Making the case for integrating radiology into electronic health records

radiology ordering cycleThis chart shows the impact of including radiology in the HITECH meaningful use requirements. By Palani Perumal, SDM ’11
July 10, 2012

Editor’s note: Palani Perumal is a Senior Program Manager at Microsoft. Most recently he has been involved in the development Microsoft’s Bing search engine for which he led the integration of Yahoo! Search into the Bing platform. Perumal recently earned an MS in Engineering and Management from MIT’s System Design and Management Program (SDM). His thesis research, which he conducted at Beth Israel Deaconess Medical Center in Boston, assesses the impact of integrating radiology into electronic health records (EHRs).

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, healthcare providers receive Medicare and Medicaid incentive payments for the "meaningful use" of certified electronic health record technologies. Meaningful use means that EHRs have to be more than simply digitized copies of paper records and should be used effectively to improve quality of care, efficiency, and safety. The systems have to allow ready exchange of information, support computerized order entry, and work with decision support systems. The Stage 1 meaningful use regulations do not explicitly include radiologists or medical imaging information. This has left radiologists in the dark about what the meaningful use regulations offer and require.

My thesis describes radiology as a system and applies the meaningful use requirements, along with qualitative research, to answer the question of whether radiologists should be considered part of the care team. I used system dynamics modeling to analyze the technology, business, and policy forces that shape the radiology field, including the increasing use and cost of medical imaging. I then updated the model to depict how including radiology in the meaningful use requirements would impact the field and healthcare on the whole.

Figure 1. This chart shows the radiology ordering cycle. The green arrow is the missing feedback loop. The radiology system is less efficient without communication between physician and radiologist.

Today communication between radiologists and physicians is at its lowest level and continues to diminish. This shortcoming hinders the ability of healthcare providers to improve care quality, avoid errors, and minimize redundant use of imaging. A key missing capability is seamlessly sharing images among healthcare providers and across different information systems. Fortunately, the problems plaguing the system can be addressed with the proper incentives.

The Radiology System

The radiology system is composed of radiologists, image capturing devices, Radiology Information Systems (RIS), Picture Archiving and Communication Systems (PACS), Digital Imaging and Communications in Medicine (DICOM) standards, and billing systems. The radiology system interfaces several other systems, notably ordering physicians, Hospital Information Systems (HIS), and payers.

Spending in the US for diagnostic imaging has been steadily increasing and is growing at twice the rate of total healthcare costs. Imaging-related expenditures are the fastest growing of all types of services in Medicare claims according to MedPAC’s June 2011 report. Advances in imaging technologies such as PET and MRI have greatly increased capital investments which has in turn increased the average cost per imaging study.

Though radiology is central to medical diagnostics and imaging is a major component of healthcare costs, there’s widespread confusion about whether to and how to apply the meaningful use requirements to radiologists. In interviews with radiologists and a review of the literature, I’ve found that radiologists are generally unclear about whether they’re included or excluded in the requirements and whether they’ll be subject to payment cuts.

These issues come at a time when there are number of issues facing radiology:

  • Lack of communication between physicians and radiologists
  • Lack of awareness of American College of Radiology (ACR) guidelines among ordering physicians
  • Absence of Clinical Decision Support systems
  • IT issues (data standards, interoperability)
  • Higher costs from the fee-for-service reimbursement model

There is a distinct lack of communication between physicians and radiologists. Technological advances and limited interaction with patients has allowed radiologists to work remotely, which contributes to this disconnect. From a systems perspective, radiology departments tend to be function oriented rather than systems oriented. The radiology system doesn’t interact seamlessly with other systems and workflow is less efficient, particularly between standalone imaging centers and providers. Without a fixed feedback loop between ordering physicians and radiologists (since such communications are completely voluntary today), there’s no formal way for radiologists to learn how the results of reports they’ve provided contributed to patient treatment. Without feedback, it’s difficult for radiologists to learn from experience. As for physicians, the lack of communication. severely limits their awareness of clinical guidelines such as the American College of Radiology Appropriateness Criteria, which can help them order the right study at the right time.

Compounding the issue of ordering the appropriate study at the appropriate time is the absence of Clinical Decision Support systems. Together, these issues sometimes result in poor-quality order requests — requests that contain little or no information about patient condition or the context of the request. This requires radiologists in some cases to request information from referring physicians, which affects productivity.

Lastly, there are longstanding standards and interoperability issues. DICOM is a complex and broad set of standards, and systems that conform to the standard are not necessarily compatible. There are also an excessive number of interface issues for connecting PACS, RIS, and EHR systems.

As a result of these issues, radiology is at risk of becoming commoditized, and the lack of incentives for stakeholders to work together has exacerbated the situation.

Integration of Radiology into Core Care and Meaningful Use Requirements

Radiologists already contribute to core care delivery by enabling physicians’ diagnoses and contributing to patients’ lifetime electronic health records. My findings show that acknowledging and fostering radiology’s role in core care has important benefits:

  • Increased care coordination between radiologists and physicians provides an opportunity for physicians to leverage the value of radiologists in ordering the right study at the right time, thereby contributing to cost effective imaging and quality care. Radiologists can continually learn from the impact their diagnostic findings have on physicians’ treatment decisions and whether they’ve helped the patient receive the right care.
  • Radiologists can review and discuss patient medical history beforehand or on demand, improving diagnoses and recommendation quality.
  • Physicians can increase their awareness of clinical guidelines and best practices for using imaging services.

Figure 2. This chart shows the impact of including radiology in the HITECH meaningful use requirements. The pink text describes the changes the meaningful use requirements would have introduced in the radiology system. The green text describes the resulting changes in the image ordering process.

An analysis of the likely impacts of including radiologists in the meaningful use requirements indicates the following benefits:

  • More meaningful use of imaging data by referring physicians.
  • Better diagnosis quality as meaningful use of patient medical history and older radiology studies improve.
  • Seamless image sharing, cumulative dose information tracking, and contribution to patient health records and population data.
  • Better physician ordering behavior as awareness of clinical guidelines and on-demand access to data improve.

Including radiology in the meaningful use requirements would give healthcare providers and Information Technology (IT) vendors an incentive to address standards and interoperability issues. Simpler interface requirements between systems and more consistent records and procedures should reduce the cost of integrating systems. Improved standards and interoperability should eventually increase access to older imaging studies and medical histories, which is likely to decrease physicians’ willingness to order imaging studies.

I argue that radiology should be included in the meaningful use requirements in order to achieve the legislation’s overall objective of improving healthcare quality and safety while reducing cost. Radiologists should be included in the meaningful use requirements as part of the care team to allow for the addition of standardized imaging data to EHRs and use of Clinical Decision Support systems in the radiology ordering workflow.

Overall, failing to bridge the gap between radiologists and physicians could further alienate radiologists from core care teams, ultimately resulting in losses for all involved, from payers to patients. Provider organizations should bridge the gap by establishing internal processes that encourage and incentivize coordinated care.

Accountable Care Organizations (ACOs) are one possible mechanism for integrating radiology into core care teams. ACOs are teams of healthcare providers that coordinate care for a patient across different facilities. The government gives ACOs a share of the savings that result from the coordinated care.

As ACOs take hold in the health care system, it’s imperative that radiologists be seen as value-contributing members of the care team and not commodity as service providers outside the team. Radiologists should carefully analyze the impact of ACOs on their business model, weigh risks and benefits, and take advantage the opportunity to overcome issues of commoditization and care coordination.

In general, healthcare consists of disparate systems that are not well coordinated. System dynamics can be used, however, to analyze system behavior in the healthcare industry to identify and eliminate inefficiencies.