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Sunday 24 March 2019
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Value-based radiology

Healthcare delivery is experiencing a great transition and the term ‘value-based healthcare’ is on everybody’s lips nowadays. The theory behind this term is that the healthcare providers are paid based on a patient’s health outcome and not for the amount of service they delivered. Outcome differs depending on the medical condition including comorbidities and is not easy to measure. For example, the most important outcome for cancer patients is survival; however, as for many other conditions, time required for recovery, complications, adverse effects, pain, psychological stress, sustainability of health and long-term consequences of the therapy could define outcome, and so the value of the healthcare. 
 
Care for a medical condition usually involves different specialties and a number of interventions, thus the value for the patient can only be achieved by the combined efforts of all players over the full cycle of care. The benefits of any one intervention for ultimate outcomes will depend on the effectiveness of further different interventions throughout the care cycle.1 The specialty of radiology is an important outcome influencing players in the whole healthcare cycle, whether contributing to diagnosis, or by minimal invasive interventional procedures, radiation therapy or therapy monitoring. Radiology departments today are faced with many challenges to improve operational efficiency, performance, and quality to keep pace with rapid transition in the healthcare delivery. 
 
In the last two decades, the field of medical imaging has benefited greatly from extraordinary technological advances. The introduction of imaging modalities such as CT and MRI has brought the biggest breakthrough in imaging science since the discovery of X-rays more than 100 years ago. Radiology has transformed from static imaging to a more dynamic diagnostic tool that is able to characterise abnormalities even on metabolic, cellular and molecular levels. Medical imaging plays a critical role in establishing the diagnoses for innumerable conditions and it is used routinely in nearly every branch of medicine, thereby playing a key role in disease management. 
 
Accordingly, the duty and workload of the radiologist has changed rapidly in the last decades; the time when a radiologist analysed ‘just a film’ are long gone. Technological advances in the field of radiology, rapidly developing therapeutic innovations, demographic shift, changing lifestyle of modern society and a rising number of chronic conditions are influencing the exponential increase of the use of medical imaging. Instead of a single X-ray film, a CT exam of the chest, for example, comprises at least 300 slices, each of which are evaluated by a radiologist on a regular basis. MRI exams are much more complex, depending on the number of sequences acquired, and not to mention complex image-reconstruction procedures which are increasingly required.
 
The flip side of the coin entails however, unwanted consequences such as increased workload, shortage of imaging specialists, and less time available for interpreting and communicating the imaging exams with patients and referring clinicians. The main challenge the field of radiology is facing nowadays is to handle an ever-increasing workload and yet to provide the greatest possible value to the patients.
 
Contribution of a radiologist to a correct and timely imaging report is key for the right treatment decision. In our opinion, the first step toward creating value for patients referred to the radiology department starts with assuring the appropriateness of the imaging examinations. There are statistics showing that up to 20% of all requests in Europe and up to 50% in the USA are not appropriate.2,3 In this regard, the radiologist should play a pivotal role in providing the right examination for the right clinical indications, and, if necessary, to reject unnecessary or redundant imaging requests. The reality, however, is somewhat complex. 
 
In many situations, especially in the case of outpatients, the information coming with the request for the radiological examination is minimal. A promising technical support could be provided by the clinical decision support (CDS) systems, which ensure whether the modality requested to the examination and patient condition is in line with currently valid guidelines. CDS systems prove, whether MRI or CT, with or without contrast agent, is the most appropriate imaging modality to answer the given clinical question. Preferably, these systems should be fed with additional information from the electronic health record (EHR) of the patient (for example, renal function, pregnancy, HIV status, diabetes). 
 
Beyond choosing the right modality, an intelligent CDS system should even be able to assign the appropriate protocol, examination lane, dose, volume of contrast, number of phases, and additional sequences in MRI, to help adequately address the medical question. In other words, CDS should help tailor and personalise examination protocols. Dose management of imaging examinations involving radiation exposure goes hand in hand with the appropriateness check, which is a part of the radiologist’s and medical physicist’s responsibility. When implemented adequately, CDS systems will increase productivity, reduce unnecessary examinations and save resources. 
 
The radiologists will benefit from time saved to engage more on patient care, whether it is appropriate reporting, communication of diagnosis or follow-up of treatment results. In order to harmonise imaging appropriateness criteria throughout European countries, the European Society of Radiology (ESR) has launched a computer-based CDS tool called ESR iGuide. This tool provides a core standard system, with guidelines adaptable to local (national and institutional) situations.4
 
Picture archiving communications systems (PACS) have revolutionised radiology in every sense. The downside of computerisation is, however, reduced in-person consultation between the treating clinicians and the radiology departments. In general, images are analysed and annotated in the PACS; radiology reports are then created mostly as a narrative text and deposited in the EHR or sent to the referring physician in a hard copy. According to a recent study, one third of radiologists’ recommendations contained in written reports are ignored or even not documented in the patient medical record by the referring physician.5
 
One approach to address this issue is the improvement of radiology reports by structuring and standardising. The solution is to be expected from IT development. Similar to a checklist, structured reports have a template with standardised content and standardised language. According to recent studies, structured radiology reports are more complete and have more relevant content.6,7 Moreover, improved linguistic quality of structured reports facilitates readability and potentially leads to better satisfaction of referring physicians.8 Diagnostic processes occur over time and can involve multiple health care professionals across different care settings that require improved interoperability and free flow of information.9
 
Generating structured radiology reports requires access to additional patient data such as previous images, histology or surgical reports, comorbidities, etc. The interface between EHRs and radiology information systems typically has limited clinical information. In this regard, the next generation EHRs supporting the interoperability of information should bring the communication between health care professionals to the next level. Structuring, not only of the radiology data, but also the complete clinical data should ease the utilisation of ‘big data’ to bring valuable benefits to clinical care, research and quality improvement. 
 
Radiologists, except those active in interventional radiology or radiation oncology, are often criticised for having little contact with patients. Different surveys have shown that most patients desire direct communication of results after imaging examinations, are comfortable hearing both normal and abnormal results, and feel a decrease in anxiety after communicatons of the results.10,11 Sharing the result of an imaging exam with patients is an important issue; however, feasibility of direct communication varies depending on the type of examination and the set up of the radiology departments. 
 
Direct communication of an ultrasound examination is shorter and easily feasible compared with a CT or MRI in a large hospital mainly caring for inpatients, and also because of the number of images and complexity of findings. The radiologists are expected to be both the doctor’s doctor and patient’s physician. However, an aspect the radiologist should be careful of is superseding of the referring physician with the statements regarding to further disease management and prognosis.12 This could cause confusion for patients and burden the relationship between the radiologist and the referring clinician. 
 
Advances in IT technology are enabling new powerful tools to medical imaging: from administrative functions through image acquisition, storage, and reporting. Currently the field of artificial imaging (AI) promises opportunities to improve the speed, accuracy, and quality of image interpretation and diagnosis in radiology.13 Surely AI will find its way into medical imaging; however, to show how these AI products reduce costs and improve outcomes will require clinical translation and industrial-grade integration into routine workflow.14
 
Value should always be defined around the patient, and in a well-functioning health care system, creating value for patients should determine the rewards for all other players in the system.1 Creating value and contributing to patient outcome in radiology departments starts with well-organised utilisation plans, shorter waiting times, appropriateness criteria, structured and timely reporting and continuous research for better imaging, intervention and therapy. The contribution of radiologists should not be considered as a factory producing imaging examinations, and attention should not be focused on the volume of procedures performed.4 Importantly, no false economic incentives should be set up, which primarily compensate for the volume of diagnostic or therapeutic measures. 
 
There are different imaging value chain metrics to be considered. The most relevant ones that can be used in the daily practice could fit in five different categories,15 namely: 
  • imaging appropriateness1,2
  • patient scheduling, preparation and protocol3 modality operations4 
  • reporting 
  • communication.5
 
Guideline compliance, adherence to CDS tools and identification of redundancy are integral parts of the first group, while in the second category, the scheduler response time, the ease of access to scanning facility, compliance with protocols or radiation limits and staff service feedback are of utmost importance. The third category comprises metrics such as on time scanning, room time and contrast reactions or extravasations. In the reporting category, the adherence to ACR incidental finding criteria, the use of standard vocabulary, the time from examination completion to finalised report and the accuracy of report to final diagnosis are the most important metrics. Finally in the fifth category, time for report availability to patient, time for closed-loop critical results reporting, ease of report access by patient and report understood by or consulted to patient are the metrics to be used.
 
The most important questions regarding the outcome effects induced by imaging are: Did the referring physician find the report information useful? Did results of imaging change diagnosis or therapy? Did the use of imaging eliminate need for more invasive or expensive procedures? 
 
Did the use of imaging reduce length of stay? Complications, patient and referring physician satisfaction are also examination outcomes to be borne in mind.
 

Conclusions

In conclusion, the goal is to achieve a sustainable and affordable care, creating value, better outcomes and satisfaction to both patients and all other players in the healthcare cycle, and of course reduce waste, keeping in mind not just stratospheric amounts of potential global or nationwide money waste (like those $750 billion of waste spent on health care reported in US16) but also those small amounts that we face daily in our practice, such as redundant or inappropriate emergent imaging exams, but summed on a year basis and even on a small hospital in a country such as Portugal17 could easily equalise a radiologist annual salary. In this way, the role of radiology in healthcare management is pivotal, and radiologists, knowing the unique field of imaging as no one else, are at the forefront to become the master of a lean organisational structure.
 

References

1 Porter ME. What is value in health care? N Engl J Med 2010;363(26):2477–81. 
2 Leitz W. AA, Richter S. A study on justification of CT examinations in Sweden. Justification of medical exposure in diagnostic imaging. IAEA 2011 Interantional Atomic Energy Agency 2011. https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1532_web.pdf (accessed May 2018).
3 Forrest W. Johns Hopkins tackles problem of unnecessary scans. www.auntminnie.com/index.aspx?sec=log&URL=http%3a%2f%2fwww.auntminnie.co... (accessed May 2018).
4 ESR concept paper on value-based radiology  (2017). Insights imaging 2017;8(5):447–54. 
5 Kadom N et al. Safety-net academic hospital experience in following up noncritical yet potentially significant radiologist recommendations. AJR Am J Roentgenol 2017;209 (5):982–6. 
6 Sabel BO et al. Structured reporting of CT examinations in acute pulmonary embolism. J Cardiovasc Comput Tomogr 2017;11(3):188–95. 
7 Schoeppe F et al. Structured reports of videofluoroscopic swallowing studies have the potential to improve overall report quality compared to free text reports. Eur Radiol 2018;28(1):308–15.
8 Gassenmaier S et al. Structured reporting of MRI of the shoulder – improvement of report quality? Eur Radiol 2017;27(10):4110–19.
9 Committee on Diagnostic Error in Health Board on Health Care, Institute of the National Academies of Sciences.  In: Balogh EP, Miller BT, Ball JR (eds) Improving Diagnosis in Health Care. National Academies Press; 2015:Washington DC, USA. 
10 Capaccio E et al. How often do patients ask for the results of their radiological studies? Insights Imaging 2010;(2):83–5. 
11 Pahade J et al. Reviewing imaging examination results with a radiologist immediately after study completion: patient preferences and assessment of feasibility in an academic department. AJR Am J Roentgenol 2012;199 (4):844–851. 
12 Hawkins M. RSNA 2017: Is a radiologist the doctor’s doctor, the patient’s physician – or both? www.healthimaging.com/topics/healthcare-economics-policy/rsna-2017-radio... (accessed May 2018). 
13 Kahn CE Jr. From images to actions: Opportunities for artificial intelligence in radiology. Radiology 2017;285(3):719–20. 
14 Dreyer KJ, Geis JR. When machines think: Radiology’s next frontier. Radiology 2017;285 (3):713–18. 
15 Boland GW, Thrall JH, Duszak R Jr. Business intelligence, data mining, and future trends. J Am Coll Radiol 2015;12(1):9–11.
16 The National Academies of Sciences EaM. http://www.nationalacademies.org/newsroom/ (accessed May 2018). 
17 Silva CF, Guerra T. Volume or value? The role of the radiologist in managing radiological exams. Acta Med Portuguesa 2017;30 (9):628–32.

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