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  • Look Ahead: Radiology’s Journey in Transparency

    Health policy expert Richard Duszak Jr, MD, offers a glimpse into the next chapter of healthcare, in which patients will expect transparency in delivery of healthcare systems. By Richard Duszak Jr., MD


    February 1, 2017

    Embedded in the virtual retina of nearly every radiologist is that first and famous image of Anna Bertha Roentgen’s hand. This enduring reminder of her husband’s discovery of the x-ray in 1895 ushered in a whole new era in medicine — that of the transparent human body. Over the ensuing century, radiology’s contributions to patient care have advanced at a dizzying pace. With medical imaging now rapidly moving toward more advanced functional and precision imaging, it is sobering to think that something as seemingly mundane as a hand radiograph started a cascade of innovation that has forever changed our healthcare delivery system.

    Seeing that first radiograph of her own hand, Wilhelm Roentgen’s wife reportedly exclaimed, “I have seen my death!” At first glance her outburst seems most peculiar, but remember the context. In the 19th century, the only time people saw human bones was when they viewed the dead — the long dead. The prospect of seeing one’s own skeleton was not only unimaginable but also downright frightening.

    Over the ensuing decades, our ability to see inside living bodies has accelerated. We now live in a world in which we can nearly instantaneously acquire anatomic information that, back in Roentgen’s time, could only be gleaned at autopsy. Bones are now easily distinguishable from soft tissue, muscles from fat, and tumors from normal organs. Today patients and providers not only take for granted the transparency of the human body, but have grown to expect it as a part of routine care.

    If one of the legacies of healthcare over the last century has been the increasing transparency of the human body, then one of its legacies in the next century will be the increasing transparency of our delivery systems. Before long, patients will grow to expect this too as part of their routine care.

    Sure, when a patient returns to the emergency department for the third time in a week with chest pain, we can easily interrogate the smallest of pulmonary arteries yet again for clot. But should we? How do we ensure that such services are utilized most judiciously? As finite healthcare resources are increasingly scrutinized, questions like this must be answered. Physicians who facilitate answers — rather than simply preserve the status quo — will lead the profession forward.

    Transparent Systems Will Increase Value for Patients

    Over the last several decades, many radiologists have focused their efforts on generating an ever increasing number of reports at an ever increasing speed. Volume was, and continues to be, the priority for many. And that’s no surprise, because it is how we have been financially incentivized. Moving forward, however, overwhelming societal forces are steering us in a very different direction, and so too are our payment systems. Like all other physicians, radiologists are increasingly charged with delivering higher quality care at a lower cost, and doing it all in a patient-centered manner. Volume is out; value is in. And delivering on that new value imperative requires a new way of thinking and a whole new kind of transparency.

    Everyone talks about value these days, but what is it? Quite simply, it’s quality divided by cost. So to increase the value of imaging we need to enhance its relevancy and impact, and reduce its overall costs — or ideally do both. As with beauty, however, value is in the eye of the beholder, and the stakeholders now doing that math are increasingly our patients. But information gradients — for both quality and cost — stand in the way of finding real value.

    Defining Quality from the Patient’s Perspective

    How can radiologists transparently deliver higher quality? First, we need to understand what quality means from the patient’s perspective and be willing to see our healthcare system through their eyes, and not just ours. Patients want more than just structured reports with quicker turnaround times. They want better outcomes — something hard for radiologists to quantify given the multitude of clinical confounders downstream from our interpretations. So we have some work cut out for us. Our patients also want better service and more engagement. Getting to the right diagnosis is important, but the journey matters, too. For example, when we deliberate the pros and cons of two diagnostic imaging modalities or the timing of a follow up study, how often do we involve our patients in those discussions? Sadly, it’s not very often. So there are lots of ways we can do better.

    With regard to the value equation’s denominator, figuring out the cost of a service sounds pretty easy, but it’s not. Cost too is in the eye of the beholder — the one paying the bill. For the rare patients who have no co-pays and no deductibles, healthcare costs are usually hidden away as premium deductions in their paychecks every couple weeks. More and more patients, however, have high deductible plans, meaning that they pay as much as $5,000 of each year’s healthcare expenses out of their own pockets. In these situations, what our facilities charge for CT and MRI really matters. Those charges vary greatly from region to region, and from institution to institution, and they’re rarely transparent. The way most people find out about the costs of a service is when they get their bill. That’s not right.

    The internet and social media have catalyzed a variety of healthcare transparency initiatives, which are now rapidly accelerating. The ultimate result will be a delivery system in which value is more readily defined and more widely promoted. But that transition could prove challenging for many radiologists. Yelp, HealthGrades and RateMDs are just a few of the multitude of digital forums available for patients to post information about their physicians. To date radiologists have been relatively invisible in these venues. When we are rated, however, our scores are usually extremely positive, but sometimes extremely negative. There is usually little in between. And the comments often seem highly subjective, reflecting the not uncommon disconnect between patients’ priorities and our own. We can lament about an unfair or flawed system, but that won’t stop this movement. Transparency means that some of us will look good, and some of us won’t. Importantly, though, it will challenge us all to become better. The huge opportunity before us is to not just embrace this movement, but help lead it and develop metrics and platforms that provide real and meaningful information to our patients so that they know who we are and what we do.

    Starting literally with just a few fingers, radiology’s early innovators moved from one organ system to the next, and from one modality to another, to make the human body transparent in a way that no one could ever have imagined. If radiologists are to be as successful in the next century as we were in the last, then our next generation of innovators will need to make our delivery system equally transparent.




    Duszak
    Richard Duszak Jr., MD, is professor and vice chair for Health Policy and Practice in the Department of Radiology and Imaging Sciences at Emory University School of Medicine, Atlanta. Dr. Duszak joined Emory after serving as founding CEO of Harvey L. Neiman Health Policy Institute, established in 2012. Nationally recognized for his work in physician payment policy development, Dr. Duszak’s research has focused primarily on health policy and practice management. He serves as associate editor for Health Services Research and Policy for the Journal of the American College of Radiology.

    Roentgen
    William Roentgen’s image of his wife Anna Bertha’s hand ushered in the age of transparency in the human body. In the next century, patients will expect transparency in healthcare delivery systems as well.




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