The Imaging Value Chain:Delivery of Appropriateness, Quality, Safety
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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.