Focus the Imaging Enterprise on health, quality, and most importantly, patients. Radiologists need to help advance the Health Care Triple Aim.

1. Re-Visioning Radiology
Jonathan Breslau, MD, FACR
President, RAS
ACR, Council Steering Committee
@jonathanbreslau

3. There is a tide in the affairs of men,
Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries.
On such a full sea are we now afloat,
And we must take the current when it serves,
Or lose our ventures.
−William Shakespeare
Julius Caesar

4. What is happening at
topline health care level
that radiologists need to
know about and respond
to?

5. National Health Expenditures per Capita, 1960-2010

6. Per Capita Total Current Health Care Expenditures, 2009
http://www.oecd-ilibrary.org

7. Putting Off Care Because of Cost
Percent who say they or another family member living in their household have done each of
the following in the past 12 months because of the cost:
Relied on home remedies or over-the-counter
drugs instead of going to see a doctor
Skipped dental care or checkups
Put off or postponed getting health care
needed
Not filled a prescription for a medicine
Skipped a recommended medical test or
treatment
Cut pills in half or skipped doses of medicine
Had problems getting mental health care
‘Yes’ to any of the above
Source: Kaiser Family Foundation Health Tracking Poll (conducted August 10-15, 2011).

8. US not in top group for life expectancy
Life expectancy by
country (years)

9. Population Health
Care for Individuals
Per Capita Costs

10. Radiology will be valued
by its role in enabling
primary care to manage
population health

11. Radiology’s first attempt at achieving Triple
Aim

12. Imaging Triple Aim
1. Right test, right time
2. Right images, right interpretation
3. Patient-focused

13. Ordering the right test – 1
EHR first line
CDS
Imaging pretest review
D2D consultation

14. Ordering the right test – 2
 “Batphone”
Use old ideas
from capitation
e.g., tracking
ordering MDs

15. Radiation safety
 Dose reduction and tracking
 Protocols
 Patient dose registry
 Build department infrastructure
 Part of quality
 Work with vendors
 Educate stakeholders with enhanced role for med
physicist
 Patients
 MD consult

16. Right images, Right
interpretation – 1
 MOC and subspecialization
 we’re talking dollars here
 Quality
 Optimal reads
 Optimal clinical interaction
 Efficiency
 Leverage size of groups
Breslau J, JACR 2012; 9:535-536.
http://download.journals.elsevierhealth.com/pdfs/journals/15
46-1440/PIIS1546144012002001.pdf

17. Right images, Right
interpretation – 2
 Image exchange
RSNA Image Share Network Reaches First Patients
September 01, 2011
Designed to help patients take control of their medical
images and reports, the RSNA Image Share network
has entered into clinical practice as patients across
the country begin to use the system as part of their
routine care.
http://rsna.org/NewsDetail.aspx?id=2409

18. Right images, Right
interpretation – 3
 Actionable reporting




Critical results
Follow-up
Manage incidental
Manage surveillance of known disease
 Another health system buzzword: variation reduction –
imaging report can help

19. Examples of variation
reduction
 Incidentalomas




Standard description
Standard recommendations for biopsy and surveillance
Radiologists do not need to memorize
Populate reports using macros from literature, such as
Fleischner Society, JACR papers, etc.
 Known disease
 Cancer surveillance protocols – automate scheduling of
F/U exams

20. ACR member response to
incidental findings
 JACR 2014; 11:30-35
 Survey on incidental abdominal CT findings
 89% respondents used the content in clinical practice
 51% recommended follow-up imaging less often

21. Clinical decision support tool
in lung nodules
 MGH – point of care for radiologists
 Guidelines based on Fleischner Society
 Analyzed only incidental nodules picked up on
abdominal CT
 Concordance 50% pre
 Went up to 96% post

22.  Communication – Health Affairs, 2013; 32:1368-1375.
Analysis of RCAs in VA system involving delays in
treatment and diagnosis in outpatient setting. Process
breakdowns frequently involved tracking of diagnostic
information and performance and interpretation of
diagnostic tests: inadequate followup, delayed
scheduling, inadequate tracking system for results and
followup. Also miscommunication of urgency between
providers.
 EHRs “need to better support “shared” thinking
processes for timely and safe patient care across a
team.”

23. Patient Focused
 “Patient Centered” can be a useless term
 Excuse for not doing anything
 The point is to make the system work for
the patient – reduce the time spent in the
health care system

24. Patient-centric Imaging Awards
 Cincinnati Childrens’ – instituted “difficult news”
process – radiologists meet with families
 UCSF/Univ of Maryland – Image Share – about 350
new patients per month sign up
 Radiology Ltd. In Tucson
 Comprehensive prescreening and exam review at time of
scheduling
 Exam protocol in advance and entered into report shell
 Patient portal – includes preregistration
http://www.healthimaging.com/topics/practice-management/2013-patient-centricimaging-awards

25. "Sixty-five percent of ... patients signed into their system
to look at their images," [David] Mendelson, MD told
FierceMedicalImaging. "What this says to me is that we
have grossly underestimated the interest patients have in
their own care.”

26. Connected patient tools
 Scheduling – like airline seat
selection
 Exam details – prep, location
 Images and reports – systemlevel
 Interact with radiologist – chat
client within EHR?

27. Price Transparency
More patients paying more
out of pocket
Wide variation
Huge opportunity
https://healthcarebluebook.com/page_Default.aspx
Uwe Reinhardt http://jama.jamanetwork.com/article.aspx?articleID=1769895

28. Zip code 92093
 Healthcarebluebook.com
 Abdomen And Pelvis CT (No
Contrast)
 Total Fair Price:$793
 Includes printable pricing agreement
to take with you

29. Healthcare Provider / Facility (hereinafter “Provider”): ____________________________
Patient (hereinafter “Patient”): _______________________________________
Service/Product: Abdomen and Pelvis CT (no contrast)
According to the Healthcare Blue Book, the Fair Price for consumers who pay healthcare providers with cash at
the time of service or product delivery is ____$793______. Price includes the total amount for both physician
(interpretation) and technical (imaging) fees. Sometimes the test will be billed in two parts but they should add
up to the listed price.
The Provider agrees to provide Abdomen and Pelvis CT (no contrast) to the Patient for a total price of (please
complete and check agreed upon price):
$793 or
_________, subject to the terms below:
1. Price includes the total amount for both physician (interpretation) and technical (imaging) fees.
Sometimes the test will be billed in two parts but they should add up to the listed price.
2. If the actual service or product required to treat the patient is different from that listed above, then Provider
will make a reasonable effort to inform Patient what the new service or product is and what the price will be
before treatment.
3. Other terms or conditions: __________________________________________
__________________________________________________________________
__________________________________________________________________
Includes signature page
Patient agrees to pay Provider in full at the time of service or in the manner that is agreed to in advance and

30. What do health system executives
want?
• Reproducible
• Predictable
• High outcome per dollar of
health care cost

31. Can Imaging influence key
performance measures?
1.
2.
3.
4.
LOS?
ED throughput?
Patient satisfaction?
…others

32. How
 Own all aspects of imaging
 Better care
 No extra imaging
 Evidence-based
 Empower patients
 IT
 Take some (data-based) risk

33. At all points
 Look for D2D opportunities
 D2P opportunities

34. We’re
here

36. Could vRVU be the answer?
 Adding Value to Relative-Value Units
 Eric C. Stecker, M.D., M.P.H., and Steven A.
Schroeder, M.D.
 N Engl J Med 2013; 369:2176-2179
 Current RVU-based – proven, potent, and efficient MD
motivators
 Could assign evidence-based values proportional to
influence on patient outcomes and clinical efficiency

37. Example of Cardiology
 20 vRVUs for certain population management
activities, per 50 pts
 Double value of office visits
 Stent value doubles if DTB <60 min
 Decrease value of stent procedure as less appropriate
 N Engl J Med 2013; 369:2176-2179

38. Challenges for imaging
enterprise with vRVUs
 Don’t order tests that are unlikely to add info
 Radiologists evolved as passive participant in care
team
 Would be a positive change in radiologists’ role to be
on the hook for inappropriate overimaging
 What’s holding us back?

39. Trying to chase the
money in new system
Need to chase the
patients and meet the
system’s goals

40. November 12, 2009
Sutter zaps pact with radiologists
November 19, 2013
Sutter Health acquires RAS, region's largest
radiological group

41. March to the beat…

42. Don’t get distracted by imperfect
messaging!

43. www.coveredca.com

44. Hot Chocolate Boy

45. “If you don’t like change,
you’ll like irrelevance even less”
Eric Shinseki