Q & A with Rasu Shrestha, MD: The “P” in PACS is for patient

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 - Resu Shrestha, MD
Rasu Shrestha, MD

As radiology struggles to find its footing in an emerging healthcare delivery paradigm that emphasizes collaboration and accountability, radiologist Rasu Shrestha, MD, finds himself at the center of the fray at the University of Pittsburgh Medical Center, Penn., where he was recently named chief innovation officer and president, Technology Development Center.

The new titles represent an evolutionary step from his previous role as that institution’s vice president of medical information technology. “My newer role is in trying to leverage innovation to take healthcare to the next level,” he told ImagingBiz. During a recent interview, Shrestha shared his vision for the next iteration of PACS, one that puts patients front and center.

How do you envision PACS data being used to improve patient care?

Shrestha: In the area of PACS, when we talk about where we’ve been and where we need to go towards in the industry, we are moving away from volume to value, and that’s fine, but what does value mean? It’s time to stop talking about it and start finding solutions that allow us to have value-based imaging solutions in place. The specifics around value are very broad, and they can very quickly go very deep, as well. There’s no doubt that there is a definite shift from a volume-based practice of imaging to one that emphasizes value across the care continuum.

We’ve had tremendous innovation in the last 10, 20 years in imaging. More than any other specialty, we’ve lead by innovating: We were the first to embrace the digital form factor. DICOM has been around since 1983.

We’ve had a number of waves of innovation in imaging informatics, the first big wave being the move from film to digital. We first said, “Our need is to get rid of film.” If you were printing film or storing film, there was a very easy ROI on PACS. Then, for five or more years, we spent a lot of time building targeted interfaces and trying to integrate solutions. There’s been a lot of activity around vendor-neutral archives and add-on modules, but it’s still volume-based imaging.

In the first wave, there was a robust business case, we garnered tremendous efficiencies, but in many ways what we did was replicate our analog workflow. PACS, as we know it today, is still very much film-centric. It is still image-centric: We are still treating a series of images at a time and not the patient. That’s my big gripe with where we are now.

Overcoming barriers

What are the key barriers to patient-centric PACS, and how can they be overcome?

Shrestha: Information is still very silo-ed. All that we have through a measly HL-7 interface is basic information such as “reason for exam: cough, or rule out pneumonia.” In this day and age of cloud computing, Facebook and zero downtimes—that just should not be the case.

There is now a lot of information around the context of these patients. The challenge is that it’s buried in other silos. The opportunity at hand is to look at where we’ve been and say, “Look, can we not evolve this image-centric workflow and paradigm and really focus on a patient-centered approach to care?” How can we break down the barriers to this imaging continuum?

How can we bring a fuller patient context to what we are looking at, so it’s not just “reason for exam: headache,” it’s “this patient has a family history of migraine, this patient actually had three or four relevant studies in the past and, oh, by the way, he had a history of a glioblastoma.” We are able to find all of this because we have systems that are talking to each other and also, as a radiologist, I have a fuller awareness of what is going on with my patient.

The other aspect of what we need in PACS going forward is communication. One side effect, and I call it an adverse effect, of PACS, is we stopped talking. Previously we had this rich conversation between a surgeon and myself. He came down with a stack of films and we’d talk about Mrs. Smith who had a family history of “x” and presented with this, and she had this funny gait walking into the clinic and here is what I think and what do you think? Today it’s an HL-7 message that comes across. Mrs Smith is essentially whittled down to a CT head and neck that appears in my worklist with hardly any information around her condition and relevant history.

It needs to be a lot more in terms of leveraging the specifics of the care collaboration between the ordering physician and the radiologist and the technologist and others involved in the care of that

Cheryl Proval is vice president, publishing, ImagingBiz, and the editor of Radiology Business Journal.