Adjusting Focus: Patient-centered Radiology
Having cold water dashed in one’s face can result in spluttering, but it can be welcome when an effective wake-up call is needed. Both reactions to a 2010 article¹ abstract on patient-centered radiology might be expected; the authors deliver a sometimes-harsh assessment of radiology’s shortcomings, but they also offer concrete suggestions that could help protect the specialty from commoditization, reduced reimbursement, and an uncertain future. Stephen J. Swensen, MD, MMM, and C. Daniel Johnson, MD, MMM, are Mayo Clinic radiologists and professors of radiology based in Rochester, Minnesota, and Scottsdale, Arizona, respectively. Their premise is that radiology is a target that cannot survive the forces converging on it unless it can become patient centered. Radiology must respond to patients’ wishes in everything that it delivers, and it must amass the data needed to prove that it does exactly that. Radiology must grant the five primary wishes of patients: for enough information to make decisions, for the correct exams to be ordered, for those exams to be performed safely, for sound interpretations to be communicated effectively, and for the prices charged to be fair, according to Swensen and Johnson. All of these wishes rely on a shift in values in radiology in which the needs of the patient supersede those of the radiologist (as well as those of the facility and the payor). Other kinds of change, no matter how effective they are in their spheres of influence, will not have the power to improve results. “All of our equipment and processes of care could be stellar, and we could still produce terrible results . . . values drive behaviors, and behaviors drive the results,” the authors write. Information and Appropriateness Swensen and Johnson cite mammography as an area where the patient’s need for information is most obvious. Despite its lifesaving importance overall, the sensitivity of mammography in breast-cancer detection varies hugely, so women considering screening need to know whether their radiologists interpret mammograms well or poorly. Describing radiology as far from transparent, Swensen and Johnson call on radiologists to share their performance data with the public. Even if this step doesn’t affect patients’ choices strongly, it will certainly change radiologists’ performance, they add. Sometimes, they continue, the best choice for the patient seeking not only the right radiologist but the right exam will be no exam at all. They write, “Our profession typically views overutilization as someone else’s problem. Sure, there are issues with cardiologists self-referring to their own imaging equipment, some cases of orthopedic surgeons with their own MRI units, and family physicians with chest x-ray machines in their back offices.” Nonetheless, the authors report, roughly 90% of commercial imaging spending goes to radiologists², and this makes appropriate utilization their responsibility. Undeniably, overuse of imaging can often be traced to patients’ demands and to referring physicians’ fear of malpractice suits (and lack of knowledge about the best imaging choices). Radiologists, however, must help physicians and patients make the correct choices, and should be able and willing to stop them when they don’t. If radiologists can’t take that step, the authors add, utilization managers will, particularly since they are already seen as effective in reducing inappropriate imaging. “Self-referral and overutilization are our professional space. Utilization management arose because we had not done our job,” Swensen and Johnson write. “Most estimates show that approximately 30% of examinations do not meet standard appropriateness criteria.” For patients, overutilization creates more than additional expense and anxiety. Often, it leads to medical and surgical interventions that are of little to no benefit (or are harmful). For example, the authors note, back-pain patients in one study³ were 2.5 times more likely to have back surgery if they underwent MRI exams instead of radiography, but their outcomes (measured as general health, pain, and disability) were no better. Swensen and Johnson write, “As a profession, we may cause more harm from overutilization than from any other action. We need to step up to it. A rational approach involves IT.” Computerized order entry using appropriateness standards is one example, but clinical prediction rules, developed by multispecialty teams, can also be applied. Overutilization is not the only form of inappropriate imaging use; underutilization should also be addressed. Low reimbursement levels are reducing utilization of breast-cancer screening, the authors say, and this is because some radiologists did not exhibit a patient-centered reaction to the DRA. Instead, they reduced the number of procedures that they perform in categories where Medicare reimbursement dropped most. This raises three questions for the specialty, Swensen and Johnson write: “Does limiting access or reducing volume because we are not paid what we want constitute patient-centered radiology? Would any patient sitting on a management committee for a radiology department or practice agree that radiologists are underpaid? Why is it that some practices have same-day or next-day access for lucrative MRI scans and yet a patient has to wait months for breast-cancer screening?” Safety There are multiple safety problems in radiology, according to Swensen and Johnson. Death is the result of 68% of radiology’s sentinel events, of which wrong-site procedures, procedure complications, medication errors, and treatment delays are the most common.&sup4; Error rates are highest for hospital radiology practices, and patients are harmed by medication errors in radiology departments eight times more often than they are harmed by medication errors in other hospital departments.&sup5; The authors recommend urgent attention to error-inducing factors that include interruption, noise, inadequate movement, low exposure to sunlight, and (especially among residents) lack of sleep. Nearly half of residents make serious errors during training, the authors note, adding that for a resident who has been awake for 24 hours, “The effective performance is that of someone who is legally drunk.” All radiologists and technologists should exhibit competence, through simulation, before they are permitted to perform a given procedure for patients. To reduce radiation exposure, radiologists should ensure that the exam is necessary, that the dose is as low as reasonably achievable, and that MRI and ultrasound exams have been considered as alternatives. Interpretation and Communication “The correct interpretation of results is our core business,” Swensen and Johnson write, adding that radiologists are obligated to measure their accuracy—and to give patients immediate access to their own exam reports, in addition to giving the public access to performance measurements. The authors stress the superiority of subspecialty interpretation and the need for subspecialty training for technologists and nurses. Adding that radiology must move more rapidly toward subspecialty interpretation, they write, “Our patients do not care if their results are interpreted locally or 10,000 miles away. Their wish is for the correct analysis, comparison, report, and recommendation.” Swensen and Johnson state that structured reporting improves communication and is preferred by referring physicians. It should be accompanied by failproof notification systems for critical results, critical tests, and semiurgent findings, as well as by the application of consistent, effective communication policies. Pricing and Value “The beauty of addressing cost is that there does not have to be a trade-off between quality and productivity. In fact, if approached from a systems engineering standpoint, they work hand in hand,” the authors write. Systems engineering can get rid of defects, waste, and variation while increasing quality (along with efficiency and productivity), they note. Because radiology is tied to every facility’s other departments, it affects their success, and it must cooperate (not compete) with them to decrease costs—for example, by reducing complication rates and lengths of stay. Partnership with other departments, administrators, and referrers leads to lower pricing for patients by promoting quality and aligning incentives. If radiology cannot prove its value, the authors predict, it will become a commodity. The market forces pushing it in that direction can be countered, however, with hard data to prove radiology’s worth. Swensen and Johnson state that if radiology can’t prove its value, it deserves to be commoditized and outsourced. They add, though, that “if we believe that our service is of high value and then go on to support it with objective, meaningful, patient-centered outcomes, safety, service, and cost data, then we not only deserve to thrive, but we will preserve our strong market position as imaging professionals. The cornerstone of proof is measurement.” Focusing on the patient, the authors write, must guide radiology. Thinking of patients first, they report, changes not only operations and planning, but interpretation. When radiologists see photos of patients before interpreting their CT exams, for example, they report 80% more incidental findings than they report if they don’t see patients’ photos.&sup6; Swensen and Johnson conclude, “When we think about patients, the game changes. We cannot go wrong with our profession if we are guided by one question: What would we want if we were the patient?” Kris Kyes is technical editor of ImagingBiz.com.