Money, the Fairest Incentive of All

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Having the government provide incentives, or even penalties, is a proven way to force markets—not just in the United States, but globally, whether digital x-ray in France, or digital archiving in Japan. All of these legislative efforts dramatically changed the market landscape and competitive playing field. Even as far back as the emergence of the first PACS, the incentive to adopt this technology was based on a business imperative. Money makes the world go round, as some might say. So as a business, the incentive is obvious. Make money. Of course to do so, you must deliver on and keep the promise of differentiated value to your customers, have a mission, etc, etc, etc, but along the way, you better watch your pennies. Enter business intelligence (BI), a tool used—or should be—to regularly track indicators about business performance, including simulators that can make determinations about what the future revenue and profit picture might look like, or where to make critical adjustments in staffing, resources, or sales efforts. Helping to guide choices, BI is a kind of decision support tool. Fear of penalty, not just losing money, is also a powerful force in the adoption of BI. The penalty of not complying with standards such as FASB, GAAP, SOX, or international standards often forces the business to replace a legacy system with a modern enterprise resource planning (ERP) system such as SAP. SAP implementation is a complex and involved process, not unlike a large-scale EMR implementation. It ends up being a lot more complicated than the simple pieces of data you might need to make a choice. The good news is that the new ERP has a business intelligence module that once it contains all of the new data can be used to make decisions. Of course, the legacy data will be retained and encapsulated, but won’t get loaded into the new system. So, forget about the past, and…oh yea, the project also is now delayed. Who says big business doesn’t get health care? In the market This year’s RSNA gave the industry, both vendors and providers, tangible examples that the concepts applied in business to support certain decisions have poured into the imaging space. Tools to support decisions about the performance of a practice in terms of things like referrals, relative value units, turnaround time, quality metrics, and so forth, have emerged. In addition, so called “clinical decision support” has emerged. This form of decision support has the potential to support the “right” decision at the point of order, or treat a patient based on the medical history. This will be a ripe area for innovation into the future, but will require close collaboration with the medical community, and enough of the right data in place to pose the right questions, and determine if the answers are right. Did I mention incentive? For any of these tools to be valuable in medicine, the definition of “right” has to be considered. What makes an order or a decision right by in large depends on whether someone is willing to pay for it. Who is going to pay for clinical decision support, more importantly, what’s the right question! In the meantime, the rest of decision support processes will asymptomatically approach the right answer as we circle around the question and answer and continue to capture and index more information. Just as in big business, the data sometimes needs to be captured in a way that supports the question and may force change in the actual systems that produce the data. Regardless, the basic foundation created by meaningful use, when applied against this challenge, has promise. The real issue, is, as we look beyond meaningful use and use technology to support medical decisions, who is going to be the gatekeeper and who is going to provide the incentive to adopt? The industry, regulators, and our society are all struggling with the question. The people with the hammer to push the issue often think in four-year increments. The industry sometimes thinks in terms of quarter year milestones. Physicians just want to do the right thing. The question of which approach is right isn’t up for debate, but capturing meaningful information about outcomes can take, well, a lifetime, and in the meantime, there’s money. Robert Cooke is an imaging informatics expert and 25-year veteran of the medical imaging industry. He can be reached at