists should take back responsibility for reminding patients about follow-up imaging exams. They should do rounds to speak with patients and get more history, and give patients their contact information to field questions.[[{"type":"media","view_mode":"media_crop","fid":"30438","attributes":{"alt":"David C. Levin, MD","class":"media-image media-image-right","id":"media_crop_6859679689564","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3194","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"David C. Levin, MD","typeof":"foaf:Image"}}]]

For example, he noted Rob Milman, MD, a radiologist in Austin, Texas provides lectures to primary care physicians, administrators, and the public about the downsides of overutilization of imaging, the value of imaging, and appropriateness criteria. Levin said he’d like to see more radiologists do this kind of outreach.

Levin acknowledged that some radiologists may balk at taking time for unreimbursed tasks. But he said taking a small pay cut may be necessary to secure the future of the profession. He also noted that other specialties, such as primary care, spend much of their day on unreimbursed work.

“That’s what real doctors do,” he said. “They take care of their patients, even if they don’t get paid.”

Levin also recommended that practices “take back the night,” and stop outsourcing night and weekend work. He argued that outsourcing commoditizes care and gives referring physicians the impression that anyone can do the work. He also said he suspects that telemedicine firms will read an image for $25–$35, compared to the $75 CMS pays a radiologist, has likely contributed to declining reimbursement rates.

It will also be necessary for radiologists to demonstrate the quality of their work. Levin suggested that each practice identify and track 10–20 quality measures. He noted that some practices are already doing this with electronic dashboards.        

To help meet these new demands for work, Levin urged practices to hire young radiologists who can take on some interpretation tasks and free up time for non-interpretive tasks.

Ultimately, he said, radiologists must make some sacrifices now to ensure a better future for the field.

“Are radiologists going to be willing to sacrifice a small amount of income and personal convenience to provide real value and save the specialty from commoditization and disruption?” he asked. 

Patients must become central to radiologists’ work, David C. Levin, MD, said at RSNA 2014.

Radiologists: Sacrifice Income to Provide Value

CHICAGO - A law passed earlier this year will mandate the use of electronic clinical decision support (CDS) to order imaging studies by 2017. To be reimbursed by the Centers for Medicare and Medicaid Services (CMS) for imaging studies, radiologists will have to document that a CDS was used when the study was ordered.

The implications of the Protecting Access to Medicare Act (PAMA) of 2014 for radiologists and a CMS imaging decision-aid demonstration project were discussed at the Radiological Society of North America’s annual meeting at the session “Clinical Decision Support for Imaging: Update on Current State and New Federal Regulations.”

The federal efforts are intended to reduce overutilization that can drive up health care costs and expose patients to unnecessary radiation.

“Imaging has gone up, and we lead the pack in costs in medicine,” said Keith Hentel, MD, MS, chief of the division of emergency/musculoskeletal radiology and executive vice chair of the department of radiology at New York-Presbyterian Hospital-Weill Cornell Medical Center. “Radiologists and our practices have become targets.”[[{"type":"media","view_mode":"media_crop","fid":"30201","attributes":{"alt":"alert","class":"media-image media-image-right","id":"media_crop_3642049726788","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3155","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 106px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Hentel noted that some private payers have created radiology benefits management (RBM) programs to reduce unnecessary imaging by requiring prior authorization. But Hentel said there is limited data on the effects of this approach. He noted one 

 found reduced utilization with RBMs and 

 that suggested that prior authorization simply shifts more costs to radiologists and ordering physicians’ offices.

Another approach to reduce overutilization and improve quality of care recommended by the Institute of Medicine and others has been to make greater use of CDS systems that can extract data from relevant clinical guidelines and medical studies available to physicians in real-time to help guide their choices.

To test whether CDS could improve physicians’ use of imaging studies, CMS funded the Medicare Imaging Demonstration project conducted at 31 practices with 5128 physicians serving more than 79,000 Medicare beneficiaries. Preliminary data were presented recently and will likely help shaped the implementation of PAMA.

Brigham and Women’s Hospital and its affiliates have been testing the use of CDS. Ramin Khorasani, DMD, associate professor of radiology at Harvard Medical School and director of information management systems at Brigham and Women’s Hospital in Boston, explained that the institution’s electronic medical records systems have been linked with an electronic evidence library that includes clinical guidelines from the American College of Radiology (ACR), the American College of Emergency Physicians, the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign, and many other guidelines. When a physician begins the process of ordering an imaging test, the system guides the physician to answer a series of questions. Then, it provides the physician with evidence about whether the test is warranted. If the physician ignores the system’s recommendation, an automatic radiology consult is ordered to discuss the need for the test.

Khorasani said the program has reduced the number of magnetic resonance imaging tests for patients with low back pain ordered on the day of the patient’s visit to their primary care physician by 30% and has reduced the number of computed tomography scans for minor brain injuries in the emergency department by 13.4%.

“It’s important to think of it as a clinical program,” Khorasani said. He explained that involving leadership and physicians in the program has been essential.

The ACR has embraced decision support tools as part of its Imaging 3.0 initiative. The college has created 

, a CDS system based on ACR Appropriateness Criteria. The system can be accessed through a website or used by electronic medical record vendors.

“We need to undergo a transformational change,” said Bibb Allen Jr, MD, chair of the ACR’s board of chancellors. He explained that the college is working toward a culture change in the profession and it is working to build the tools and incentives needed.

Allen noted that while the initial phase of PAMA targets decision support tools for imaging, later phases will involve other specialties. By being the first specialty to implement widespread use of decision support, radiologists are positioning themselves as leaders and strengthening their relevance, Allen said.

“Wouldn’t we rather not do the things that don’t matter and promote the ones that do,” he said.

Federal mandates for clinical decision support for imaging studies can put radiologists in the forefront of a trend that’s likely to grow. 

Radiology Can Lead the Way in Clinical Decision Support

CHICAGO - Radiologists at academic medical centers must piggyback on their institution’s efforts to comply with a federal incentive program designed to promote use of electronic medical records, agreed speakers at the Radiological Society of North America annual meeting session, “Health IT Incentive Programs: Experience from Radiology Practices in Hospitals and Health Systems.”

Without strong institutional IT support and coordination, many departments simply will not be able to meet the meaningful use requirements set out in the 2009 economic stimulus law. The law lays out a series of carrots and sticks to accelerate the adoption of electronic medical records and ensure that the systems are used to improve medical care.

The law greatly accelerated the adoption of electronic medical records, increasing the number of physicians using the systems from 20%, when the law was passed, to 70% now, said Curtis Langlotz, MD, PhD, professor of radiology and biomedical informatics at Stanford University. Many radiologists support the goals of the program and wish to take advantage of its incentives, which were up to $44,000 per physician for those who began in 2012 and have declined each year since. But it has been difficult for some to meet the law’s requirements.

Many meaningful use requirements are not relevant to radiologists, so academic center radiologists must build off the meaningful use efforts of their institution and referring physicians in order to comply, explained session moderator Ramin Khorasani, DMD, associate professor of radiology at Harvard Medical School and director of information management systems at Brigham and Women’s Hospital in Boston.

“Leveraging the institutional electronic medical record system and meaningful use initiative is really the only way to do this,” Khorasani said.

Khorasani and his colleagues have piggybacked off Brigham and Women’s institutional meaningful use push, and have tapped into the institution’s electronic medical records system to extract data, like a patient’s smoking history, that are required to meet meaningful use standards but that are not routinely collected by radiologists.

It takes a substantial investment in IT to make it possible for radiologists to tap into their institution’s larger medical record system. For example, Khorasani’s department requested $300,000 (about 6% of the $1.8 million meaningful use incentive the department was eligible for) from Brigham and Women’s to make necessary IT upgrades. In addition to allowing the department to access data needed to meet meaningful use requirements, the upgrades allowed the radiologists to access more clinically useful information about patients.

“Radiologists now have access to  very detailed clinical information they didn’t have before,” Khorasani said. “It ended up being clinically useful.”

The radiologists and their staff had to be trained to enter other data, such as a list of patient’s medical concerns, or to ask patients to fill out forms for additional required information. But the radiologists have been pleased to receive incentives of about $14,000 each over 5 years in their pay, Khorasani said. The rest of the incentives went to the institution or department. So far, 92 of the department’s radiologists have qualified and the program has collected $1.7 million in incentives.

But some academic radiology departments may find that it is simply not feasible to meet meaningful use requirements. Keith Hentel, MD, MS, chief of the division of emergency/musculoskeletal radiology and executive vice chair of the department of radiology at New York-Presbyterian Hospital-Weill Cornell Medical Center, said his department tried and failed to comply with the meaningful use requirements.

“I was caught up in the excitement about becoming a meaningful user, but we failed,” he said.

He explained that his institution’s electronic medical records system and the electronic systems used by the radiology department didn’t communicate well enough to allow his department to piggyback on the hospital’s patient data. The cost for implementing the IT changes necessary to bridge this divide would have been substantial and much of the incentive funds would have gone to the institution and not the department.

“We are working with bridging the divide,” he said.

For those starting after 2014, there are no longer financial incentives to meet meaningful use requirements. Financial penalties for those physicians who don’t meet meaningful use requirements were set to begin in 2015. Hentel noted, however, that a hardship exemption has been created that applies to many radiologists. He also noted that a 2014 law created a new set of penalties that radiologists should be concerned about. The law requires documentation that an imaging decision support system has been used or the radiologist’s CMS claim won’t be paid. That new requirement is a major incentive for radiologists to make necessary electronic upgrades, Hentel noted.

Langlotz said he hoped that, going forward, federal incentives and penalties will be simplified into a single program. In the meantime, he encouraged radiologists to stay up-to-date.

“It’s highly relevant to our practice today and in the future,” Langlotz said.

Academic radiologists need institutional support to achieve meaningful use. 

For Academic Radiologists, Meaningful Use Takes Support

CHICAGO - As radiologists work to stay relevant and embrace a more patient-centered practice model  in an evolving health system, breast cancer imaging may provide a useful model for others in the field to emulate, according to Michael N. Linver, MD, director, Mammography X-Ray Associates of New Mexico at the Radiological Society of North America (RSNA).

Linver, a clinical professor of radiology at the University of New Mexico School of Medicine, spoke at the session “Unsolved Dilemmas in a Digital World: Improving Radiologist and Technologist Communication” and said the key to success in this model is a respectful relationship between the radiologist and breast imaging technologist.

Strong communication and good relationships with other team members, like referring physicians, and patients also are important, he said.  These relationships, he emphasized, are essential for radiology practices that want to remain relevant in the face of reimbursement pressures, outsourcing, and encroachment into imaging by other specialties.

“We need to provide a service that can only be provided in person, that no one else can,” he said.

Linver outlined the lessons radiologists can learn from successful breast imaging practices. He explained that breast imaging teams include the radiologist and dedicated technologists in mammography or magnetic resonance imaging, tech assistants, and a nurse-navigator. The breast-imaging radiologist is the “lynchpin” for the team and must set a positive tone for working with patients.

He said it is important for the radiologist team leader to meet with patients to help allay fears, get a good history, explain any findings, and break bad news. He offered tips on how to show patients respect and make them comfortable during interactions. For example, he said, he has two chairs in every room so he can sit next to his patients and speak to them on the same level. He stressed the importance of body language that is open and non-threatening.

“Never speak down to the patient,” Linver said. “You have to use words they understand. No jargon.”

He noted that patients receiving bad news may be afraid and in shock, so they may not hear or understand what their radiologist is telling them. He said he likes to give them his card, write the diagnosis on the back so the patient can look it up online, and invite the patient to call with follow-up questions.

Good patient relationships, he said, are essential to good care. Positive relationships also provide a marketing bonus. Women who have had a good experience with your practice will refer others, he noted.

“Patients assume you are competent, but they can measure your affability and availability,” he said.

The team technologist’s professionalism is just as critical to success, he emphasized. He noted that technologists have more contact with patients than anyone else on the team. They are responsible for meeting MQSA quality standards, working seamlessly with the front desk, and being a second set of eyes if the radiologist misses something in an image.

The patient navigator is a newer role in the breast imaging practice. This individual helps work as a physician-extender and may be a nurse or technologist, Linver said. He or she may deliver non-cancerous results, assist patients in accessing services, and provide one-on-one patient education.

To help his team stay engaged and up-to-date, Linver said he regularly brings in outside trainers. He also involves his team members in efforts to improve workflow and ergonomics.

“You must have strong relationships of respect and trust,” Linver said.

He also recommended that radiologists maintain strong relationships with referring physicians and play an active role in clinical decision-making.

“If we as breast imagers abdicate this role, physicians will look elsewhere,” he said.

In a changing landscape, radiologists’ relationships with technologists, referring physicians, and patients need to change.

Breast Imaging a Model in Radiologists’ Relationships

CHICAGO - New informatics tools are emerging that can help radiologists leverage patient and other medical information to more accurately interpret images, avoid medical errors, and reduce unnecessary imaging, according to speakers at RSNA 2014.  

Like most physicians, radiologists are facing a growing pressure to increase efficiency and quality. They are being asked to help reduce unnecessary imaging and procedures, improve the accuracy of their image interpretations, and work more effectively with their physician colleagues. A new generation of health informatics tools presented at session called “Leveraging your Data: Informatics Approaches and Solutions to Improve Imaging Care Delivery” aim to help radiologists meet these growing demands by making relevant patient information, guidelines, and medical references available to them in real time.

“I expect these tools will evolve rapidly,” said Michael E. Zalis, MD, an associate professor of radiology at Massachusetts General Hospital.

Zalis explained that electronic medical records have made an unprecedented amount of patient information available to physicians. But these tools were largely designed to aid with billing, so they often don’t provide information in a way that is useful to clinicians. Relevant information may be lost in the sea of data, or context that is relevant to the patient’s care may be missing.

 “The patient’s story gets lost,” Zalis said. “We need tools to extract that.”

 To help physicians get the information they need out of electronic health records, Zalis and his colleagues at MGH developed a system called Queriable Patient Inference Dossier (QPID) that makes the electronic records searchable using ontologies. Physicians can use the system to search by clinical concepts or to automate certain queries. For example, Zalis said a radiologist could use the system to search a patient’s records for medical implants, and the system retrieves information about all relevant devices without having to search for each by name. 

Arun Krishnaraj, MD, MPH, the director of the division of body imaging at the University of Virginia Health System, tested the QPID system with fellows at his institution and found it reduced interpretation time by 20%. He explained that a normal electronic medical record may only provide the radiologist with a line describing the reason for the order. The QPID system can allow the radiologist to quickly access patient information necessary to rule out possible diagnoses and narrow down the options to the appropriate choice. For example, it allowed his team to diagnose a 39-year-old woman with a hepatic adenoma without needing a biopsy or additional imaging.

“We saved the patient a diagnosis that is wrong and anxiety inducing,” Krisnaraj said.

Informatics tools can also be used to allow radiologists to view images and annotation from medical atlases alongside their patient’s images, explained Cree Gaskin, MD, vice chair of informatics at the University of Virginia Heath System. For example, he explained viewing an annotated image of an age appropriate bone scan alongside a patient’s scan can allow radiologists to more quickly and accurately distinguish an injury from a normal developmental feature.

Some tasks can also be automated. For example, Cree noted integrated software for determining bone age was preferred by the system’s physicians compared to manual studies, and produced fewer errors, 0% compared with 23%.

Decision support tools can also be integrated into electronic health records to help physicians order fewer inappropriate or unnecessary images, explained Giles Boland, MD, vice chair the department of radiology at MGH.

“You are not creating any value if you order the wrong test,” Boland said.

But a decision support tool based on American College of Radiology guidelines for imaging can help physicians determine if imaging is appropriate given the patient’s records. Such a system can also help flag safety issues or notify a physician if an image has already been taken.

He noted that studies have demonstrated that these systems reduce imaging, which may reduce income for radiologists. However, he noted that emerging payment systems also reward value.

“It’s about what’s best for the patient,” he said.

Informatics tools can let radiologists more accurately interpret images, avoid medical errors, and reduce unnecessary images, said speakers at RSNA 2014.