The Only Constant
As technology transforms the current health care model, radiologists must lead the way.
Radiology is an IT business. We process certain types of information and translate them to others (for example, data are transformed into images, which are process and summarized in reports, and so on).
The ultimate goal is to deliver information that will be useful in the care of our patients. Furthermore, the direct product of our efforts, the report, contains many types of information that, through data mining, can help assess such issues as quality, cost of care, and the health of the population. The complexity of medical care requires the expertise and input of many individuals. Thus, communication is as important as knowledge when it comes to providing good care and positive outcomes.
As the Information Age emerged, so did discussion about whether IT can improve care. A recounting of the evolution of IT as a key element in health policy is beyond the scope of this column. Suffice it to say that by the early 2000s a series of reports ended any lingering debate as to the usefulness of health IT among policy-makers and set in motion an irreversible trend of promoting the use of IT in health care. This included incentives and penalties to support policy goals aimed at safer, more effective, more efficient care. As the discussion about improving health care continues, it has become axiomatic that information and the ways it is communicated have profound effects on the access, efficiency, and outcomes of care.
The recognition of the importance and rapid development of IT and its relation to our specialty are exemplified by the almost monthly articles in the ACR Bulletin on IT-related topics. Under the aegis of the ACR Commission on Clinical Research and Information Technology, the ACR is actively engaged in many IT activities. The College's annual IT Informations Summit brings together policy-makers, industry partners, consumers, and providers to advance imaging informatics. The College is also developing an IT reference manual to help members apply technology to the management and quality of their departments and practices. We are developing a clinical decision support product, ACR Select™, whereby we will make practical use of the ACR Appropriateness Criteria®. Lastly, with the emergence of health IT as a critical component of the nation's health care reform activities, the ACR has taken an active role advocating on behalf of radiology on related topics, such as making the meaningful use program relevant to our specialty.
The New Physics
The field of health informatics is complex and evolving rapidly. It involves a new body of scientific knowledge, competencies, and lexicon. As radiology battles the forces of commoditization, outsourcing, and integration into the practices of non-radiologists, competency in and even control of informatics will be keys to preserving our central roles in patient care and extending our value to current and future models of care. IT has a role in patient care and safety as foundational as those of medical physics and radiation safety. And, like these, IT should be a core competency of radiologists, i.e., "the new physics." As with physics and radiation safety, the training of physicians supervising and interpreting medical imaging should include informatics, with meaningful, ongoing didactic courses and practical exposure, such as residency rotations. There should also be radiology IT fellowships, and IT should be a component of the ABR examinations.
The ACR and our fellow specialty organizations have a long history of active engagement in Digital Imaging and Communications in Medicine, the Integrating the Healthcare Enterprise initiative, Health Level 7 standards, and a variety of other important standards activities. It is time to develop a coordinated approach to the integration of IT into ACR's "Practice Guidelines and Technical Standards." This will institutionalize the role of IT in radiology and reaffirm the ACR's guidelines as the gold standard for practice. It will raise the bar for all providers of medical imaging, health systems, and vendors with respect to the level of service required to provide imaging in the electronic age. Some examples of the types of things that would be included are mandatory electronic availability of reports and images; guidelines as to the formats, scope, and safe sharing of information; electronic ordering of examinations, including adherence to accepted standards of appropriateness; interoperability among disparate systems and among affiliated and unaffiliated providers; and training of involved personnel.
Unintended, Counterproductive Consequences
The importance of informatics in patient care and health policy is amplified by various legislative initiatives and even some subsidies. As with many disruptive innovations, we must be on guard against unintended consequences. David J. Brailer, MD, PhD, an early proponent of digitizing records and an official in the George W. Bush administration, acknowledged that the use of electronic medical records "makes it faster and easier to be fraudulent." Two examples of inappropriate use of informatics include fraudulent applications to billing and reporting and the use of technology to restrict access to information, thereby undermining federal laws, programs, and subsidies promoting the adoption of electronic medical records (EMRs).
With respect to billing and reporting, EMR tools familiar to radiologists, such as macros and coding software, facilitate upcoding by providers and billing for services not actually performed. Overall, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments due to increases in use of higher-level codes between 2006 and 2010, the latest year for which data are available. Compare this with a 32 percent rise at hospitals that have not received any government incentives.
With respect to the restriction of broad access to information, certain provider systems and entities actively exclude independent providers from interfacing with their EMR, thereby maintaining economic benefit to themselves and their affiliates. Without functional interfaces or integration between the systems of imaging providers and referring physicians, imaging reports cannot be transmitted to referring physicians' EMRs and into patients' charts, and referring physicians cannot order examinations online, thereby eliminating many of the benefits and efficiencies of the new systems. This, in effect, creates a new form of self-referral by internalizing referrals to those using the same system, who are invariably economically affiliated entities. Thus, where the intent of the process is to build bridges among providers, some integrated systems and hospitals are constructing moats around their economic castles. (Stay tuned for an upcoming issue of the Bulletin about this type of activity.)
Radiology is at a crossroads. Those who understand IT, accept it, and adopt it into their medical practices will be integral to the evolution of imaging. These individuals will be valued resources to colleagues in patient care. We must marshal our specialty through this paradigm and advocate for the fair and honest implementation of IT's transformation of the entire industry.
By Alan D. Kaye, MD, FACR