- Email: [email protected]
IT Infrastructure in the Era of Imaging 3.0
ADDITIONAL RESOURCES
IT Infrastructure in the Era of Imaging 3.0
Geraldine B. McGinty, MD, MBAa, Bibb Allen Jr, MDb, J. Raymond Geis, MDc,d, Christoph Wald, MD, PhDe,f
Imaging 3.0 is a blueprint for the future of radiology modeled after the description of Web 3.0 as “more connected, more open, and more intelligent.” Imaging 3.0 involves radiologists’ using their expertise to manage all aspects of imaging care to improve patient safety and outcomes and to deliver high-value care. IT tools are critical elements and drivers of success as radiologists embrace the concepts of Imaging 3.0. Organized radiology, specifically the ACR, is the natural convener and resource for the development of this Imaging 3.0 toolkit. The ACR’s new Imaging 3.0 Informatics Committee is actively working to develop the informatics tools radiologists need to improve efficiency, deliver more value, and provide quantitative ways to demonstrate their value in new health care delivery and payment systems. This article takes each step of the process of delivering high-value Imaging 3.0 care and outlines the tools available as well as additional resources available to support practicing radiologists. From the moment when imaging is considered through the delivery of a meaningful and actionable report that is communicated to the referring clinician and, when appropriate, to the patient, Imaging 3.0 IT tools will enable radiologists to position themselves as vital constituents in cost-effective, high-value health care. Key Words: Imaging 3.0, accountable care organizations, patient experience, value-based imaging J Am Coll Radiol 2014;11:1197-1204. Copyright © 2014 American College of Radiology
OVERVIEW
Radiologists recognize that a significant portion of important imaging care occurs before and after the interpretation of an imaging study. However, for a variety of reasons, radiologists are not optimally leveraging their role in providing the majority of that care. By using their expertise, radiologists can skillfully manage all aspects of imaging care to improve patient safety and outcomes and to deliver more cost-effective care. IT systems and processes promulgated by organized radiology can foster the development and provision of the tools radiologists need at the point of care to optimize preinterpretation and postinterpretation imaging-guided health care. Providing this type of care will increase radiologists’ value a
Department of Radiology, Weill Cornell Medical College, New York, New York.
b
Department of Radiology, Trinity Medical Center, Birmingham, Alabama.
c
Advanced Medical Imaging Consultants, PC, Fort Collins, Colorado.
d Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado. e
Department of Radiology, Lahey Hospital and Medical Center, Burlington, Massachusetts.
f Department of Radiology, Tufts University Medical School, Boston, Massachusetts.
Corresponding author and reprints: Geraldine B. McGinty, MD, MBA, Weill Cornell Medical College, 1305 York Avenue, 3rd Floor, New York, NY 10021; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.09.005
to the health care system. With proper incentives from policymakers, optimized imaging care beyond image interpretation will improve patients’ care experience and promises to lower the per capita cost of care. Imaging 3.0 is loosely modeled after the evolving concept of Web 3.0. Nova Spivak [1] described Web 3.0 as “more connected, more open, and more intelligent. It will transform the Web from a network of separately siloed applications and content repositories to a more seamless and interoperable whole.” Parallels may be drawn to describe the next evolutionary stage of radiology practice. The label “Imaging 3.0” was chosen to signify a departure from the conventional way in which radiologists have engaged in health care. The constituent parts of the Imaging 3.0 framework are all selected to serve an overriding philosophy for the path forward for radiologists in the new, integrated health care environment. Imaging 3.0 encompasses the entire imaging care pathway, from the point at which a referring clinician considers imaging to the end point of delivery of actionable recommendations to the referring provider and sometimes the patient directly. The more traditional view of the radiologist’s role (to acquire images and generate a report on those images) is no less important in the new paradigm of Imaging 3.0, but it resides within an expanded concept of how radiologists contribute to value-based, integrated health care delivery. 1197
1198 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
A significant portion of important imaging care occurs before and after interpretation, but many radiologists are unaware of this and may not provide care effectively under the traditional paradigm. IT tools are critical elements and drivers of success. These tools must be developed and used with the goal of providing radiologists with “just-in-time” information to keep patients at the center of the system, delivering high-value imaging care. Organized radiology, specifically the ACR, is the natural convener and resource for the development of this Imaging 3.0 toolkit. The implementation of Imaging 3.0 will improve patients’ outcomes and increase radiologists’ relevance to the health care system and, with proper incentives from policymakers, will allow radiologists to play their vital role in the delivery of high-value care. The ACR’s new Imaging 3.0 Informatics Committee is actively working to develop the informatics tools radiologists need to improve efficiency, deliver more value, and provide quantitative ways to demonstrate their value in new health care delivery and payment systems. BACKGROUND
The triple aim of health care—to improve population health and health care quality, to optimize patients’ experiences of health care, and to control costs—is increasingly becoming embedded in health care policy and payment design. Radiologists have tended to be viewed as part of the old “volume-driven,” transactional, and fragmented world of care delivery. This misperception has developed largely because radiologists frequently do not become involved until after examinations have been performed. Using the defense that “we are only doing what was ordered,” radiologists have abrogated their role in only providing appropriate imaging care. Yet the vast majority of the rapid rise in imaging utilization in the early years of this century has clearly resulted from the spectacular diagnostic possibilities afforded by technologies such as CT and MR and the positive impact these modalities have on effective diagnosis and treatment. This was evident in a survey of 225 internal medicine physicians published by Fuchs and Sox [2], who considered CT and MRI the most important medical innovations of the past 30 years. However, with decisions regarding the appropriateness of imaging completely in the hands of ordering physicians, knowledge gaps, defensive medicine, and economically motivated self-referral have all contributed to overutilization [3,4]. Unfortunately, policymakers and payers have chosen to respond to this increase in volume by across-the-board reimbursement cuts rather than by system redesign to incentivize the appropriate use of imaging. Faced with cascading cuts in reimbursement and recognizing changing health care policy, ACR leadership embarked on a clear-eyed evaluation of the ways in which radiologists could survive and thrive in this new world. Taking a fresh look at how radiologists might be able to provide maximum value to health care delivery, our
profession is realizing that this approach represents a tremendous opportunity to enhance the impact of imaging care on our patients [5]. Imaging 3.0 is the corresponding framework that allows radiologists to optimally position themselves for this transformation. TECHNICAL DETAILS
Imaging 3.0 principles can and should inform every step of the delivery of imaging care. From strategic planning (to ensure that patients and referring providers have access to the most appropriate and current technology) to optimizing imaging protocols, the philosophy that places the patient at the center of the care-delivery process should be paramount. This philosophy is captured in Figure 1, the Imaging 3.0—Beyond Image Interpretation flowchart. Specific attention to IT solutions offers several important opportunities to apply the Imaging 3.0 paradigm. Radiologists can and need to be involved every step of the way, but a useful framework to consider the opportunities afforded by Imaging 3.0 looks at the process of imaging care in 3 phases: before imaging acquisition, during image acquisition and interpretation, and after acquisition. Clearly, overarching IT processes and tools inform the universe of Imaging 3.0 care. OVERARCHING IT PROCESSES, SOLUTIONS, AND TOOLS Meaningful Use and Certified Electronic Health Record Technology
A radiology practice that espouses the principles of Imaging 3.0 will be committed to leveraging every opportunity to improve its technology infrastructure. It can certainly be argued that the applicability of meaningful use incentives to radiologists has not always been clear. In addition, busy practitioners who are focused on providing care to their patients may not have had time to spend the time needed to understand the regulations and profit from these incentives. This issue of JACR features an article on meaningful use by Krishnaraj et al [6], which is highly recommended to the reader. Other excellent resources are available from CMS, the Healthcare Information and Management Systems Society, and RadiologyMU.org. These resources may be used to inform and help radiologists participate in meaningful use incentive programs. Standards
The use of evidence-based practices is important in the delivery of Imaging 3.0 care. Brent James’s seminal work at Intermountain Healthcare [7] has demonstrated the need to reduce variability to drive better outcomes. Are standards universally applicable? Of course not, but their use is an excellent framework from which to innovate. Radiologists should acquire a working knowledge of IT standards because they influence important equipment purchasing and operational decisions that support the infrastructure enabling Imaging 3.0. An article by
McGinty et al/IT Infrastructure and Imaging 3.0 1199
Fig 1. ACR Imaging 3.0—Beyond Image Interpretation flowchart.
Wang et al [8] in this issue of JACR discusses the most important aspects of IT standards. Security and Privacy
As previously stated, the Imaging 3.0 radiologist has the patient at the forefront of his or her practice decisions. We cannot provide the best imaging care to our patients if we do not act as their advocates and ensure that their imaging records are available freely to those who need them in care decisions; alternatively, it is critical that their imaging records be inaccessible to those who might try to access them inappropriately. Proliferation of cloud-based image processing and reporting technologies and remote, off-site disaster recovery solutions for imaging archives drives the need for radiologist experts to weigh convenience and accessibility against patient privacy concerns and strike a balance that enables efficient care delivery while maintaining the integrity of sensitive information. There is an increasing role and responsibility for Imaging 3.0 radiologists to exert leadership in this regard, not least if they view themselves as part of the team of treating physicians. Workflow Processes
A radiology practice that adheres to the principles of Imaging 3.0 will have a constant process to document, critique, and improve its workflow processes. Informed by the philosophy of patient-centered imaging care, the Imaging 3.0 radiologist will always look for ways to
improve departmental processes to better serve the health care community. Examples include monitoring CT dose estimates via machines and technologists to discover opportunities for dose reduction, initiating projects to decrease patient wait times, improving turnaround time for reporting, working on the communication of critical findings, and implementing systems that link prioritization of examinations to be read to actual clinical status or future patient appointments. Business Intelligence Analytics
As referenced previously, the Imaging 3.0 practice involves a constant search for knowledge and improvement. Using key performance indicators and leveraging IT to share and communicate results is a key driver of Imaging 3.0 success. Part of the knowledge gained comes from business intelligence analytics and is expanded on in an article by Cook and Nagy [9] in this issue. IMAGING 3.0 BEFORE IMAGING ACQUISITION AND INTERPRETATION Clinical Decision Support (CDS)
An important Imaging 3.0 milestone was reached with the inclusion of a requirement for the use of CDS for advanced imaging in the Medicare program in House Resolution 4302, also known as the March 2014 sustainable growth rate patch legislation. This important new program will go into effect in 2017. Radiologists
1200 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
now have a tremendous opportunity to serve as leaders in implementing CDS programs for their communities and ensuring that the essential role of the radiologist is not only recognized but also valued. We have a gamechanging chance to rediscover and highlight our role as consultants to referring physicians and patients. Even as imaging utilization growth has flattened, every radiologist regularly encounters requests for the wrong imaging test or an imaging test that may not be helpful or may use excessive radiation considering the question at hand. The imaging armamentarium is filled with phenomenal tools, but choosing the right one can be a challenge. For a busy primary care provider or, as is expected to be the new normal under the Patient Protection and Affordable Care Act, a midlevel provider, decision making regarding the type of imaging test best suited to answer the clinical question is hard enough. The implementation of CDS in the Medicare program holds promise to significantly shift the balance toward more appropriate imaging care. Radiology benefit management companies (RBMs) have heretofore captured a large market share with commercial insurance carriers in their role as gatekeepers to high-cost imaging examinations and are likely not going away any time soon. Although these companies tout significant savings in terms of reducing advanced imaging utilization, it is by no means clear that these reductions are intransient. As a result, costs have shifted to providers who must employ staff members to log hours on the phone to get imaging studies approved as well as manage steerage programs that divert patients away from trusted imaging providers; these consequences have limited the popularity of RBMs to the payers who use their services. The algorithms by which RBMs determine the appropriateness of examinations are opaque and may not be based solely on medical necessity and evidence. The ACR Appropriateness Criteria have been freely available to the health care community since 1995. However, after licensing this intellectual property to the National Decision Support Company, the Appropriateness Criteria have been morphed into an invaluable decision support tool for providers and are continually updated and expanded. Whether embedded in the electronic health record system or accessed via computers or even mobile devices as a stand-alone, online portal (website), CDS for imaging facilitated by radiologists is a clear demonstration of the value of our profession in determining care pathways. Some radiologists have expressed concern that the use of CDS tools would render their expertise irrelevant. The growing set of decision-support tools, which can be accessed by modality or based on indications or symptoms, though comprehensive, is by no means all inclusive. Individual clinical situations and patient characteristics will require consultation with the radiologist. Priorities and preferences of the interdisciplinary or institutional team of physicians may affect the way in
which decision support is implemented or modified to best serve the local standard of care. When the system indicates that a particular examination order is considered indeterminate or even inappropriate, the need for consultation with the imaging expert arises quickly. The Imaging 3.0 radiologist will be readily available by phone, secure messaging, or even online chat to aid the referring provider in choosing the appropriate imaging examination and to discuss the various alternatives. The willingness of radiologists to overcome stereotypes about being the beneficiaries of the volume culture of fee-for-service medicine allows the ACR to tell a new and compelling story to policymakers and payers about the key role radiologists play in the delivery of highvalue, cost-effective care. Imaging 3.0 is that story. Dose and Safety
Although “Imaging 3.0” is a new term for the framework of the imaging care process beyond actual examination interpretation, many components of the Imaging 3.0 toolkit have been in existence for decades. However, by placing these existing tools and concepts under the Imaging 3.0 umbrella, we can highlight where ongoing programs are congruent with the goals of optimizing imaging care. One such initiative is patient safety during imaging. As imaging experts, radiologists are best positioned to ensure that imaging care is delivered as safely as possible. The ACR and the RSNA formed the Joint Task Force on Adult Radiation Protection in 2009 with support from the American Society of Radiologic Technologists (ASRT) and the American Association of Physicists in Medicine to address concerns about the surge of public exposure to ionizing radiation from medical imaging. These organizations, as well as scientific publications, media, and government, have addressed radiation concerns in recent years. The various activities are nicely summarized in two publications by Amis et al [10,11]. The ACR and RSNA have also collaborated to develop a comprehensive patient information resource on all issues revolving around imaging, RadiologyInfo.org. Of particular interest may be the Radiology Benefits and Risks Primer, which directly addresses patients’ concerns about the use of radiation in medical imaging examinations. Patients can also learn about radiation dose from xray and CT examinations from this trusted resource. The joint task force collaborated with the American Association of Physicists in Medicine and the ASRT to create the Image Wisely, campaign with the objective of lowering the amount of radiation used in medically necessary imaging studies and eliminating unnecessary procedures. The Image Wisely website offers resources and information to radiologists, medical physicists, other imaging practitioners, and patients. The Image Gently campaign is an initiative of the Alliance for Radiation Safety in Pediatric Imaging. The campaign goal is to change practice by increasing awareness of the opportunities to promote radiation
McGinty et al/IT Infrastructure and Imaging 3.0 1201
protection in the imaging of children. Pledging to image wisely and gently and modifying imaging practices to adhere to the principles promulgated by these campaigns demonstrate this leadership. The ACR Dose Index Registry should be used to allow practices to see aggregated radiation exposure, benchmark their groups against other practices, and correct issues if there are outliers. The ACR was a founding member of the Choosing Wisely campaign in collaboration with multiple other medical specialties under the auspices of the American Board of Internal Medicine. This widely publicized campaign seeks to change providers’ behavior regarding the use of diagnostic tests. The aforementioned programs and collaborations all preceded the development of the Imaging 3.0 initiative, but all are comfortably within it. By demonstrating leadership in radiation safety and commitment to patient and provider education, radiologists are espousing the Imaging 3.0 philosophy. There is a dedicated article on patient safety considerations in this issue of JACR by Morin et al [12]. Medical Imaging and Technology Alliance Smart Dose
In addition to mandating consultation of imaging appropriateness criteria by referring physicians, section 218 of HR 4302 sought to address concerns surrounding patient safety associated with CT radiation dose levels. Congress was particularly attracted to implementing a CT equipment dose standard developed by the Medical Imaging and Technology Alliance (MITA) within the National Electrical Manufacturers Association because the concept was estimated to save the federal government approximately $200 million over 10 years. Under this policy, starting on January 1, 2016, select diagnostic imaging studies performed on equipment that cannot comply with tional Electrical Manufacturers Association XR 29, Standard Attributes on CT Equipment Related to Dose Optimization, or MITA’s Smart Dose standard will be subjected to technical component reimbursement reductions on a per scan basis. The ACR supports the radiation safety goals outlined by the MITA Smart Dose standard. One of the College’s principal obligations related to Imaging 3.0 is to ensure that patients seek diagnostic imaging care only from those practices at which the radiation dose used is optimized for the diagnostic need of the examination. Although the ACR acknowledges that some imaging centers and hospitals will face some technical component reductions if their equipment cannot meet these new dose standards, proper use of the new MITA Smart Dose standard features should be encouraged to help ensure that patients receive the safest, most effective imaging. ACR members interested in learning if their CT equipment complies with the MITA Smart Dose standard should contact their respective equipment manufacturers.
IMAGING 3.0 DURING IMAGE ACQUISITION AND INTERPRETATION Education, Training, and Qualifications
Health care IT has evolved rapidly and represents critical infrastructure to efficiently implement Imaging 3.0 concepts across their respective practice space. As a result, radiologists should place high value on their IT solutions and the staff members supporting those resources. IT is generally perceived as a generic or one-size-fits-all support service that is interchangeable throughout an organization. The reality is that IT has become subspecialized. The article by Morgan et al [13] in this issue of JACR is designed to serve as a guide for you, the practicing radiologist, to build an effective IT division by considering education, training requirements, and suitable personnel qualifications. It also focuses on the critical role of the radiologist IT liaison in bridging gaps among organizations’ IT, medical, and administrative functions. Additionally, attaining certification and accreditation by appropriate certifying bodies is critical to demonstrating quality and expertise to patients, peers, and payers. Facility accreditation, physician and technologist certification, and ongoing peer review programs are all important in demonstrating this quality. Physicians should also demonstrate their commitment to quality and expertise by achieving certification by the ABR or equivalent (as delineated in the ACR practice parameters and technical standards) and by meeting the requirements of the ABR Maintenance of Certification program. Radiologic and ultrasound technologists should be accredited by the ASRT and the American Registry for Diagnostic Medical Sonography, respectively. Peer review, continuing education, and the provision of a learning environment for all personnel in the imaging department represent the Imaging 3.0 commitment to high-value care. PACS administrators and others involved with managing radiology images should be accredited by the American Board of Imaging Informatics, which awards the Certified Imaging Informatics Professional designation as the standard for demonstrated knowledge and competence in medical imaging informatics. The American Board of Imaging Informatics was founded by the Society for Imaging Informatics in Medicine and the American Registry of Radiologic Technologists. The Society for Imaging Informatics in Medicine offers extensive training in imaging informatics for staff members as well as physicians. Image Acquisition
At the image acquisition stage, radiologists must work closely and proactively with medical physicists, radiologic technologists, and ultrasound technologists to develop protocols that combine the highest diagnostic accuracy with the safest and most comfortable patient experience. Minimizing radiation dose is a key focus. Finding a balance between reproducibility and standardization of image quality and the type of customization that is especially important in pediatric
1202 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
imaging will be critical. Novel technology being developed promises to connect remote reading stations with scanner consoles in an efficient and easy manner. This may allow radiologists to play a more active role in tailoring examinations to individual clinical scenarios and patient anatomy. Archive and Retrieval
Providing the highest quality imaging care requires comparison with relevant prior studies and secure storage of current data to facilitate future care. As outlined above, Imaging 3.0 promotes that the requisite steps in the IT process be streamlined so that they become invisible to patients and referrers. A patient should never have to undergo a repeat study because prior imaging is not available. A referring physician should rarely have to delay a decision because a report is incomplete and awaiting prior studies. The responsibility for ensuring the availability of prior imaging data and the secure storage of the current study falls squarely on the shoulders of the Imaging 3.0 radiologist. It is not acceptable to blame IT or hospital administration. Imaging 3.0 requires the radiologist be part of the decision-making process regarding archiving and data storage solutions. We must act as advocates for our patients in this regard.
IMAGING 3.0 IN THE POSTIMAGING ACQUISITION AND INTERPRETATION PERIOD Transmission and Communication
Imaging 3.0 stresses the tremendous added value of the timely delivery of actionable, accurate reports on imaging examinations to the point of care. With “length of stay” in the emergency department and in the hospital becoming a major efficiency measure, it is crucial that such information be delivered in a secure, complete, and timely manner. The multiplicity of electronic health record vendors necessitates a nimble and flexible approach to ensure delivery of the report where and when the referring clinician requires it. Radiology Information Systems and Electronic Medical Records
Making actionable imaging reports available seamlessly in the electronic medical record is a key deliverable of Imaging 3.0 and is the subject of the article by McEnery [17]. The use of structured reporting, the implementation of communication protocols around the reporting of critical results, and the ability to communicate securely with both referring providers and patients are all tools that can enhance a practice’s Imaging 3.0 performance.
Display
Communication With Mobile Devices
Apart from the obvious need for image displays to support the work of the radiologist, Imaging 3.0 requires that attention be paid to the all-important work of consulting with referrers and patients regarding the information contained within the images. Consideration should therefore be given to how imaging information can be displayed in a way that optimizes those interactions. Please review the article on displays by Hirschorn et al [14] in this issue for all related issues to consider.
Imaging 3.0 means delivering diagnostic decision support to our referring providers and imaging care to our patients in a way that is convenient and relevant for them. It is no longer acceptable to indiscriminately cite privacy concerns or software incompatibilities as reasons not to embrace mobile technology. The world runs on a mobile communication platform, and Imaging 3.0 challenges radiologists to securely and accurately make imaging information available on mobile devices. Please refer to the article by Hirschorn et al [18] for more detailed information on issues surrounding mobile devices.
Reporting and Communication
Effective radiologist participation in the care-delivery process is at the heart of Imaging 3.0. An actionable, comprehensible, and appropriately communicated report is the most important product we deliver. Work is under way at the ACR to deliver content to IT vendors to enhance the delivery of imaging reports to referring physicians and patients alike. Some approaches favor the inclusion of hyperlinks to key images, including relevant measurements and even the addition of representative images within a multimedia report format. The use of structured reporting systems provided by the ACR (eg, LI-RADS, BI-RADS, and Lung-RADSTM) is strongly encouraged as it serves to standardize reporting and reliably connects certain key diagnostic findings with appropriate downstream imaging and clinical care activities. Careful handling of incidental findings in future reports is another challenge radiologists need to face responsibly; a growing number of resources are available that provide guidance on how to handle such findings appropriately [15]. For more on reporting and communication, read the article in this issue by Weiss et al [16].
PRACTICAL IMPLICATIONS AND IMPLEMENTATION
Imaging 3.0 is a journey that individual radiologists and practices will make at different speeds. It is important to remember that the philosophy of being at the center of care depends mostly on the willingness of radiologists to assume that position. Our radiology forefathers did not have sophisticated IT tools but perhaps occupied a more pivotal and direct role in the care-delivery process. Some of our most important IT advances have had unintended consequences and have removed us from our physician colleagues and patients. Payment system design has incentivized productivity over radiologist interaction with physician colleagues and patients. In the future, it will be wise to leverage IT tools to make us more available and visible. Radiologists must take on this leadership challenge now; it requires intense communication with our colleagues to align them (and imaging operations) with our professional direction and vision
McGinty et al/IT Infrastructure and Imaging 3.0 1203
for the future and hard work to motivate all individuals involved with the idea that, in the end, radiology and its patients will be better for these changes. A useful first exercise for any practice or practitioner is to “walk” through the Imaging 3.0 workflow. Making optimal use of the tools already available and communicating those to the patient and referrer communities is an excellent start. For example, a review of a practice’s radiology information system and PACS capabilities can be used to determine where there are as yet unused opportunities to connect with patients and referrers. Consider using the PACS in a nontraditional way to place radiologists within clinical care areas while allowing them to remain connected with the main radiology department [19,20]. A practice that has already pledged to image gently and image wisely and has attained full ACR accreditation can benefit from ensuring that these commitments to high-value care are widely communicated to its health care network. Next, the practice should perform an assessment of the Imaging 3.0 tools and activities it is not currently active in and pursue as many as is practical. Some decisions, such as improving Physician Quality Reporting System participation, may be practitioner-level decisions, whereas others, such as adopting CDS, will be at the health system level. A key parallel initiative should be for members of the radiology practice to become as active as possible in the health system’s committees and workgroups. If the practice participates in a shared savings model, a seat on the governing board of the accountable care organization is ideal.
DEDICATED ACR IMAGING 3.0 ONLINE RESOURCES
The ACR maintains a dedicated collection of web-based resources on the topic of Imaging 3.0. Among other items, several case studies are available on the site. Other resources on this topic include frequently asked questions, overview of relevant organizations, the presentation “What Is Imaging 3.0?” information on accountable care organizations, the Imaging 3.0 track of the Radiology Leadership Institute, and other items. CONCLUSIONS
The Imaging 3.0 initiative represents a framework designed to facilitate a profound culture and practice paradigm shift within radiology. It aims to equip the 21st-century radiologist with the necessary knowledge, tools, and attitude to embrace a leadership role in evolving health care delivery in general and imaging care in particular. By critically examining and leveraging all opportunities for value delivery in integrated imaging care, radiologists will be able to provide quality patient care under the new payment models. From this realization flows the need for investments in technology and human resources to ensure success. However, a radiologist in rural solo practice can embrace Imaging 3.0 concepts as successfully as a radiologist in a large integrated health system. The effective use of IT may serve as an important catalyst. An informed review of existing practice tools already available and applying the same Imaging 3.0 perspective to new technology acquisitions will enable radiologists to position themselves as vital constituents in cost-effective, high-value health care.
QUESTIONS TO ASK YOUR IT STAFF AND VENDORS
Imaging 3.0 and the philosophy of expanding the understanding of what constitutes imaging care should inform all interactions around IT. It is no longer enough for an IT tool to promote radiologist productivity. Although if that is the case, the tool’s value should be measured in terms of the time it affords the radiologist to interact with referrers and patients. Ease of use for patients and referrers is a key deliverable for IT tools that should assume a much higher priority in the Imaging 3.0 practice. The goal of controlling costs, along with the greater number of integrated practices, makes it imperative that IT tools and systems be as cost effective as possible. As such, an Imaging 3.0 value checklist for IT tools might include such questions as the following: How does this product help my patients? How does this product help the providers who refer patients to my practice? Does this product optimize my practice costs? Do I currently have a way to measure noninterpretive, value-added work performed by radiologists that benefits patient care but is not currently captured in work relative value units?
TAKE-HOME POINTS
Imaging 3.0 is a blueprint for radiologists’ future. At each step of the care delivery process, IT tools are available or in development that can support the Imaging 3.0 paradigm. By embracing these tools, radiologists can demonstrate their critical role in the delivery of high-value imaging care.
ADDITIONAL RESOURCES
National Quality of Care Forum. Bridging the gap between theory and practice: exploring outcomes management. Available at: http://intermountainhealthcare. org/qualityandresearch/institute/Documents/articles_ outcomesmeasurement.pdf. Accessed September 18, 2014. American College of Radiology. Image Wisely. Available at: http://www.imagewisely.org. Accessed September 18, 2014. American College of Radiology. Imaging 3.0. Available at: http://www.acr.org/Imaging3. Accessed September 18, 2014.
1204 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
American College of Radiology. Imaging 3.0 FAQ. Available at: http://www.acr.org/FAQs/Imaging-3-FAQ. Accessed September 18, 2014. American College of Radiology. What is Imaging 3.0 and how is it going to be radiology’s escape fire? Available at: http://www.acr.org/w/media/ACR/Documents/PDF/ Economics/Imaging3/AMCLC Imaging 30 Presentation McGinty.pptx. Accessed September 18, 2014. American College of Radiology. The Imaging 3.0 track at the Radiology Leadership Institute. Available at: http://www.acr.org/Advocacy/Economics-Health-Policy/ Imaging-3/Curriculum. Accessed September 18, 2014.
8. Wang KC, Kohli M, Carrino JA. Technology standards in imaging: a practical overview. J Am Coll Radiol 2014;11:1251-9. 9. Cook TS, Nagy P. Business intelligence for the radiologist: making your data work for you. J Am Coll Radiol 2014;11:1238-40. 10. Amis ES, Butler PF, Applegate KE, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007;4:272-84. 11. Amis ES Jr, Butler PF. ACR white paper on radiation dose in medicine: three years later. J Am Coll Radiol 2010;7:865-70. 12. Morin RL, Seibert JA, Boone JM. Radiation dose and safety: informatics standards and tools. J Am Coll Radiol 2014;11:1286-97. 13. Morgan MB, Meenan CD, Safdar NM, Nagy P, Flanders A. Informatics leaders in radiology: who they are and why you need them. J Am Coll Radiol 2014;11:1241-50. 14. Hirschorn DS, Krupinski EA, Flynn MJ. PACS displays: how to select the right display technology. JACR 2014;11:1270-6.
REFERENCES 1. Spivak N. Web 3.0: the third generation web is coming. Available at: http://lifeboat.com/ex/web.3.0. Accessed October 7, 2013. 2. Fuchs VR, Sox HC Jr. Physicians’ views of the relative importance of thirty medical innovations. Health Aff (Millwood) 2001;20:30-42. 3. Kilani RK, Paxton BE, Stinnett SS, Barnhart HX, Bindal V, Lungren MP. Self-referral in medical imaging: a meta-analysis of the literature. J Am Coll Radiol 2011;8:469-76. 4. Levin DC, Rao VM. Turf wars in radiology: updated evidence on the relationship between self-referral and the overutilization of imaging. J Am Coll Radiol 2008;5:806-10.
15. Berland LL, Silverman SG, Gore RM, et al. managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7:754-73. 16. Weiss DL, Kim W, Branstetter BF, Prevedello LM. Radiology reporting: a closed-loop cycle from order entry to results communication. J Am Coll Radiol 2014;11:1226-37. 17. McEnery K. Coordinating patient care within radiology and across the enterprise. J Am Coll Radiol 2014;11:1217-25. 18. Hirschorn DS, Choudhri AF, Shih G, Kim W. Use of mobile devices for medical imaging. JACR 2014;11:1277-85.
6. Krishnaraj A, Siddiqui A, Goldszal A. Meaningful use: participating in the federal incentive program. J Am Coll Radiol 2014;11:1205-11.
19. Rosenkrantz AB, Lepor H, Taneja SS, Recht MP. Adoption of an integrated radiology reading room within a urologic oncology clinic: initial experience in facilitating clinician consultations. J Am Coll Radiol 2014;11:496-500.
7. James BC, Savitz LA. How intermountain trimmed health care costs through robust quality improvement efforts. Health Aff (Millwood) 2011;30:1185-91.
20. Tillack AA, Borgstede JP. An evaluation of the impact of clinically embedded reading rooms on radiologist-referring clinician communication. J Am Coll Radiol 2013;10:368-72.
5. Enzmann DR. Radiology’s value chain. Radiology 2012;263:243-52.
IT Infrastructure in the Era of Imaging 3.0
Geraldine B. McGinty, MD, MBAa, Bibb Allen Jr, MDb, J. Raymond Geis, MDc,d, Christoph Wald, MD, PhDe,f
Imaging 3.0 is a blueprint for the future of radiology modeled after the description of Web 3.0 as “more connected, more open, and more intelligent.” Imaging 3.0 involves radiologists’ using their expertise to manage all aspects of imaging care to improve patient safety and outcomes and to deliver high-value care. IT tools are critical elements and drivers of success as radiologists embrace the concepts of Imaging 3.0. Organized radiology, specifically the ACR, is the natural convener and resource for the development of this Imaging 3.0 toolkit. The ACR’s new Imaging 3.0 Informatics Committee is actively working to develop the informatics tools radiologists need to improve efficiency, deliver more value, and provide quantitative ways to demonstrate their value in new health care delivery and payment systems. This article takes each step of the process of delivering high-value Imaging 3.0 care and outlines the tools available as well as additional resources available to support practicing radiologists. From the moment when imaging is considered through the delivery of a meaningful and actionable report that is communicated to the referring clinician and, when appropriate, to the patient, Imaging 3.0 IT tools will enable radiologists to position themselves as vital constituents in cost-effective, high-value health care. Key Words: Imaging 3.0, accountable care organizations, patient experience, value-based imaging J Am Coll Radiol 2014;11:1197-1204. Copyright © 2014 American College of Radiology
OVERVIEW
Radiologists recognize that a significant portion of important imaging care occurs before and after the interpretation of an imaging study. However, for a variety of reasons, radiologists are not optimally leveraging their role in providing the majority of that care. By using their expertise, radiologists can skillfully manage all aspects of imaging care to improve patient safety and outcomes and to deliver more cost-effective care. IT systems and processes promulgated by organized radiology can foster the development and provision of the tools radiologists need at the point of care to optimize preinterpretation and postinterpretation imaging-guided health care. Providing this type of care will increase radiologists’ value a
Department of Radiology, Weill Cornell Medical College, New York, New York.
b
Department of Radiology, Trinity Medical Center, Birmingham, Alabama.
c
Advanced Medical Imaging Consultants, PC, Fort Collins, Colorado.
d Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado. e
Department of Radiology, Lahey Hospital and Medical Center, Burlington, Massachusetts.
f Department of Radiology, Tufts University Medical School, Boston, Massachusetts.
Corresponding author and reprints: Geraldine B. McGinty, MD, MBA, Weill Cornell Medical College, 1305 York Avenue, 3rd Floor, New York, NY 10021; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.09.005
to the health care system. With proper incentives from policymakers, optimized imaging care beyond image interpretation will improve patients’ care experience and promises to lower the per capita cost of care. Imaging 3.0 is loosely modeled after the evolving concept of Web 3.0. Nova Spivak [1] described Web 3.0 as “more connected, more open, and more intelligent. It will transform the Web from a network of separately siloed applications and content repositories to a more seamless and interoperable whole.” Parallels may be drawn to describe the next evolutionary stage of radiology practice. The label “Imaging 3.0” was chosen to signify a departure from the conventional way in which radiologists have engaged in health care. The constituent parts of the Imaging 3.0 framework are all selected to serve an overriding philosophy for the path forward for radiologists in the new, integrated health care environment. Imaging 3.0 encompasses the entire imaging care pathway, from the point at which a referring clinician considers imaging to the end point of delivery of actionable recommendations to the referring provider and sometimes the patient directly. The more traditional view of the radiologist’s role (to acquire images and generate a report on those images) is no less important in the new paradigm of Imaging 3.0, but it resides within an expanded concept of how radiologists contribute to value-based, integrated health care delivery. 1197
1198 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
A significant portion of important imaging care occurs before and after interpretation, but many radiologists are unaware of this and may not provide care effectively under the traditional paradigm. IT tools are critical elements and drivers of success. These tools must be developed and used with the goal of providing radiologists with “just-in-time” information to keep patients at the center of the system, delivering high-value imaging care. Organized radiology, specifically the ACR, is the natural convener and resource for the development of this Imaging 3.0 toolkit. The implementation of Imaging 3.0 will improve patients’ outcomes and increase radiologists’ relevance to the health care system and, with proper incentives from policymakers, will allow radiologists to play their vital role in the delivery of high-value care. The ACR’s new Imaging 3.0 Informatics Committee is actively working to develop the informatics tools radiologists need to improve efficiency, deliver more value, and provide quantitative ways to demonstrate their value in new health care delivery and payment systems. BACKGROUND
The triple aim of health care—to improve population health and health care quality, to optimize patients’ experiences of health care, and to control costs—is increasingly becoming embedded in health care policy and payment design. Radiologists have tended to be viewed as part of the old “volume-driven,” transactional, and fragmented world of care delivery. This misperception has developed largely because radiologists frequently do not become involved until after examinations have been performed. Using the defense that “we are only doing what was ordered,” radiologists have abrogated their role in only providing appropriate imaging care. Yet the vast majority of the rapid rise in imaging utilization in the early years of this century has clearly resulted from the spectacular diagnostic possibilities afforded by technologies such as CT and MR and the positive impact these modalities have on effective diagnosis and treatment. This was evident in a survey of 225 internal medicine physicians published by Fuchs and Sox [2], who considered CT and MRI the most important medical innovations of the past 30 years. However, with decisions regarding the appropriateness of imaging completely in the hands of ordering physicians, knowledge gaps, defensive medicine, and economically motivated self-referral have all contributed to overutilization [3,4]. Unfortunately, policymakers and payers have chosen to respond to this increase in volume by across-the-board reimbursement cuts rather than by system redesign to incentivize the appropriate use of imaging. Faced with cascading cuts in reimbursement and recognizing changing health care policy, ACR leadership embarked on a clear-eyed evaluation of the ways in which radiologists could survive and thrive in this new world. Taking a fresh look at how radiologists might be able to provide maximum value to health care delivery, our
profession is realizing that this approach represents a tremendous opportunity to enhance the impact of imaging care on our patients [5]. Imaging 3.0 is the corresponding framework that allows radiologists to optimally position themselves for this transformation. TECHNICAL DETAILS
Imaging 3.0 principles can and should inform every step of the delivery of imaging care. From strategic planning (to ensure that patients and referring providers have access to the most appropriate and current technology) to optimizing imaging protocols, the philosophy that places the patient at the center of the care-delivery process should be paramount. This philosophy is captured in Figure 1, the Imaging 3.0—Beyond Image Interpretation flowchart. Specific attention to IT solutions offers several important opportunities to apply the Imaging 3.0 paradigm. Radiologists can and need to be involved every step of the way, but a useful framework to consider the opportunities afforded by Imaging 3.0 looks at the process of imaging care in 3 phases: before imaging acquisition, during image acquisition and interpretation, and after acquisition. Clearly, overarching IT processes and tools inform the universe of Imaging 3.0 care. OVERARCHING IT PROCESSES, SOLUTIONS, AND TOOLS Meaningful Use and Certified Electronic Health Record Technology
A radiology practice that espouses the principles of Imaging 3.0 will be committed to leveraging every opportunity to improve its technology infrastructure. It can certainly be argued that the applicability of meaningful use incentives to radiologists has not always been clear. In addition, busy practitioners who are focused on providing care to their patients may not have had time to spend the time needed to understand the regulations and profit from these incentives. This issue of JACR features an article on meaningful use by Krishnaraj et al [6], which is highly recommended to the reader. Other excellent resources are available from CMS, the Healthcare Information and Management Systems Society, and RadiologyMU.org. These resources may be used to inform and help radiologists participate in meaningful use incentive programs. Standards
The use of evidence-based practices is important in the delivery of Imaging 3.0 care. Brent James’s seminal work at Intermountain Healthcare [7] has demonstrated the need to reduce variability to drive better outcomes. Are standards universally applicable? Of course not, but their use is an excellent framework from which to innovate. Radiologists should acquire a working knowledge of IT standards because they influence important equipment purchasing and operational decisions that support the infrastructure enabling Imaging 3.0. An article by
McGinty et al/IT Infrastructure and Imaging 3.0 1199
Fig 1. ACR Imaging 3.0—Beyond Image Interpretation flowchart.
Wang et al [8] in this issue of JACR discusses the most important aspects of IT standards. Security and Privacy
As previously stated, the Imaging 3.0 radiologist has the patient at the forefront of his or her practice decisions. We cannot provide the best imaging care to our patients if we do not act as their advocates and ensure that their imaging records are available freely to those who need them in care decisions; alternatively, it is critical that their imaging records be inaccessible to those who might try to access them inappropriately. Proliferation of cloud-based image processing and reporting technologies and remote, off-site disaster recovery solutions for imaging archives drives the need for radiologist experts to weigh convenience and accessibility against patient privacy concerns and strike a balance that enables efficient care delivery while maintaining the integrity of sensitive information. There is an increasing role and responsibility for Imaging 3.0 radiologists to exert leadership in this regard, not least if they view themselves as part of the team of treating physicians. Workflow Processes
A radiology practice that adheres to the principles of Imaging 3.0 will have a constant process to document, critique, and improve its workflow processes. Informed by the philosophy of patient-centered imaging care, the Imaging 3.0 radiologist will always look for ways to
improve departmental processes to better serve the health care community. Examples include monitoring CT dose estimates via machines and technologists to discover opportunities for dose reduction, initiating projects to decrease patient wait times, improving turnaround time for reporting, working on the communication of critical findings, and implementing systems that link prioritization of examinations to be read to actual clinical status or future patient appointments. Business Intelligence Analytics
As referenced previously, the Imaging 3.0 practice involves a constant search for knowledge and improvement. Using key performance indicators and leveraging IT to share and communicate results is a key driver of Imaging 3.0 success. Part of the knowledge gained comes from business intelligence analytics and is expanded on in an article by Cook and Nagy [9] in this issue. IMAGING 3.0 BEFORE IMAGING ACQUISITION AND INTERPRETATION Clinical Decision Support (CDS)
An important Imaging 3.0 milestone was reached with the inclusion of a requirement for the use of CDS for advanced imaging in the Medicare program in House Resolution 4302, also known as the March 2014 sustainable growth rate patch legislation. This important new program will go into effect in 2017. Radiologists
1200 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
now have a tremendous opportunity to serve as leaders in implementing CDS programs for their communities and ensuring that the essential role of the radiologist is not only recognized but also valued. We have a gamechanging chance to rediscover and highlight our role as consultants to referring physicians and patients. Even as imaging utilization growth has flattened, every radiologist regularly encounters requests for the wrong imaging test or an imaging test that may not be helpful or may use excessive radiation considering the question at hand. The imaging armamentarium is filled with phenomenal tools, but choosing the right one can be a challenge. For a busy primary care provider or, as is expected to be the new normal under the Patient Protection and Affordable Care Act, a midlevel provider, decision making regarding the type of imaging test best suited to answer the clinical question is hard enough. The implementation of CDS in the Medicare program holds promise to significantly shift the balance toward more appropriate imaging care. Radiology benefit management companies (RBMs) have heretofore captured a large market share with commercial insurance carriers in their role as gatekeepers to high-cost imaging examinations and are likely not going away any time soon. Although these companies tout significant savings in terms of reducing advanced imaging utilization, it is by no means clear that these reductions are intransient. As a result, costs have shifted to providers who must employ staff members to log hours on the phone to get imaging studies approved as well as manage steerage programs that divert patients away from trusted imaging providers; these consequences have limited the popularity of RBMs to the payers who use their services. The algorithms by which RBMs determine the appropriateness of examinations are opaque and may not be based solely on medical necessity and evidence. The ACR Appropriateness Criteria have been freely available to the health care community since 1995. However, after licensing this intellectual property to the National Decision Support Company, the Appropriateness Criteria have been morphed into an invaluable decision support tool for providers and are continually updated and expanded. Whether embedded in the electronic health record system or accessed via computers or even mobile devices as a stand-alone, online portal (website), CDS for imaging facilitated by radiologists is a clear demonstration of the value of our profession in determining care pathways. Some radiologists have expressed concern that the use of CDS tools would render their expertise irrelevant. The growing set of decision-support tools, which can be accessed by modality or based on indications or symptoms, though comprehensive, is by no means all inclusive. Individual clinical situations and patient characteristics will require consultation with the radiologist. Priorities and preferences of the interdisciplinary or institutional team of physicians may affect the way in
which decision support is implemented or modified to best serve the local standard of care. When the system indicates that a particular examination order is considered indeterminate or even inappropriate, the need for consultation with the imaging expert arises quickly. The Imaging 3.0 radiologist will be readily available by phone, secure messaging, or even online chat to aid the referring provider in choosing the appropriate imaging examination and to discuss the various alternatives. The willingness of radiologists to overcome stereotypes about being the beneficiaries of the volume culture of fee-for-service medicine allows the ACR to tell a new and compelling story to policymakers and payers about the key role radiologists play in the delivery of highvalue, cost-effective care. Imaging 3.0 is that story. Dose and Safety
Although “Imaging 3.0” is a new term for the framework of the imaging care process beyond actual examination interpretation, many components of the Imaging 3.0 toolkit have been in existence for decades. However, by placing these existing tools and concepts under the Imaging 3.0 umbrella, we can highlight where ongoing programs are congruent with the goals of optimizing imaging care. One such initiative is patient safety during imaging. As imaging experts, radiologists are best positioned to ensure that imaging care is delivered as safely as possible. The ACR and the RSNA formed the Joint Task Force on Adult Radiation Protection in 2009 with support from the American Society of Radiologic Technologists (ASRT) and the American Association of Physicists in Medicine to address concerns about the surge of public exposure to ionizing radiation from medical imaging. These organizations, as well as scientific publications, media, and government, have addressed radiation concerns in recent years. The various activities are nicely summarized in two publications by Amis et al [10,11]. The ACR and RSNA have also collaborated to develop a comprehensive patient information resource on all issues revolving around imaging, RadiologyInfo.org. Of particular interest may be the Radiology Benefits and Risks Primer, which directly addresses patients’ concerns about the use of radiation in medical imaging examinations. Patients can also learn about radiation dose from xray and CT examinations from this trusted resource. The joint task force collaborated with the American Association of Physicists in Medicine and the ASRT to create the Image Wisely, campaign with the objective of lowering the amount of radiation used in medically necessary imaging studies and eliminating unnecessary procedures. The Image Wisely website offers resources and information to radiologists, medical physicists, other imaging practitioners, and patients. The Image Gently campaign is an initiative of the Alliance for Radiation Safety in Pediatric Imaging. The campaign goal is to change practice by increasing awareness of the opportunities to promote radiation
McGinty et al/IT Infrastructure and Imaging 3.0 1201
protection in the imaging of children. Pledging to image wisely and gently and modifying imaging practices to adhere to the principles promulgated by these campaigns demonstrate this leadership. The ACR Dose Index Registry should be used to allow practices to see aggregated radiation exposure, benchmark their groups against other practices, and correct issues if there are outliers. The ACR was a founding member of the Choosing Wisely campaign in collaboration with multiple other medical specialties under the auspices of the American Board of Internal Medicine. This widely publicized campaign seeks to change providers’ behavior regarding the use of diagnostic tests. The aforementioned programs and collaborations all preceded the development of the Imaging 3.0 initiative, but all are comfortably within it. By demonstrating leadership in radiation safety and commitment to patient and provider education, radiologists are espousing the Imaging 3.0 philosophy. There is a dedicated article on patient safety considerations in this issue of JACR by Morin et al [12]. Medical Imaging and Technology Alliance Smart Dose
In addition to mandating consultation of imaging appropriateness criteria by referring physicians, section 218 of HR 4302 sought to address concerns surrounding patient safety associated with CT radiation dose levels. Congress was particularly attracted to implementing a CT equipment dose standard developed by the Medical Imaging and Technology Alliance (MITA) within the National Electrical Manufacturers Association because the concept was estimated to save the federal government approximately $200 million over 10 years. Under this policy, starting on January 1, 2016, select diagnostic imaging studies performed on equipment that cannot comply with tional Electrical Manufacturers Association XR 29, Standard Attributes on CT Equipment Related to Dose Optimization, or MITA’s Smart Dose standard will be subjected to technical component reimbursement reductions on a per scan basis. The ACR supports the radiation safety goals outlined by the MITA Smart Dose standard. One of the College’s principal obligations related to Imaging 3.0 is to ensure that patients seek diagnostic imaging care only from those practices at which the radiation dose used is optimized for the diagnostic need of the examination. Although the ACR acknowledges that some imaging centers and hospitals will face some technical component reductions if their equipment cannot meet these new dose standards, proper use of the new MITA Smart Dose standard features should be encouraged to help ensure that patients receive the safest, most effective imaging. ACR members interested in learning if their CT equipment complies with the MITA Smart Dose standard should contact their respective equipment manufacturers.
IMAGING 3.0 DURING IMAGE ACQUISITION AND INTERPRETATION Education, Training, and Qualifications
Health care IT has evolved rapidly and represents critical infrastructure to efficiently implement Imaging 3.0 concepts across their respective practice space. As a result, radiologists should place high value on their IT solutions and the staff members supporting those resources. IT is generally perceived as a generic or one-size-fits-all support service that is interchangeable throughout an organization. The reality is that IT has become subspecialized. The article by Morgan et al [13] in this issue of JACR is designed to serve as a guide for you, the practicing radiologist, to build an effective IT division by considering education, training requirements, and suitable personnel qualifications. It also focuses on the critical role of the radiologist IT liaison in bridging gaps among organizations’ IT, medical, and administrative functions. Additionally, attaining certification and accreditation by appropriate certifying bodies is critical to demonstrating quality and expertise to patients, peers, and payers. Facility accreditation, physician and technologist certification, and ongoing peer review programs are all important in demonstrating this quality. Physicians should also demonstrate their commitment to quality and expertise by achieving certification by the ABR or equivalent (as delineated in the ACR practice parameters and technical standards) and by meeting the requirements of the ABR Maintenance of Certification program. Radiologic and ultrasound technologists should be accredited by the ASRT and the American Registry for Diagnostic Medical Sonography, respectively. Peer review, continuing education, and the provision of a learning environment for all personnel in the imaging department represent the Imaging 3.0 commitment to high-value care. PACS administrators and others involved with managing radiology images should be accredited by the American Board of Imaging Informatics, which awards the Certified Imaging Informatics Professional designation as the standard for demonstrated knowledge and competence in medical imaging informatics. The American Board of Imaging Informatics was founded by the Society for Imaging Informatics in Medicine and the American Registry of Radiologic Technologists. The Society for Imaging Informatics in Medicine offers extensive training in imaging informatics for staff members as well as physicians. Image Acquisition
At the image acquisition stage, radiologists must work closely and proactively with medical physicists, radiologic technologists, and ultrasound technologists to develop protocols that combine the highest diagnostic accuracy with the safest and most comfortable patient experience. Minimizing radiation dose is a key focus. Finding a balance between reproducibility and standardization of image quality and the type of customization that is especially important in pediatric
1202 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
imaging will be critical. Novel technology being developed promises to connect remote reading stations with scanner consoles in an efficient and easy manner. This may allow radiologists to play a more active role in tailoring examinations to individual clinical scenarios and patient anatomy. Archive and Retrieval
Providing the highest quality imaging care requires comparison with relevant prior studies and secure storage of current data to facilitate future care. As outlined above, Imaging 3.0 promotes that the requisite steps in the IT process be streamlined so that they become invisible to patients and referrers. A patient should never have to undergo a repeat study because prior imaging is not available. A referring physician should rarely have to delay a decision because a report is incomplete and awaiting prior studies. The responsibility for ensuring the availability of prior imaging data and the secure storage of the current study falls squarely on the shoulders of the Imaging 3.0 radiologist. It is not acceptable to blame IT or hospital administration. Imaging 3.0 requires the radiologist be part of the decision-making process regarding archiving and data storage solutions. We must act as advocates for our patients in this regard.
IMAGING 3.0 IN THE POSTIMAGING ACQUISITION AND INTERPRETATION PERIOD Transmission and Communication
Imaging 3.0 stresses the tremendous added value of the timely delivery of actionable, accurate reports on imaging examinations to the point of care. With “length of stay” in the emergency department and in the hospital becoming a major efficiency measure, it is crucial that such information be delivered in a secure, complete, and timely manner. The multiplicity of electronic health record vendors necessitates a nimble and flexible approach to ensure delivery of the report where and when the referring clinician requires it. Radiology Information Systems and Electronic Medical Records
Making actionable imaging reports available seamlessly in the electronic medical record is a key deliverable of Imaging 3.0 and is the subject of the article by McEnery [17]. The use of structured reporting, the implementation of communication protocols around the reporting of critical results, and the ability to communicate securely with both referring providers and patients are all tools that can enhance a practice’s Imaging 3.0 performance.
Display
Communication With Mobile Devices
Apart from the obvious need for image displays to support the work of the radiologist, Imaging 3.0 requires that attention be paid to the all-important work of consulting with referrers and patients regarding the information contained within the images. Consideration should therefore be given to how imaging information can be displayed in a way that optimizes those interactions. Please review the article on displays by Hirschorn et al [14] in this issue for all related issues to consider.
Imaging 3.0 means delivering diagnostic decision support to our referring providers and imaging care to our patients in a way that is convenient and relevant for them. It is no longer acceptable to indiscriminately cite privacy concerns or software incompatibilities as reasons not to embrace mobile technology. The world runs on a mobile communication platform, and Imaging 3.0 challenges radiologists to securely and accurately make imaging information available on mobile devices. Please refer to the article by Hirschorn et al [18] for more detailed information on issues surrounding mobile devices.
Reporting and Communication
Effective radiologist participation in the care-delivery process is at the heart of Imaging 3.0. An actionable, comprehensible, and appropriately communicated report is the most important product we deliver. Work is under way at the ACR to deliver content to IT vendors to enhance the delivery of imaging reports to referring physicians and patients alike. Some approaches favor the inclusion of hyperlinks to key images, including relevant measurements and even the addition of representative images within a multimedia report format. The use of structured reporting systems provided by the ACR (eg, LI-RADS, BI-RADS, and Lung-RADSTM) is strongly encouraged as it serves to standardize reporting and reliably connects certain key diagnostic findings with appropriate downstream imaging and clinical care activities. Careful handling of incidental findings in future reports is another challenge radiologists need to face responsibly; a growing number of resources are available that provide guidance on how to handle such findings appropriately [15]. For more on reporting and communication, read the article in this issue by Weiss et al [16].
PRACTICAL IMPLICATIONS AND IMPLEMENTATION
Imaging 3.0 is a journey that individual radiologists and practices will make at different speeds. It is important to remember that the philosophy of being at the center of care depends mostly on the willingness of radiologists to assume that position. Our radiology forefathers did not have sophisticated IT tools but perhaps occupied a more pivotal and direct role in the care-delivery process. Some of our most important IT advances have had unintended consequences and have removed us from our physician colleagues and patients. Payment system design has incentivized productivity over radiologist interaction with physician colleagues and patients. In the future, it will be wise to leverage IT tools to make us more available and visible. Radiologists must take on this leadership challenge now; it requires intense communication with our colleagues to align them (and imaging operations) with our professional direction and vision
McGinty et al/IT Infrastructure and Imaging 3.0 1203
for the future and hard work to motivate all individuals involved with the idea that, in the end, radiology and its patients will be better for these changes. A useful first exercise for any practice or practitioner is to “walk” through the Imaging 3.0 workflow. Making optimal use of the tools already available and communicating those to the patient and referrer communities is an excellent start. For example, a review of a practice’s radiology information system and PACS capabilities can be used to determine where there are as yet unused opportunities to connect with patients and referrers. Consider using the PACS in a nontraditional way to place radiologists within clinical care areas while allowing them to remain connected with the main radiology department [19,20]. A practice that has already pledged to image gently and image wisely and has attained full ACR accreditation can benefit from ensuring that these commitments to high-value care are widely communicated to its health care network. Next, the practice should perform an assessment of the Imaging 3.0 tools and activities it is not currently active in and pursue as many as is practical. Some decisions, such as improving Physician Quality Reporting System participation, may be practitioner-level decisions, whereas others, such as adopting CDS, will be at the health system level. A key parallel initiative should be for members of the radiology practice to become as active as possible in the health system’s committees and workgroups. If the practice participates in a shared savings model, a seat on the governing board of the accountable care organization is ideal.
DEDICATED ACR IMAGING 3.0 ONLINE RESOURCES
The ACR maintains a dedicated collection of web-based resources on the topic of Imaging 3.0. Among other items, several case studies are available on the site. Other resources on this topic include frequently asked questions, overview of relevant organizations, the presentation “What Is Imaging 3.0?” information on accountable care organizations, the Imaging 3.0 track of the Radiology Leadership Institute, and other items. CONCLUSIONS
The Imaging 3.0 initiative represents a framework designed to facilitate a profound culture and practice paradigm shift within radiology. It aims to equip the 21st-century radiologist with the necessary knowledge, tools, and attitude to embrace a leadership role in evolving health care delivery in general and imaging care in particular. By critically examining and leveraging all opportunities for value delivery in integrated imaging care, radiologists will be able to provide quality patient care under the new payment models. From this realization flows the need for investments in technology and human resources to ensure success. However, a radiologist in rural solo practice can embrace Imaging 3.0 concepts as successfully as a radiologist in a large integrated health system. The effective use of IT may serve as an important catalyst. An informed review of existing practice tools already available and applying the same Imaging 3.0 perspective to new technology acquisitions will enable radiologists to position themselves as vital constituents in cost-effective, high-value health care.
QUESTIONS TO ASK YOUR IT STAFF AND VENDORS
Imaging 3.0 and the philosophy of expanding the understanding of what constitutes imaging care should inform all interactions around IT. It is no longer enough for an IT tool to promote radiologist productivity. Although if that is the case, the tool’s value should be measured in terms of the time it affords the radiologist to interact with referrers and patients. Ease of use for patients and referrers is a key deliverable for IT tools that should assume a much higher priority in the Imaging 3.0 practice. The goal of controlling costs, along with the greater number of integrated practices, makes it imperative that IT tools and systems be as cost effective as possible. As such, an Imaging 3.0 value checklist for IT tools might include such questions as the following: How does this product help my patients? How does this product help the providers who refer patients to my practice? Does this product optimize my practice costs? Do I currently have a way to measure noninterpretive, value-added work performed by radiologists that benefits patient care but is not currently captured in work relative value units?
TAKE-HOME POINTS
Imaging 3.0 is a blueprint for radiologists’ future. At each step of the care delivery process, IT tools are available or in development that can support the Imaging 3.0 paradigm. By embracing these tools, radiologists can demonstrate their critical role in the delivery of high-value imaging care.
ADDITIONAL RESOURCES
National Quality of Care Forum. Bridging the gap between theory and practice: exploring outcomes management. Available at: http://intermountainhealthcare. org/qualityandresearch/institute/Documents/articles_ outcomesmeasurement.pdf. Accessed September 18, 2014. American College of Radiology. Image Wisely. Available at: http://www.imagewisely.org. Accessed September 18, 2014. American College of Radiology. Imaging 3.0. Available at: http://www.acr.org/Imaging3. Accessed September 18, 2014.
1204 Journal of the American College of Radiology/Vol. 11 No. 12PB December 2014
American College of Radiology. Imaging 3.0 FAQ. Available at: http://www.acr.org/FAQs/Imaging-3-FAQ. Accessed September 18, 2014. American College of Radiology. What is Imaging 3.0 and how is it going to be radiology’s escape fire? Available at: http://www.acr.org/w/media/ACR/Documents/PDF/ Economics/Imaging3/AMCLC Imaging 30 Presentation McGinty.pptx. Accessed September 18, 2014. American College of Radiology. The Imaging 3.0 track at the Radiology Leadership Institute. Available at: http://www.acr.org/Advocacy/Economics-Health-Policy/ Imaging-3/Curriculum. Accessed September 18, 2014.
8. Wang KC, Kohli M, Carrino JA. Technology standards in imaging: a practical overview. J Am Coll Radiol 2014;11:1251-9. 9. Cook TS, Nagy P. Business intelligence for the radiologist: making your data work for you. J Am Coll Radiol 2014;11:1238-40. 10. Amis ES, Butler PF, Applegate KE, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007;4:272-84. 11. Amis ES Jr, Butler PF. ACR white paper on radiation dose in medicine: three years later. J Am Coll Radiol 2010;7:865-70. 12. Morin RL, Seibert JA, Boone JM. Radiation dose and safety: informatics standards and tools. J Am Coll Radiol 2014;11:1286-97. 13. Morgan MB, Meenan CD, Safdar NM, Nagy P, Flanders A. Informatics leaders in radiology: who they are and why you need them. J Am Coll Radiol 2014;11:1241-50. 14. Hirschorn DS, Krupinski EA, Flynn MJ. PACS displays: how to select the right display technology. JACR 2014;11:1270-6.
REFERENCES 1. Spivak N. Web 3.0: the third generation web is coming. Available at: http://lifeboat.com/ex/web.3.0. Accessed October 7, 2013. 2. Fuchs VR, Sox HC Jr. Physicians’ views of the relative importance of thirty medical innovations. Health Aff (Millwood) 2001;20:30-42. 3. Kilani RK, Paxton BE, Stinnett SS, Barnhart HX, Bindal V, Lungren MP. Self-referral in medical imaging: a meta-analysis of the literature. J Am Coll Radiol 2011;8:469-76. 4. Levin DC, Rao VM. Turf wars in radiology: updated evidence on the relationship between self-referral and the overutilization of imaging. J Am Coll Radiol 2008;5:806-10.
15. Berland LL, Silverman SG, Gore RM, et al. managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7:754-73. 16. Weiss DL, Kim W, Branstetter BF, Prevedello LM. Radiology reporting: a closed-loop cycle from order entry to results communication. J Am Coll Radiol 2014;11:1226-37. 17. McEnery K. Coordinating patient care within radiology and across the enterprise. J Am Coll Radiol 2014;11:1217-25. 18. Hirschorn DS, Choudhri AF, Shih G, Kim W. Use of mobile devices for medical imaging. JACR 2014;11:1277-85.
6. Krishnaraj A, Siddiqui A, Goldszal A. Meaningful use: participating in the federal incentive program. J Am Coll Radiol 2014;11:1205-11.
19. Rosenkrantz AB, Lepor H, Taneja SS, Recht MP. Adoption of an integrated radiology reading room within a urologic oncology clinic: initial experience in facilitating clinician consultations. J Am Coll Radiol 2014;11:496-500.
7. James BC, Savitz LA. How intermountain trimmed health care costs through robust quality improvement efforts. Health Aff (Millwood) 2011;30:1185-91.
20. Tillack AA, Borgstede JP. An evaluation of the impact of clinically embedded reading rooms on radiologist-referring clinician communication. J Am Coll Radiol 2013;10:368-72.
5. Enzmann DR. Radiology’s value chain. Radiology 2012;263:243-52.