C. Matthew Hawkins, MD

Physician burnout is receiving a substantial amount of national attention currently. There are a number of organizations that have identified this entity as an epidemic – one that threatens health care in this country. Many professionals have begun to devote their academic careers to burnout and figure out how best to mitigate it. In fact, the emotions that this topic elicits are impressive. Simply reading the comment sections following various blogs/posts addressing burnout reveal an inner-fury that is insinuating throughout the fabric of physicians from all specialties. This is indeed a problem.

There are some very smart people implementing creative solutions to this crisis. And before I continue any further – I must acknowledge that I think physician burnout is real, it is important, and we need to deal with this swiftly and effectively.

But, while it is easy to jump on the burnout bandwagon, a few hard questions should be asked and answered – before we collectively reach (perhaps overreach) for solutions to a problem we are yet to fully understand.

1. In an era of work-hour restrictions and emphasis on work-life balance, why is burnout at an all-time high NOW?

2. What are physicians who are NOT burnt-out doing differently? (Maybe they’re just emotionally numb...?)

Oft cited reasons for burnout among radiologists and other physicians are plentiful. Pain points include EMR mandates, lack of tort reform/defensive medicine, quality reporting metrics, increased individual accountability, voice-recognition software, increasingly challenging patients, health care websites, student loans, declining reimbursement, non-physician administrators, insurance companies, pre-authorization, radiology benefit managers, peer-review discoverability, driving Hondas instead of Acuras, other policies, offices without windows, bad parking, and cessation of unlimited free scrubs.

We can’t fix all of these things in health care. And yet – again – there are physicians that aren’t burning out. Why?

Now – I don’t claim to be an expert in the burnout field. I am far from it. I am classified by many as a failing work-aholic that put life out to pasture while pursuing a fairy-tale treasure at the bottom of a career-abyss. But I think one singular question may begin to at least raise attention regarding a dominant reason many of us in health care are burning out.[[{"type":"media","view_mode":"media_crop","fid":"52453","attributes":{"alt":"Physician burnout","class":"media-image media-image-right","id":"media_crop_1868704444348","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6514","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: 205px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Lightspring/Shutterstock.com","typeof":"foaf:Image"}}]]

How many of us like the people we work with?

I don’t mean “like” as in, “He is so nice!” or, “She is great to hang out with.” I’m talking about a relationship of mutual understanding and common goals. Where team members respect the skill set that each brings to the table and where each is intrinsically motivated to do a little extra to reach the level of performance that is jointly expected by all members of the team. Where accountability is considered premium. Where everyone on the team is excited about the opportunity to excel beyond the conventional bounds of health care-workflow-limiting vices. How many people work with a team like that?

High-functioning teams have a few common characteristics:

 Ability to adapt to unforeseen circumstances quickly

 Continuous learning and willingness to identify areas for improvement

We should all take a moment and reflect on these characteristics and ask ourselves whether or not our work-teams embody them. And I am not suggesting to only think about our physician teams – rather I am imploring us to reflect upon the 

 teams we work with every day. Nurses, technologists, trainees, medical assistants, ancillary staff, etc.

Now again, let’s think about physicians that 

 burning out. Are they more or less likely to be a part of high-functioning teams? Perhaps, nurturing and promoting the development of high functioning teams in health care would be a sound strategy for battling the health care burnout epidemic.

But, how much time to we actually devote in health care to building and studying high-functioning teams? I think we all agree that there are some high-functioning teams in health care. Why aren’t we studying them more? What is the highest functioning team in your department? What are they doing differently?

 regarding high-functioning teams is by Liz Ryan. And to quote her directly, “Making your team’s focus the achievement of goals and milestones imposed on them by someone high up in the chain, someone who is not part of the team and has no mission-connection to them, is the best way to stop your team’s forward motion.”

I would offer that most of our teams in health care and in radiology are charged with doing exactly what is described in the quote above. Seems like a poor strategy…

I am not here to endorse or criticize existing efforts to fight physician burnout. But I would encourage that our profession – radiology – lead the charge in creating environments that promote the development of flourishing, high-functioning teams. To trust our leaders to function autonomously and intrinsically motivate their teams, rather than menially “manage” them and “monitor” performance.

If physicians work on teams with people they like -- putting effort into work that they believe in -- they won’t burn out.

Articles

Addressing physician burnout in radiology.

Physician Burnout and High-functioning Teams

Some stories must be told. Even when they are not your own.

So here it goes. This is the story of a radiologist with a vision. Conviction. And an unwavering passion to make that vision tangible, despite institutional inertia and human blockade. His drive has cultivated a movement that will transcend our profession…if we allow it. 

David Larson (Stanford), through a variety of experiences during training and his early career, deduced that there had to be a better way of doing things; that our broken health care system could be fixed with a systematic approach to quality and improvement. He believed that rather than overly focusing effort and resources complying with arbitrary benchmarks and federally legislated standards, institutions could transform health care by scientifically implementing performance improvement programs that continuously evaluate quality, implement change when necessary, and monitor the effectiveness of interventions. Rather than “meeting a standard” or “aiming for compliance” – we should strive to “

This type of thinking is transcendent. Instead of telling health care workers “how” they should do something – this approach empowers teams of people to solve problems and discover improved methods to perform their craft. It promotes engagement, coaching, introspection, and willingness to tolerate failure (in light of the underlying premise of improvement). It is the antithesis of “policies” and “standards” that are often unilaterally determined yet universally enforced. This mind-set suggests that only through trial and error, iterative attempts, and systematic methods can real improvement and 

 be achieve in health care. This value is realized in both reduced cost and improved outcomes. [[{"type":"media","view_mode":"media_crop","fid":"46263","attributes":{"alt":"lesson in radiology","class":"media-image media-image-right","id":"media_crop_4637267334449","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5358","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":"float: right;","title":"Â©CoraMax/Shutterstock.com","typeof":"foaf:Image"}}]]

The scientific field of “improvement” has transformed manufacturing and service industries. Pioneers such as Demming and Crosby serve as role models, such that this ideal of performance improvement is founded by reality – not simply wishful thinking. Isn’t it time we learn from this scientific discipline and utilize its principles to transform medicine – health care – caring for the disease(d)?

In the radiology department at Stanford, a Radiology Improvement Team has been constructed and charged with helping members of the radiology team improve and solve problems. They are not relied upon for solutions – but rather deployed to aid dedicated teams in mapping processes, identifying areas for improvement, implementing interventions, and tracking sustainability of their efforts. The improvement team empowers front-line workers to influence behavior and execution – and inspire other co-workers. They do not solve the problems. They help others do so.

The improvement team is comprised of individuals trained in quality improvement methodologies. They are not necessarily physicians, nurses, or technologists (although they can be).  Rather they are experts at change management, program implementation, and team building. When accompanied by visionary physician leadership – this team becomes remarkably influential. 

The team in Palo Alto is aligned with the leadership structure of the department, and integrated throughout the enterprise. In a very short time, their squad has successfully improved workplace satisfaction for administrative associates and reduced the amount of time it takes to transport patients to and from the radiology department. They have reduced wait times for women being screened for breast cancer and slashed time-to-treatment for patients suffering from a stroke. Wouldn’t it be nice if this could be accomplished at all institutions?  (Pause) 

Why can’t it be?  Why shouldn’t it be?

While reading this story, do not be distracted by the definition of “quality.” For “quality” is in the eye of the beholder. The beauty of this transcendent approach is that while “quality” can depend on perception, “performance” cannot. Either you are getting better, staying the same, or getting worse.  There is not poetic license in the interpretation of “performance.”

Dr. Larson and his team have demonstrated that this approach works even in complex organizations. It has redefined “quality” – such that the definition used by members of this camp refer to “quality” as “consistent excellent performance;” a definition that offers a time-frame and degree of expected performance. This counters antiquated quality-assurance workers who aimed to investigate “never-events” and audit “compliance” – rather than driving behavior change and performance improvement.

The conundrum is that “performance improvement” in radiology is not yet a discipline. There is little guidance, literature, or precedent. In comparison – in the “discipline” of interventional radiology – there is literature and a body of knowledge that can help a new leader build an interventional oncology program or thrombolysis clinical care guidelines. In contradistinction, a radiologist charged with improving performance in his/her department usually has little (if any) guidance or formal training to help build their program. While the work at Stanford is a breakthrough, they need our community’s support and resources to allow for patients outside of Silicon Valley to reap the benefits of health care entities that embrace this methodology. Does this emerging discipline need its own society? Does it need a journal for scholarly publication? Does it need a formal fellowship training program for physician leaders?

But I do know that existing leaders would be wise to acknowledge this movement, embrace it – and re-organize existing radiology leadership structures such that performance improvement teams can influence change and improve performance throughout the organization, rather than function on the periphery in isolation from operational managers and business-types. I know that peer-reviewed journals would be wise to inspect the scholarly work stemming from radiology performance teams and consider it worthy of publication and impactful. I know that a culture change such as this can only be achieved by influencing our trainees to dive headfirst into the methodologies that are scientifically proven to improve performance in our profession.

This is only the beginning. A birthing. Thank goodness someone started it.

The start of something great in radiology.

The Discipline of Performance Improvement in Radiology

Developing a new CPT code is hard. And as the number of minimally-invasive therapeutic options available to interventional radiologists continues to multiply, despite clear proof of improved efficacy (in the setting of improved technical capabilities of physicians), the challenges for crafting codes that accurately capture the degree of physician work, and practice expense associated with these procedures is becoming increasingly complex.

But why is it hard? Can’t you just apply for a new code once a new technology is developed and start getting paid? 

Understanding the code development process- and using percutaneous ablation procedures as a case example- might help to elucidate some of the challenges.

There are a few basic requirements to understand up front: 1) A certain amount of literature is required to get a Category I (Cat1) CPT code. Without it, no code. No code = no payment. 2) The procedure must be performed by many physicians across the United States. 3) The procedure must be performed at a reasonable frequency within the patient population for which it was intended.

If a procedure does not meet the criteria for a Cat1 code, it may be eligible for a category III code, which can be helpful for tracking the frequency with which the procedure is being performed, despite not being reimbursed.

Currently, some of the existing Cat1 percutaneous ablation codes include RF and cryoablation in the liver, kidney, and bone. There is a Cat1 percutaneous RF ablation code for pulmonary tumors, as well. What is conspicuously missing is percutaneous pulmonary cryoablation, which is being performed across the United States. And despite coding guidance clarifying that microwave ablation is part of the RF spectrum and should be reported with radiofrequency ablation codes, some payers are not paying for microwave ablation as there are no microwave-specific ablation codes. Lastly – irreversible electroporation is a novel ablation technique with a growing of body of literature supporting its use in certain scenarios. The bottom line is that there are a number of established and budding ablative technologies that are not being (or going to be) reimbursed in the current coding milieu.[[{"type":"media","view_mode":"media_crop","fid":"42421","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9450852386728","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4588","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":"C. Matthew Hawkins, MD","typeof":"foaf:Image"}}]]

So, should our specialty societies just apply for new Cat1 codes for all of these ablation techniques in the organs in which they are being used? Should we get a liver microwave ablation code, a pulmonary cryoablation code, and a pulmonary microwave ablation code? Sounds great, right? Then everyone that is performing these procedures might get reimbursed appropriately for the work being done and the equipment being used. Physicians would be happy, hospitals would be happy, and vendors can begin to reap their return on investment.

But, chew on this possibility for a minute. Let’s say we craft and propose a Cat1 CPT code for pulmonary cryoablation – which, for all intents and purposes seems appropriate based on the frequency of use and supporting literature. And let’s assume that the code is approved by the AMA’s CPT Editorial Panel.

Once approved, a new code must then be surveyed by the specialty societies in order to assess the amount of work involved in performing a procedure, as compared to existing CPT codes. The results of these surveys inform the RUC, which then submits recommendations to CMS about what the valuation of the code should be. But, precedent exists from the RUC (who determines relative value for all CPT codes) to ask that when a new code is introduced, that the 

 of codes be resurveyed and revalued. And let’s not forget that by “revalue” – the RUC and CMS actually mean “devalue”.   

So in the instance of pulmonary cryoablation, what is considered the 

? Should only pulmonary RF ablation be resurveyed? That seems most sensible. Or should all percutaneous ablation codes be resurveyed? Remember, this is not the choice of our specialty societies. If all percutaneous ablation codes are resurveyed – it is exceedingly unlikely that current reimbursement will be preserved. And if imaging guidance is currently not bundled into the CPT code – you can bet the ranch that after resurveying and revaluing, it will be bundled. While it is likely that a Cat1 CPT code for pulmonary cryoablation can be attained – is it worth the risk of potentially decreasing valuation for existing CPT codes? Furthermore – will re-valuation appropriately account for the variation in practice expense associated with the different ablation technologies? Will what be lost be gained with new codes? Is the data that currently exists accurate enough to answer these questions?

The challenge is real, but not insurmountable. All is not lost. This scenario simply accentuates the necessity for accurate coding (so that coding data can be mined) and population of data registries (so that clinical outcomes can be tracked). Accurate claims and outcomes data allow our specialty societies the ability to study how often procedures for which an existing Cat1 code exists are performed, how often they are performed in hospitals versus outpatient facilities, and what the economic impact of “re-valuation” might be for the family – should a new Cat1 code be introduced.

If you haven’t audited the accuracy of your practices’ coding efforts – audit it. Make sure it is accurate. If you haven’t yet planned to enroll in the ACR’s IR registry – please register. Report your outcomes and resource utilization. Our specialty needs accurate data in order to make informed decisions about these complex scenarios.

These types of practice management issues – that impact the collective diagnostic and interventional radiology communities – will continue to be of heightened importance as we move into the era of mixed alternative payment models and incentive payments systems.

Is it worth re-valuing if it de-values other procedures in radiology?

Re-valuation: Examining the Economic Impact of New CPT Codes

Is your radiology group stagnant? Has it been slogging along – providing adequate service that lacks differentiating features? What about apathetic? Or inertia-ridden? Are these adjectives synonymous with your group?  Perhaps there is a better way to frame the question. 

It is very hard for people and organizations to admit to being average. And average is a dangerous place to be.

We have heard and read the tales of radiology groups that have fundamentally restructured how they function and provide service. Strategies of co-management, value quantification, and noninterpretive value measurement have been successfully implemented by multiple radiology groups with tremendous success. These groups have restored relationships with hospital administrators and are now excelling. These are valuable stories.

Will other groups follow their lead?  Or will they wait until their jobs are threatened by the hospital? Or when an RFP is sent out by the health system? And even if they were to implement change – what would be the first step? What will be the strategy?

If you and your group are struggling to formulate a cogent strategy - try this. Imagine a radiology group that could move into the region tomorrow and destroy your practice. What would it look like? What weaknesses of your group might this new business exploit to capture their target audience? It is a beneficial exercise because it often illuminates the most glaring shortcomings of an existing practice.

Do you think they would build a business centered on volume – continuously aiming to have every radiologist read 22,000 RVUs annually? Would they consider themselves technologically advanced because they have PACS and voice recognition software? Would they sell themselves to hospitals by emphasizing their ludicrously fast turn-around-time?

Unlikely. Your group already has those bases covered. This new group – “Modern Radiology” – is going to target your weaknesses.


“Modern” will offer convenience. Patients will be able to schedule imaging tests online with online registration and payment systems. Their results will be available quickly – and they’ll receive a text message to let them know when their report has been posted online. The report will be downloadable as a PDF so that they can easily share with other physicians. Patients will also get a copy of their images before they leave their appointment.

See – convenience is more than valet parking. Think about how we interact with the airline and banking industries. That is how patients want to interact with health care. “Modern” plans to exploit this need with readily available software solutions.


“Modern” recognizes that there is an enormous amount of time that each of us spends each day doing activities that do not require our level of training and expertise. Spending time on these menial tasks negatively impacts the value we can provide for our hospitals and referring physicians. They will exploit this by becoming an early adopter of artificial intelligence in radiology and employ Watson for chest X-rays, musculoskeletal radiographs, and screening mammograms. They have plans, when the technology is ready, to use artificial intelligence for trauma CTs and cancer follow-up cross sectional imaging. This allows “Modern” radiologists to spend time analyzing the perplexing cases and consult on the phone and in-person with referring docs and patients. The visibility of a “Modern” radiologist is exponentially greater than an “average” radiologist, consequently. 


In a similar move, “Modern” plans to supplement its interventional radiologists with advanced practice providers (when appropriate) to perform some central venous access procedures, percutaneous biopsies, paracenteses, and thoracenteses. APPs will also make “Modern’s” E&M coding revenue more robust – a revenue source that your average radiology group is not tapping into. Consequently, “Modern’s” interventional radiologists spend more time consulting with referring physicians, performing complex procedures, and providing clinical care.


The leadership at “Modern” sees an opportunity to negotiate directly with payers to develop some alternative payment models (APMs). They first plan to build a bundled APM for breast imaging, and then plan to roll out a similar program for patients with uterine fibroids. Leadership knows this will require data to design. Costs associated with providing care for these patients must be known. Volume trends are necessary. Money saved should be calculated. And data-driven risk-sharing will be required.  “Modern’s” leadership knows that a robust data collection and analysis system will be needed for this sector of their strategy. Thus, they plan to invest a substantial portion of their budget on software tools and an informatics team charged with becoming a data/analytics leader in the radiology space. 

You get the picture.  By highlighting weaknesses – existing groups can begin to see, with greater clarity, the areas to which energy should be channeled. Do this exercise with your group leadership and build a vision for where you want to take your practice. We can all see it coming.  “Modern Radiology” is moving to a town near you soon. Don’t be left behind when they finally arrive.

Be prepared for your biggest radiology competition.

Know Thy Competition

It happened. On April 16, 2015 to be exact. The tyrannous reign of the Sustainable Growth Rate formula came to an abrupt end. It is hard to believe two months have passed already – but, the well-publicized, effusive celebrating, 

, and back-patting have certainly made the time fly. I guess we can all rest easy, now that the SGR’s annual 25% reimbursement cut threat has been eliminated from our political action committee agendas. 

It turns out that the SGR was only sort of repealed. More accurately, it was 

. The new payment systems proposed by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are complex, incentivized, value-driven, and in many instances – vague. For radiology groups, important decisions will need to be made regarding which payment system to participate in. For national societies, influencing what metrics their respective specialties should be measuring will be paramount. Despite the satisfaction gleaned from SGR’s destruction, meaningful action is needed now to appropriately position radiology in the new reimbursement milieu.

Fortunately, the authors of MACRA were kind enough to give physicians a three-and-a-half year cushion before new payment models kick in. From July 1, 2015 until 2019, current Medicare physician reimbursement will be annually updated by 0.5%. (Note that payment penalties from PQRS and other incentive programs still apply during this time, though.) But starting in 2019, physicians will have two reimbursement pathways to choose from: 1) Alternative payment models (APM), and 2) the Merit Based Incentive Pay System (MIPS). What does this mean for radiology?[[{"type":"media","view_mode":"media_crop","fid":"38950","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3772578526259","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3911","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: 200px; width: 200px; float: right;","title":"Â©nikolarisim/Shutterstock.com","typeof":"foaf:Image"}}]]

APMs include existing models such as ACOs, patient-centered medical homes, and other CMS Innovation Center programs. However, “eligible” APMs also include health care entities that use certified EHR technology, pay physicians using quality measures, and bear financial risk. To complicate matters further, in order to be a “qualifying APM participant” beginning in 2019, the aforementioned criteria are required PLUS at least 25% of Medicare payments must be received via APMs. Why might one care about becoming a “qualifying APM participant”?  Because between 2019 and 2024, “qualifying APM participants” will receive a 5% bonus of total Medicare Part B payments, which is paid 

 to physicians. Sounds pretty good, huh?  Furthermore, beginning in 2025, Medicare payments for providers participating in “qualifying APMs” will receive 0.75% annual updates. (This is compared to only 0.25% annual updates for those participating in the MIPS model. More to come on that later.) 

I say we all scurry around and start developing some bundled payments for imaging! Five percent bonuses! Annual updates 200% above the alternative reimbursement model! Eureka!

It turns out that the feds are going to annually increase the required percentage of Medicare payments obtained through APMs in order to qualify for APM bonuses. In 2023, 75% of Medicare payments will be required through alternative models in order to qualify for the 5% bonus. (Rather than the meager 25% necessary in 2019.) For a specialty like radiology, which is intimately involved in many organ systems, illnesses, and multi-disciplinary teams – earning 75% of all Medicare payments through APMs may be an unrealistic expectation.

So what happens if your group is not eligible for APMs? 

Well, you’re eligible for MIPS. But, what is MIPS?

Imagine melding together the key elements of the Meaningful Use (MU), Physician Quality Reporting System (PQRS), and the Value-based Payment Modifier (VBM) programs – and then unnaturally combining these programs with the existing RVU payment model through some miraculous, catalytic, nuclear fusion process. That is MIPS. 

Performance/compliance with MU, PQRS, VBM, and clinical practice improvement activities (yet to be defined) are added together to give each 

 provider a composite score from 1 to 100. Based on that provider’s composite score, the total Medicare payments received that year are adjusted, up or down, by a certain percentage. By 2022, the payment incentive will be as high as 9% – and penalty as steep as -9%. And as I mentioned earlier – the MIPS reimbursement is updated by only 0.25% per year beginning in 2025.

So – if your group participates in an ACO, has met MU criteria, and reports PQRS – you are likely to get a favorable MIPS reimbursement. But if your group aims to participate in APM reimbursement and doesn’t qualify – AND you did not measure and report necessary metrics for MIPS – then your group is subject to the harshest MIPS penalty.  The bottom line is that all groups should report MIPS metrics even if aiming for APM qualification.

The last thing to consider is that all of the “quality” measures that will be used to measure “value” are in a primitive state, to say the least. CMS must release a draft plan for these quality measures by January 2016. These measures are to be prioritized by 1) outcomes, 2) patient experience, 3) care coordination, and 4) appropriate use of services. Simply stated – our national societies and organizations must respond nimbly and offer appropriate measures to CMS prior to January 2016. Time is of the essence. 

Moving forward, CMS must update the list of MIPS quality measures annually, and new quality measures must be published in a specialty-appropriate peer-reviewed journal prior to being finalized. While these are encouraging stipulations, it will require our professional engagement at a national policy-making level.

So hooray – the SGR is gone. And we’re left with three options:  1) Pretend we don’t know that APMs and MIPS are coming and then wage a war to delay implementation (a la ICD-10), 2) Begin immediately pushing for repeal (see recent SGR repeal), or 3) Embrace the opportunity to define the metrics that demonstrate real value that we provide for patients and discover new ways to efficiently care for diseases that are appropriate for bundled payments.

SGR Is Gone! But Now What?

Strategic alignment has historically been discussed in business literature and tends to focus on the integration of business strategy and information systems/technology (IS/IT). “Alignment” is said to maximize return on IT investments, achieve competitive advantage through information systems, and provide direction and flexibility for new opportunities.  Alignment has also been referred to as 

 (The incessant insertion of synonymous buzzwords used to describe this entity reveals the deep secret that “alignment” is difficult to describe, a challenge to depict, and even harder to implement, don’t you think?) Tightly integrate your IS/IT teams with your business’ strategy, and the improved systems efficiency will harness efficiency and leverage core values and skills possessed by your organization! 

I don’t know how alignment directly applies to health care.  But I do know that the previous paragraph sounds like an IBM commercial.

In all seriousness, the concept of tight integration of IS/IT into health care operations is not new. We’ve been having this discussion for quite some time now.  But I wonder if revisiting this concept of alignment (which ran rampant at the turn of the 21st century in the world of business) could offer clues as to how we might contemporarily organize our health care systems.

As I mentioned, alignment can be a difficult concept to describe. Prior authors have used diagrams riddled with a myriad of shapes and arrows to portray alignment. But rarely are real-world businesses, hospitals, and health systems constructed to fit onto such a 2D surface. Our 3D world presents innumerable business interactions, inter-departmental exchanges, and real-life patient variables that render 2D strategic alignment diagrams as useful as Mattel board-games.  [[{"type":"media","view_mode":"media_crop","fid":"34547","attributes":{"alt":"health care technology","class":"media-image media-image-right","id":"media_crop_3665593726882","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3683","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: 133px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©Kamira/Shutterstock.com","typeof":"foaf:Image"}}]]

Despite this, even though alignment is a challenge to describe, most (nearly everyone) agrees that business strategy and IS/IT should be tightly integrated within our industry. In healthcare, our charge is to become patient-centered and subsequently be reimbursed based on the value of the care we provide. This reform will require increasing patient access to medical records, optimizing information sharing across systems, and allowing patients to use mobile devices for scheduling appointments and getting results. Demonstrating value will require aggregation of large pools of patient and cost data with real-time monitoring of results and patient tracking. IS/IT is absolutely essential for this transformation in health care. No doubt.

But how are we tightly integrating IS/IT with our strategy in health care? How are we aligning the activity of our IS/IT teams with the over-arching goals of our health care system? Meaningful Use (MU) has been a nice attempt at emphasizing the importance of health information technology. But, unfortunately, MU has resulted in an obsessive compulsion to meet fairly random mandates that are required to receive various incentives and avoid payment penalties. MU has become the goal – rather than a means towards building a patient-centered, value-driven health care system. The same can perhaps be said of ICD-10. Are we implementing ICD-10 to improve patient centeredness? Hmmm…

In radiology, we are now faced with a similar situation in that clinical decision support (CDS) software has been mandated by the federal government for physicians ordering advanced imaging beginning in 2017. Will we scurry to purchase and install CDS to meet the mandate, or use it to optimize value?

The amount of manpower required to bring our IS/IT systems “up to speed” to meet these legislative mandates is enormous. And it is a colossal distraction. A distraction from allowing our brightest informatics minds to find new ways to provide solutions to our everyday dilemmas in health care. 

So let’s be honest with ourselves. Beyond federal mandates, how aggressively are we integrating IS/IT into our health care strategies? Are we filling our senior management/leadership positions with informaticists? Are we readily investing in the multitude of vendor-created IT tools built for patient-centeredness and value? Or do we view these investments as costs?  Do we view dollars spent on IT as an expense or as an enabler of better business? Some institutions are. But are most?

This issue doesn’t just involve radiology departments. This mindset needs to permeate through entire health care org charts. Revisiting the concept of “alignment” may provide a lesson. By truly integrating our IS/IT talent with health care strategy, we can begin using our energy towards discovering new, better ways to achieve patient-centeredness and value rather than simply implementing IT tools to avoid payment penalties.

In radiology, and all of medicine, are we implementing technology to satisfy mandates without realizing its real potential?

Alignment in Health Care: What is our Strategy?

Lung cancer screening, mammography, and CT colonography are the imaging tests we have collectively, as a profession, paid the most interest and time to in recent years – particularly in regards to advocacy. Whether performing huge trials that influence sweeping policy implementation, responding to accusations about the efficacy of breast cancer screening, or re-emphasizing that our President chose virtual colonoscopy over the “real thing” – we have been publically touting imaging’s role in screening, preserving health, and promoting wellness. Our efforts have been worthwhile. Radiologists now play a greater role in public health than ever before. It’s not unreasonable to expect more imaging-based screening exams in the near future.

Historically, though, we have mostly imaged sick people: people with symptoms, people who needed a diagnosis.

Now we image people for – well – just being people really. And this carries implications for how we offer imaging services, how we interpret images, how we educate patients, and how we teach about risk.

Screening for Disease and Invoking Unease


The concept of using imaging to screen for disease (mostly cancer) seems simple. Look for asymptomatic cancer in appropriate populations, discover it in early stages, treat it, and save lives.  Easy, right? But as any radiologist will tell you, getting an imaging study puts all patients at risk of discovering a dreaded “incidentaloma”. These inconvenient imaging findings carry potential to strike fear in patients, possible need for future follow-up studies, and induce uneasy feelings in physicians. 

Granulomas posing as lung cancer, complex cysts imitating renal cell carcinoma, regenerative nodules acting like hepatocellular carcinoma, and benign adenomas impersonating malignant adrenal adenocarcinoma. Yikes. [[{"type":"media","view_mode":"media_crop","fid":"32253","attributes":{"alt":"puzzle","class":"media-image media-image-right","id":"media_crop_8795651007192","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3412","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: 133px; width: 159px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©RATOCA/Shutterstock.com","typeof":"foaf:Image"}}]]

The patients being screened are virtually always asymptomatic – so there is no clinical picture to shrink the differential. The imaging appearance is the only feature that informs the list of potential ailments, thus, malignancy “cannot be entirely excluded.”

We, as radiologists, are becoming more adept at dealing with these commonly benign incidental findings.  The series of manuscripts addressing incidental findings in the 

 has been ragingly successful and delivered some of the most widely read articles in the history of the blue journal.  Ultimately, however, these guidelines are driven by expert consensus. It is difficult for an individual patient to read about their unexpectedly discovered new mass that is “most likely” benign, react calmly, and follow the consensus guidelines. 

Some experts believe that human beings do not have the brain capacity to realistically assess risk to their own person.  Applying a “20% increased risk of malignancy” to one’s own healthy self is a challenging task for anyone.  Recognizing relative risk and comprehending a small percentage increase of a very small baseline risk may be easy for researchers, statisticians, and wonky-types. But for an individual, it may be impossible. A marginally increased risk of cancer can abolish all rationality and only invoke fear.

To make matters even more complex, our increased propensity to use imaging as a screening tool will unveil more and more malignancies that people are likely to die with rather than die from. Try telling someone not to worry about their low-grade malignancy and to just be patient until they die from something else. It’s a troubling thought. But not far-fetched.

“But Matt,” a skeptic might say, “just wait until other screening tests are developed that don’t involve imaging – such as breathalyzers and blood tests!”

Point taken. Modern screening exams that may be cheaper and involve no ionizing radiation are certainly being developed. But in the modern milieu, when those tests come back positive –asymptomatic patients are likely to get imaging in order to find the cancer. And the cycle begins...

These challenges are by no means insurmountable. However, as a specialty that is predominantly accustomed to imaging sick people, we must understand how this will impact resource utilization and our role in public health. 

Ultimately, if we want to continue increasing radiology’s role in disease screening, we must recognize the dilemmas introduced by imaging healthy people.

Radiologists need to prepare for screening asymptomatic patients.

On Imaging Healthy People

What is your diagnostic miss-rate? Do you know? I don’t know mine. Not my real one, at least.

If your miss rate is unknown, what do you estimate that it is? Research says that we all tend to grossly overestimate our actual performance and underestimate the frequency of our mistakes, so be wary of your estimate. And even if your miss-rate has been measured, was it measured by an independent, objective party that is not invested in the success of the practice?

To probe further, what is your group’s collective accuracy rate? How does that compare to national benchmarks? Are there detectable patterns in errors derived from faulty search patterns that can be used as teaching points? 

Perhaps most importantly- are we getting better, worse, or staying the same?[[{"type":"media","view_mode":"media_crop","fid":"29391","attributes":{"alt":"C. Matt Hawkins","class":"media-image media-image-right","id":"media_crop_306355657539","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3040","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":"C. Matt Hawkins, MD","typeof":"foaf:Image"}}]]

Radiology, as a profession, is in an era of redefinition. We’re redefining our day-to-day clinical operations. We’re redefining our image. We’re redefining our relevance. For radiology to emerge as a clinical service that is trusted by referring physicians, patients, policy makers, and administrators, we simply must begin measuring our performance. And we have to do it right. Peer review done well allows us to measure the ultimate “quality-metric” in radiology: how often we are right, and how often we are wrong. While we can measure the frequency of guideline compliance in report recommendations, or how often incidental findings are handled appropriately (ie, pseudo-quality metrics), in a profession whose livelihood hinges on the correctness of our diagnoses, there is nothing more important or relevant for us to measure than our accuracy rate.

There are certainly examples of institutions that have superb peer review programs. But most existing peer review programs in diagnostic radiology are shallow. They are tedious and incomplete. They are biased.

There are nuances to peer review in diagnostic radiology that render it challenging. I recognize that. All findings are not black and white. Hedges can be difficult to review. Clinically irrelevant findings that are not mentioned in reports are just that: irrelevant. And the clinical impact of overcalls can be difficult to assess. It is likely that a variety of miss-rates would need to be measured.

Despite these predictable challenges - just as financial companies want to know how their mutual funds are performing as compared to the Lipper average - radiologists need to know how their accuracy rates compare to national standards and make adjustments to search patterns, imaging protocols, and pace accordingly. A real radiology peer review system could take on many forms. But it needs to cover broad geographies and have de-identified studies reviewed by people that are not invested in the practice where the study was performed. (A legitimate appeal/adjudication process will also be necessary.) 

What should be done with all of the data?  I am not suggesting that radiologists failing to meet certain benchmarks be fired. Or that the bottom 10% is eliminated Jack Welch style. This information can instead be used for coaching and improvement. David Larson and colleagues have already 

how peer review can be used in this manner. Misses are radiology’s greatest teaching tool. Our misses are eternally engrained in our brains. They are quickly recalled and rarely, if ever, repeated. And for less severe, more frequent misses, a genuine non-biased peer review process might teach us how to alter our search patterns to improve detection. Each group’s collective de-personalized data can also be used to provide hospital administrators with a gauge of how the radiology services provided at their hospital compare to neighboring rivals as well as top-tier academic institutions. Groups that are better than average can revel, and those that are not can strategically intervene and improve.

In the grand scheme, there are many ways that all specialties need to change in their day-to-day clinical practice. In radiology, peer review is only one of many targets for reform. But as we begin to publish our prices, convey our value to patients and administrators, and learn the costs of incorrect diagnoses, it will be paramount to know how often we’re right. If we cannot quantify our value, then we will be paid purely according to how we are perceived, with nothing but effusively abstract descriptions of our worth left to offer those who distribute the dollars.

It’s time to take peer review seriously.

In order to thrive, radiologists need to know their diagnostic miss-rate.