GILES W. BOLAND, MD IMAGING VALUE CHAIN RICHARD DUSZAK JR, MD Delivery of Appropriateness, Quality, Safety, Efficiency and Patient Satisfaction Giles W. Boland, MD, Richard Duszak Jr, MD, Geraldine McGinty, MD, MBA, Bibb Allen Jr, MD

Although radiology’s dramatic era. This spawned the development medical imaging. It offers the major evolution over the last century has of subspecialty radiology and benefits of these 2 eras, but pri- profoundly affected patient care for further raised the overall profile of marily focuses on the advancement the better, the current system is too the profession; radiologists are now of 2 key concepts: information fragmented and many providers critical to the investigation of most integration and patient centricity. focus more on technology and diseases. Yet the digital nature of Put together, these place patients at physician needs rather than what Imaging 2.0 has led to unintended the center of the imaging work really matters to patients: better consequences. Clinical interactivity process, which will be transformed value and outcomes. This latter with both referring physicians and into one dedicated to delivering dynamic is aligned with current patients has diminished dramati- enhanced patient value. national health care reform initia- cally, and the delivery of imaging This article represents the first in tives and creates both challenges services has become increasingly a series of 7 designed to guide ra- and opportunities for radiologists to fragmented, primarily through tel- diologists through the important find ways to deliver new value for eradiology, such that some are now and necessary Imaging 3.0 trans- patients. The ACR has responded even questioning the value and formation process. Herein, we to this challenge with the intro- future role of radiologists. As a discuss the general concept of the duction of Imaging 3.0TM, which response, the ACR has introduced imaging value chain and outline represents a call to action to all ra- the Imaging 3.0 initiative [1,2]. the scope of the tasks at hand. diologists to assume leadership roles Imaging 3.0 is a call to action to in shaping America’s future health all radiologists to assume a leader- VALUE IS OUR FUTURE care system through 5 key pillars: ship role in shaping America’s For radiologists, future success will imaging appropriateness, quality, future health care system [1,2]. require a change in mindset to safety, efficiency, and satisfaction. The campaign’s goal is for radiol- embrace the full scope of the That enhanced value will require ogists to move beyond being sim- Imaging 3.0 vision. This can be modulation of imaging work pro- ply image interpreters to become crystallized into a single and simple cesses best understood through the integrated leaders in the new and question: How can we deliver more concept of the imaging value chain, evolving health care environment. value to patients? Getting there will which is introduced in this first of a Imaging 3.0’s thrust is for radiol- require a fundamental rethink of 7-part series. Further articles will ogists to deliver enhanced value the radiologists’ work product. then prescribe in detail the pathway to patients through 5 key pillars: Indeed, few health care organiza- forward at each link in the value imaging appropriateness, quality, tions in the United States have chain to effect the work process safety, efficiency, and satisfaction substantially changed their culture changes necessary for radiologists to [1,2]. For this effort to succeed, to adapt to the changes afoot in deliver better value and outcomes radiologists must be primary health care. Some are beginning to for patients. drivers (rather than followers) of explore ways to deliver better value the change processes necessary to to patients, but most are perplexed THE IMAGING 3.0 CALL TO achieve the vision of Imaging 3.0. as how best to proceed. Many of ACTION Culturally and professionally the answers lie in adopting and Under Imaging 1.0, the era of indoctrinated into focusing on following best practices. But health analog imaging, radiologists steadily procedural volume, radiologists will care as an industry has a problem of gained increasing importance in the need instead to prioritize value execution. Even though a number role of the delivery of health care. (the so-called volume to value dy- of best practice guidelines have This role has been dramatically namic), a measure unfamiliar to been developed and despite abun- amplified over the last generation most radiologists [3-5].Imaging dant data, the workflows and with the ongoing development and 3.0 is not so much a repudiation of practices of many, if not most, deployment of the digital imaging Imaging 1.0 and 2.0, but rather health care organizations vary sub- revolution during the Imaging 2.0 the next step in the evolution of stantially. Profound variation is

ª 2014 American College of Radiology 7 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.07.016 8 Imaging Value Chain inherent to medical practice, and the “value-chain” concept has chain [3,4]. The term has even imaging is no exception [6-11].It pervaded the business landscape started to percolate into the radi- is almost certain that no 2 imaging for nearly 30 years and is ology parlance [5]. Ironically, departments in the nation use the now embedded into many success- much of the macro thinking same imaging appropriateness ful business workflow practices behind health care reform has also criteria, modality protocols, and [12,13]. It is through optimization come from Michael Porter, who workflows; the same interpretation of the value-chain work processes has argued for years that health care tools, recommendation guidelines, that businesses deliver enhanced must shift away from its current reporting, and communication customer value. As it happens, this system, which focuses on value to criteria. Standardization and the is also the ultimate goal of Imaging providers, to a dramatically new adoption of evidence-based care in 3.0. This series of articles will, one, which prioritizes value to their medical practice fundamentally therefore, use the concept of the customers (ie, their patients) [3-6]. competes with the cultural axiom imaging value chain to outline key Porter argues that providers—both that a physician always “knows imaging work processes necessary hospitals and physicians—have had what’s best” for his or her patients for delivering a radiology de- goals that conflict to the one of and this will be one of the biggest partment’s ultimate value: timely delivering better value to patients obstacles of creating and imple- and actionable information. This [4]. Although providers may desire menting a robust blueprint for first article introduces steps and the best treatments and outcomes Imaging 3.0. general concepts of the imaging for their patients, they frequently Fortunately, although practice value chain and outlines the scope define success based on revenue- variation abounds, solutions are of the task at hand. Separate subse- generating activities (usually the not as daunting as they might first quent articles will evaluate each link number of procedures performed). appear. The radiology work process in the chain in detail and will pro- Given these misaligned incentives, is inherently digital, which offers vide solutions for workflow optimi- it is not surprising that the costs of radiologists unique opportunities zation that in aggregate deliver this US health care are about twice to leverage information technology enhanced value. that of many other industrialized (IT) to meet the expectations of nations [14]. Imaging 3.0. Yet, only few de- The Chain from Volume to The new health care dynamic, partments nationwide, if any, have Value embodied in the controversial fully leveraged IT, as well as their In his book, “Competitive Advan- Affordable Care Act, attempts to workforce and work processes, to tage: Creating and Sustaining gear the delivery of health care comprehensively address the full Superior Performance,” Michael away from a volume-based para- range and scope of Imaging 3.0. Porter introduced the concept of the digm to one that is value-based— Furthermore, Imaging 3.0 is de- value chain as a “systematic way of one where value is defined by the signed to be a dynamic process. As examining all the activities a firm patient rather than the provider practices and technology evolve, performs and how they interact [3-4,15-16,17]. CMS plans to perpetual modifications will be (which) is necessary for analyzing implement 65 measures in 5 do- necessary to deliver ever better value the sources of competitive advan- mains as the basis for future pay- to patients. The question is, how do tage” [12]. Each link of that chain ments [18-19]. Most will address we get there? How do radiologists represents a discrete number of quality, patient safety, and experi- change their work processes to unique value opportunity activities, ence—all key pillars of Imaging deliver better value to patients? such as design, production, mar- 3.0—and so, notwithstanding the The answers to these questions keting, delivery, and support. Their patient care impact of these goals, can be found by turning to the aggregate is what a customer pur- radiologists will increasingly be business community. The knowl- chases and experiences. Put another incentivized to pursue Imaging 3.0 edge, tactics, and tools needed to way, “value activities are the discrete initiatives. Future compensation will answer the value question have been building blocks of competitive take the form of global or capitated well known to the business com- advantage” [12-13]. payments based on the populations munity for decades. Successful Given the current health care served by a provider or those tightly businesses live and die by their focus on delivering better value to linked to an “episode” of care that ability to deliver ever better value to patients (simplistically defined as encompasses a standard complete their customers. Although there are outcomes divided by cost) health care continuum (often from pre- numerous methodologies that busi- care organizations are increasingly sentation to recovery) [3-4,20-21]. nesses employ to stay competitive, turning to the concept of the value Accordingly, future payments will Imaging Value Chain 9

issues for their patients and the need to avoid unnecessary dupli- cate testing. This represents the first pillar of Imaging 3.0 and the first link in the imaging value chain (Fig. 1). Unfortunately, most or- ganizations do not have consistent and reproducible work processes that ensure imaging appropriate- ness. Accordingly, marked varia- tion in practice, therefore, exists across the nation, undermining radiologists’ and departments’ ability to deliver maximal patient value [7-11]. Ultimately, it will be through the use electronic decis- ion support tools with embedded information regarding radiation safety, combined with peer-to-peer consultations with radiologists, that referring physicians will be able to request the appropriate imaging test at the point of care for the right patient at the right time, in a timely and seamless manner [22]. Such referring physician imaging Fig. 1. Schematic representation of the imaging value chain. appropriateness and scheduling value activities will be detailed in be aligned with results, rather than design, these are in tandem with part 2 of this series. with volumes, shifting the focus the goals of Imaging 3.0. from outputs to outcomes [3-4]. The steps below represent Imaging protocols. After the Whether new payment models will discrete integrated components of appropriate imaging modality has truly result in better patient out- the imaging value chain. These are been selected, the radiologist must comes remains uncertain, but the briefly introduced and outlined determine the optimal imaging metaphorical “train has left the below in this first of a 7-part series, protocol for that particular patient station.” No longer can physicians which lays the foundation for forth- given the clinical situation. Optimal assume that more procedures will coming detailed articles focusing protocol choice will vary dependent mean more money. Many ques- on each step. A schematic represen- on indication, ancillary clinical in- tions remain as to how providers tation of Imaging 3.0 outlines the formation, age, weight, previous imaging, modality access and avail- will divide limited bundled pay- backbone of the imaging value chain fi ments for given episodes of care, (Fig. 1). ability, staf ng resources, patient but physicians, including radiolo- preferences, amongst others. Once again, marked variation is present gists, will need to collaborate and Imaging appropriateness and across the nation, again limiting a coordinate their disparate activities patient scheduling. The value department’s value and patient far more closely to achieve better chain begins when a patient pre- outcomes [7-11]. Much data, outcomes for patients—and pay- sents to their physician with a however, exist on managing these ments for themselves [20].The medical complaint or for a routine variables, and part 3 in this series shift from volume to value will visit. If imaging is indicated, that will detail mechanisms to effectively therefore require all providers to physician must first be aware of implement consensus based best re-engineer their work processes. what imaging tests are available practices. To achieve success in new delivery and, perhaps more importantly, models, radiologists will need to when they are appropriate. Addi- Modality operations. Akeypa- reorganize their activities to achieve tionally, ordering physicians must tient safety, efficiency, and patient these goals. Fortuitously, and by be cognizant of radiation safety satisfaction metric (the third, 10 Imaging Value Chain fourth and fifth Imaging 3.0 pil- this series will detail the radiologist subpopulations of patients with lars) is the efficiency of the mo- reporting process and recommend similar findings that might have dality operations, particularly as it modifications to this value activity implications for diagnosis, ther- pertains to patient access and to optimize actionable reporting. apy and outcomes, one of the experience. Again, variation in key goals of delivering precision Report communication and refer- operational performance is wide- medicine [27]. ring physician interaction. An spread in the industry [23-25]. actionable report is meaningless until Many organizations operate in a it is widely and readily accessible to TAKE-HOME POINTS relatively customer unfriendly appropriate caregivers. Departments environment and many hospital- have different methodologies and Imaging 3.0 represents a call to based modality operations do not protocols for report communication action to all radiologists to as- tailor their workflows sufficiently and opportunities exist to ensure that sume leadership roles in shaping to cater for the inherent differ- ’ actionable information reaches America s future health care ences between inpatient versus appropriate referrers in a timely system. outpatient scanning. Additionally, manner consistent with the acuity of As evolving health care delivery many organizations with multiple the findings and clinical scenario. Part models increasingly change their imaging sites and modalities co- 6inthisserieswilladdressmethodsof focus from providers to patients ordinate their activities too poorly report communication and demon- and from volume to value, radi- to maximize patient access and strate how refinements to communi- ology practices that align their throughput across their network. cation algorithms can enhance the priorities accordingly will more Part 4 in this series will detail quality and safety of clinical care and, likely achieve success than those mechanisms to optimize patient therefore, the patient and referring which do not. experience and modality opera- physician experience. The imaging value chain high- tions in conjunction with ACR lights opportunities at each step accreditation standards. Data mining, business intelli- in the delivery of radiology ser- gence and future trends. The vices for radiologists to best Image interpretation and repor- routine use of relevant emerging deliver value to their patients. ting. The ultimate goal of a business intelligence tools will be radiology department is to deliver critical to the effective moni- REFERENCES timely, meaningful, and actionable toring of all components of the information [5].Evidence-based imaging value chain ranging from 1. ACR, Imaging 3.0. Available at:http:// www.acr.org/Advocacy/Economics-Health- actionable reporting requires that adherence to imaging appropri- Policy/Imaging-3. Accessed June 8, 2013. radiologists extract, either alone ateness guidelines, to modality 2. Imaging 3.0. 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Giles W. Boland, MD, is from the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Richard Duszak Jr, MD, is from Harvey L. Neiman Health Policy Institute, Reston, Virginia. Geraldine McGinty, MD, MBA, is from NRAD Medical Associates, PC, Garden City, New York. Bibb Allen Jr, MD, is from Trinity Medical Center, Birmingham, Alabama. Giles W. Boland, MD, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; e-mail: Boland. [email protected].