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Reinterpreting
Interpretation It will take more than images for radiologists to maintain their image. Connectivity, like most buzzwords, conveys a sense of potential while being appropriately vague. In healthcare, greater connectivity has the potential to remove administrative hurdles and reduce medical errors, but will it truly change the way facilities deliver care and conduct business? In the case of medical imaging, it already has to a certain extent. But even with more pieces of the healthcare system being connected on a seemingly daily basis, perhaps the best way to ensure that the future prominently includes radiologists is to focus on how physicians can use new technologies to add value to radiology services. In the business world, a commodity is perceived as being something, while a service is perceived as doing something. A medical image, in and of itself, is a commodity. And because radiologists are so closely associated with medical images, Paul J. Chang, MD, FSIIM, and others fear they risk being commoditized. “If you take care of value, if you provide value to your customers, the rest of it takes care of itself,” says Chang, vice chairman of radiology informatics and medical director of pathology informatics at the University of Chicago’s Pritzker School of Medicine. “So the question is, when you’re talking about radiology, ‘What is our value? What do we provide?’ It used to be, before PACS, we controlled the image. Well now, with PACS, we don’t.” Radiologists’ expertise and service are factors that separate whether they are perceived as being something or doing something. “Usually, the patients don’t come to us directly,” says Chang. “In the radiology world, we have a referring physician who orders the study. From a business perspective, you might view that physician as our customer. So my view is, unless that doc thinks we add value, we’re not really adding value. “If my car is broken and I take it to the shop, they do some diagnosis, and a lot of those tests they do are very similar to what we do to patients in the ICU [intensive care unit],” adds Chang. “I don’t pay a dime for the diagnosis until they fix the car. In other words, I pay for my car’s outcome. In medicine—in radiology in particular—I get paid irrespective of whether it helps you or not. I get paid for what I do, not whether or not what I do actually affects outcome. That’s going to change.” Contributing to Outcomes “You can make money in a bear market,” says Chang. “If every radiologist is blind as a lemming and just jumping off the curve, you can survive—and thrive even—if you’re the one lemming that says, ‘You know what? I don’t want to be globalized. I don’t want to be commoditized. I want to add value.’ “Our job is not done until our interpretation—that is our value really, not the image, the interpretation of that image—gets delivered to the appropriate healthcare provider who’s actually going to do something for the patient,” he adds. “If they don’t do anything, we haven’t accomplished anything.” More Useful Reports “Why not add electronic decision support?” suggests Chang. “You have companies who have very nice electronic decision support tools for the radiologist. Now, they were designed primarily for the radiologist in the reading room, not at the PACS workstation. I’d like to use the same decision support as part of a hyperlink to my report. … Imagine me giving an electronic report to one of my physicians saying … ‘Click here and have decision support that explains what this disease is and what you should do about it.’” Some researchers are looking at methods to not only change the way reports are interpreted but also the way they’re viewed. “Dr. Bruce Reiner [MD] and I wrote an article recently on an alternative for radiology reporting where we proposed an approach that we refer to as symbol- or gesture-based reporting,” says Eliot L. Siegel, MD, FSIIM, professor and vice chairman of information systems at the University of Maryland School of Medicine’s department of diagnostic radiology and chief of imaging at the VA Maryland Healthcare System. “If a radiologist is interpreting mammograms or reading a chest radiograph, for example, rather than dictating the case, the radiologist would do something analogous to what we used to do many years ago on film. “As residents reviewing cases with our attendings, we would mark the pathology using a red or black wax pencil,” says Siegel. “So, for example, if there was a nodule, we’d circle it. If there was a pneumothorax, we’d mark the air/lung interface, and if there was a pneumonia, we’d annotate it with markings that indicated an alveolar process so that when we went back to dictate a batch of cases afterwards, we would be able to recall all of the findings that we had gone over with the attending.” Referring clinicians also learned to recognize these markings when they reviewed the films on the film alternator. Siegel believes that a system using an electronic stylus to mark images and generate reports could potentially increase a report’s utility and value. “A referring physician could either read an automatically generated report from the marked-up images or just look at the image and see the overlay information on top of it,” he says. “Based on some studies that we’ve done, it looks as though that could significantly decrease the time required for reporting. So that’s one of many different, out-of-the-box ways with which we can change what currently is a limited image interpretation paradigm that continues to be limited by its historic analog roots.” Virtual Conferencing Allowing a case conference to take place virtually offers convenience and potential time savings for everyone involved, yet only a limited number of facilities are currently doing it. While the technology is available, privacy issues present some difficulties. “One of the biggest issues you’re going to have is HIPAA,” Wendt notes. “Let’s say you’re a small hospital, and you want someone from M.D. Anderson [Cancer Center] or Mayo [Clinic] to consult,” says Wendt. “The patient would have to know that you’re going to release their records to Mayo. And who at Mayo are you going to release them to? You can’t just give a doctor at Mayo a call and say, ‘Here, I’m going to send you a CT scan. Look it over,’ without explaining it to the patient and getting their consent to do that.” HIPAA rules make it difficult to utilize virtual case conferences in a multihospital environment. “If a person doesn’t have the capability to log onto your Web server, they can’t get into the conference,” Wendt adds, “because if you wanted to do that, you’d have to basically put up a separate server, make sure every bit of data that went into it was anonymized, and then hand out passwords to everyone. “You have to start considering other things,” he suggests. “Maybe like a Web [exchange] or something like that, where you could have an entirely anonymized presentation and then just log into Web ex and do a PowerPoint or something.” Aside from HIPAA, Wendt believes the biggest challenge to implementing virtual case conferences is educating the presenter. “You would have to be technically adept and willing to learn because presenting a case conference virtually is much different than standing up there, even if you’re showing things electronically. If you’re standing up there and going through images electronically in a room with everyone, you can be scrolling through 5,000 or 10,000 images, and you really don’t have to care about the fact that somebody may be 1,000 miles away at the end of a T1 line and may not be able to see what you’re actually doing,” he says. “So, I think, it’s just the fact that it’s a different paradigm, and you’d have to change the way you present conferences.” Despite privacy and technical issues, virtual case conferences may be an important way for radiologists to connect with their colleagues. What’s more important, though, is a willingness for radiology departments to reconsider how they connect to patient care. A Robust EMR Chang believes medicine needs a more interactive approach to patient care, and he sees a useful example of how this may work when he looks at the younger generation of computer users. “The only time they’re using a browser is because they have to do homework and get information. They don’t use the browser,” he says. “What are the applications kids use? They’re using IM [instant messaging], Skype, YouTube, MySpace. Now, these applications are completely different. They’re not using the Internet to passively consume information. They’re using the Internet to foster virtual collaboration. That’s the difference.” Even with computerized physician order entry, Chang sees a need to build on the foundation of the EMR to truly add value across the healthcare enterprise. “I think the modern-day EMR, yes, you still need order entry, yes, you still need results review, not as the end itself, but as the starting point,” he says. “That’s how we start to share the context of the patient. But now, let’s have the proper communication tools, both synchronous and asynchronous, to carry on virtual, collaborative, asynchronous dialogue. “Get me, virtually, out of the reading room because that’s the reason why we’re being outsourced. That’s the reason why we’re viewed as a commodity. It shouldn’t be just, ‘Oh, they create reports, and we read them,’” he adds. “It was better in the old days, before PACS, when docs came to me and asked me, ‘What do you think, Paul?’ and I could demonstrate my value.” With the right tools, radiologists may be able to demonstrate their value in new ways. “Well, that’s what we have the opportunity to go back to by using Web 2.0 technology to foster collaboration,” says Chang. “So that now they’ll say, ‘You know what? I was so stupid. I always thought those radiologists were lousy people, and we were going to outsource to India. No. These people really help. They’re everywhere helping me.’ You see what I’m getting at? Virtual collaboration.” — David Yeager is assistant editor of Radiology Today.
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