YOUR MEDICAL IMAGING CLOUD. EBOOK Advancing Radiology Operations: Your Guide to Measuring, Improving, and Elevating Radiology Operational Performance

Transcription

1 YOUR MEDICAL IMAGING CLOUD EBOOK Advancing Radiology Operations: Your Guide to Measuring, Improving, and Elevating Radiology Operational Performance

2 A Changing Radiology Landscape In today s changing healthcare environment, radiology is evolving. Whether within health systems, radiology and teleradiology groups, or in referring physician and patient interactions with radiology, the last few years have seen a wave of disruption. For radiology, it's no longer enough issue reports. Adding value to health care delivery means that radiology leaders need to provide timely and efficient turnaround, track performance and follow up, and even shift from being the doctor s doctor to engaging directly with the patients and even competing for them. Health systems and hospitals with inpatient radiology services are facing challenges around reimbursement, and looking to better manage radiology utilization and their own fixed costs. In turn, community hospitals and urgent care facilities have a growing degree of imaging capabilities. They re often looking to partner closely with health systems, radiology groups, or teleradiology organizations, and gain access to radiology subspecialties to interpret imaging. Finally, increasing consumer awareness about radiology is also contributing to this growth with empowered healthcare consumers looking to shop for radiology services. What's becoming clear is imaging and radiology in the current technology environment is increasingly misaligned. On-premise PACS, behind firewalls, or buried in film libraries, lock imaging down, anchoring it rather than letting it flow across the network to the right expertise and services. This paper explores the implications of the changing radiology landscape, MACRA, metrics to deliver best-in-class radiology operations, and how to improve workflows and using new technology. IMAGE INTERPRETATION Imaging Producers Community Hospitals Imaging Centers Private Practices LOW Patient Drivers Various Providers LOW HIGH End-to-End Radiology Academics Health Systems Radiology Groups HIGH Remote Interpreters Teleradiology Radiology Groups (reading only) IMAGE PRODUCTION 2

3 MACRA S Impact on Radiology What is MACRA? MACRA is a Medicare payment law passed in April 2015 driving health care payment and delivery system reform for health systems, physicians, Medicare, and other payers. It s focused on more closely aligning payment with quality and outcomes. It offers financial incentives to participate in risk-bearing, integrated care models, and moving away from the traditional fee-for-service approaches. Fifty percent of physicians surveyed said they have never heard of the law and 32 percent recognize it by name but are not familiar with its requirements. DELOITTE SURVEY OF 600 PRIMARY CARE AND SPECIALTY PHYSICIANS Physicians, including radiologists, and other healthcare professionals who are paid under Medicare fee schedules choose between participating in the Alternative Payment Models (APMs) or by the Merit-Based Incentive Payment System (MIPS), which is based on individual performance. What MACRA Means for Radiology RECOMMENDATION FOLLOW UP. Radiology has long expressed concerns about the relatively low-rate of follow up on results from referring physicians. For example, a study of 6,851 patient reports generated at Boston Medical Center found that 33% of radiologist recommendations were not followed. 15.4% of electronic exam notifications are not read by referring physicians. JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Of those, 39% were not acknowledged in the referring physician s notes, even though 43% were significant. In response, the Centers for Medicare & Medicaid Services (CMS) has created requirements around follow up to imaging screening exams and incidental findings to address concern over the low rate of follow up on radiologist recommendations. EXTERNAL IMAGE SHARING AND SEARCHING. Providers are encouraged to make DICOM images available to external health care facilities. To help reduce patient exposure to radiation, facilities are advised to search for patient images prior to ordering another imaging exam which might not otherwise be necessary. RADIATION DOSE MANAGEMENT. Multiple performance metrics within MACRA address minimizing the amount of radiation patients receive. One of the areas include managing documentation of radiation dose exposure and participation in a radiation dose index registry. MEASURING PERFORMANCE. MACRA and MIPS all require better metrics, benchmarking, and performance management. For radiology, data collection is key, such as recording the impacts of imaging on care, and the cost-effectiveness of imaging across different scenarios and conditions. 3

4 The Radiologic Value Chain There many different workflows in radiology scenarios. But when understanding how to cement radiology s role in this new demand and value-driven landscape, it s important to establish a high-level picture of how each stakeholder in the value chain engages with radiology, and what they look for in that relationship: Referring clinicians measure value in radiology in the quality, speed, and efficiency of the radiology services they request, such as the turnaround times on orders. They re looking for fluid access to expertise whether it be within a health system, rad group, academic institution, or tele-rad organization. Patients gauge how smoothly both imaging procedures are scheduled and managed as part of their treatment plan, and how fast they get radiologic results from their physician. Increasingly empowered patients also want to access their radiology reports themselves too. CMIOs and other healthcare executives look for efficiency and quality measures, and image turnaround times, examine fixed costs in the face of reimbursement, and ensure cost-effective staffing and utilization. IT staff look to engage with radiology by ensuring imaging accessibility and compliance with privacy and data security policies by minimizing rogue sharing, all while ensuring that the systems radiology uses are resilient and available. And radiologists find themselves in the middle of an increasingly image-centric healthcare model. They re looking for strong follow-up from referring physicians and increased involvement in patient care, and clear prioritization of relevant studies, especially when pressed with increasing image volume. The most successful health systems and private practices are re-evaluating how imaging flows in and out of their subspecialties, and closely examining workflows to help radiology work more effectively in an increasingly challenging landscape. 4

5 The Six Measures of Radiology Operational Performance The saying goes, you can t manage what you can t measure. It holds true for improving radiology operations to understand the drivers and levers that impact operational performance:.01 MEASURING AND OPTIMIZING TURNAROUND TIMES Report turnaround time is perhaps one of the least well-analyzed areas of radiology, yet is one of areas that is ripest for improvement and the most measurable. Turnaround time is typically measured from the time the images are provided to the radiologist to the delivery and signing of the report. But a broader and more relevant definition includes the amount of time taken between the initial order from the physician and the images being ready for interpretation by radiology. Setting and tracking clinical performance objectives is key, like looking for a turnaround time of 30 minutes and 2 hours for emergency department and non-emergency cases. Many private practices and health systems are measuring each segment of the flow, from order, to imaging, to radiology, back to physician and analyzing efficiency within each sub-step, and comparing with industry norms. They re then applying process changes and technology to improve that step, whether routing imaging faster to radiology workstations, or using worklists to ensure timely follow-up from physicians. By targeting issues within the imaging workflow, turnaround times can be addressed more effectively. When diagnostic imaging is completed faster, other departments that rely on these exams can operate better as well PHYSICIAN ORDERING ANALYSIS Another optimization opportunity is to reduce unnecessary orders, and lower any frivolous workload on the radiology department. It also can free up modalities and report workflows by freeing radiology to focus on the studies that matter most. One opportunity is to analyze which in-house or referring physicians have the highest yield of abnormal findings, versus those that don t. Using an image management platform and integrating it with the order management system, can enable analytics and benchmarks around orders and findings, and subsequently, overall efficiency. ROUTING OPTIMIZATION Hospitals and referring physicians must ensure that their workflows are routing the right study to the right radiologist and subspecialty, and many are reexamining the processes and tools they are using to ensure correct delivery. Measuring incorrect routing of orders can improve efficiency. Better yet, specialized applications can ensure the right studies are automatically sent to the right subspecialists. 5

6 .04 RIGHT MODALITY. RIGHT ORDER Ensuring that the right imaging is ordered, and that it s appropriate, is another important measure. Exams that are unnecessarily expensive drive up both patient and facility costs. Having a clear understanding of the kinds of studies that are being ordered and using comparative benchmarks from similar institutions can begin the process of ensuring the right modality is always used for the right order..05 DOSE MEASUREMENT MACRA puts a heavy focus on dose measurement, and advises the use of the radiation dose index registry. Cumulative dose tracking measures radiation doses delivered to patients undergoing a variety of imaging procedures, and provides balance between image quality and dose. Centralized management of imaging and priors can provide both a powerful tool for understanding all the studies a patient has undergone as well as minimizing unnecessary doses through redundant studies..06 CAPACITY MANAGEMENT Ensuring the right capacity is also key for radiology teams balancing fast turnaround time with high quality care within subspecialties. Measuring image flow and routing can provide important visibility into resource allocation and understanding how capacity aligns with demand. Integrating an image sharing platform across the value-chain can provide a common foundation for measuring these areas to gain a holistic view of image and report flow, utilization, and routing effectiveness, and enables a single area to make changes and improve processes. One of my goals, and especially in the pediatric setting, is trying to reduce radiation, trying to reduce unnecessary tests and procedures value based care is the vehicle to do that. DR. SAFWAN HALABI, MEDICAL DIRECTOR RADIOLOGY INFORMATICS, STANFORD CHILDREN'S HEALTH 6

7 Technology The Deconstructed Stack: A Solution for Radiology Efficiency In an increasingly distributed healthcare system, all-in-one traditional PACS systems have become increasingly hard to integrate with newer healthcare technology like EHRs/EMR systems. They ve also struggled to meet a desire for universal viewing. Deconstructed PACS enable customized workflows, hybrid storage models, and universal viewing, separating the components of a PACS system archiving, viewing, exchange to maximize interoperability. A key benefit of deconstructing the PACS for radiology is image sharing. Image sharing platforms provide a foundation to connect applications, processes, and people in the radiology workflow chain, from order, to integrating priors and patient data, and routing back to referring physician and patient. Typically, an image sharing platform is cloud enabled to ensure ease of integration and access by referring physicians and staff, radiology, or downstream, such as the patient. The faster and more accurately radiology can interpret images and clinicians can provide care, the greater chance both will achieve better outcomes and reduce healthcare costs. Cloud-based image sharing systems save facilities money directly through more efficient operating costs, and by increasing radiologic output within and beyond the health system. Patient Portal Referring Admin Staff Hospital Clinical/ Admin Staff CD Upload/Import Referring Image Archive Exchange Studies Store Normalized Study Hospital PACS/ Archive Cloud Image Sharing Referring Clinical Users RIS Auto/manual PHI Normalization EMR/EHR Image sharing integrates people, processes, and technology in the radiology workflow 7

8 A Technology Checklist for Radiology AREA CRITERIA CAPABILITY Technology Deconstructed PACS VNA capabilities Cloud delivery Viewing Zero footprint mobile viewer FDA 510(k) diagnostic universal viewer Integrate reporting and imaging data Workflow Universal worklist and prioritization Automatic image routing to subspecialties Imaging exchange over internet and to/from HIEs Integration Integrate imaging to patient/referring physician portals EMR/RIS integration Integrate with in-house/referring PACS Management Searchable archive Match patient data and priors Store DICOM and non-dicom data Automatically prune and eliminate images Interoperability. Routing. Workflow: The Emergence of Cloud VNA Unlike a PACS, which are typically designed to serve one department, a VNA is designed to be a long-term archive, a central repository for images housing images from a variety of systems. While VNA s were first developed to connect siloed departments, and manage distribution throughout and beyond hospital, cloud VNAs make interoperability beyond the confines of the hospital much easier, and make connecting to the RIS or EHR a real possibility. They make it simple to transfer and view studies, join patient imaging and data together, integrate priors, and create a holistic patient health record by unifying reporting and imaging together. 8

9 Imaging Performed at Facility Priors prefetched from cloud VNA Patient imaging sent to radiologist workstation to complete report Auto-routed to referring physician via branded portal Image available to patient via link or CD An Example Integrated Workflow Using Cloud VNA Cloud VNAs can even be used to bypass the PACS system completely in some cases, where modalities can all send to the cloud VNA, so the radiologist can at least give preliminary reads, or a full read if they need to, while waiting for the traditional PACS system to become available. One method of adoption is a hybrid approach: using a traditional PACS solution while leveraging a cloud VNA to get imaging out to the rest of the world. It's easier to manage, and it costs a lot less to provide access, without the need for complex desktops and VPN connections. EMPLOYING CLOUD VNA AT JEFFERSON RADIOLOGY Established in 1963, Jefferson Radiology is the largest private practice radiology group in Connecticut and has affiliations with 7 regional hospitals. Jefferson Radiology offers a breadth of services and a level of diagnostic and therapeutic radiology expertise unparalleled in the region. Jefferson partnered with Ambra Health to establish a cloud VNA to create a more connected imaging workflow that routed images, incorporated priors, and connected with patients and referring physicians. IMPROVING IMAGE ROUTING At Jefferson, any prior studies are pre-fetched from the cloud VNA and searched across the network. If prior studies are found, they are normalized into the workflow. Patient imaging is automatically sent to the radiologist workstation where reporting is completed. Studies and completed reports are auto-routed back to referring physicians through a custom cloud-branded portal. In keeping with their patient centric view, Jefferson makes studies available to patients through an easy-to-access electronic link. Using a cloud VNA has enabled us to image-enable our patient and physician portals, integrate with our RIS, ease access to images, and be collaborative. MICHAEL QUINN, CHIEF TECHNOLOGY OFFICER OF JEFFERSON RADIOLOGY 9

10 Improving Radiology Productivity Through Universal Worklists and Viewers With increasingly disparate workflows in radiology, it s easy for radiology to become overwhelmed, or focus on the wrong reads. Universal worklists ensure the right radiologist will read the right exam the first time. Typically, they provide a single view containing a prioritized worklist, an embedded study-driven third-party viewer, and relevant clinical reports ensuring each radiologist has the right exams to read based on the order. Universal viewers make it simple to view DICOM imaging types from CRs to intensive imaging studies such as PET, US, Angio, and Tomo, while also handling non-dicom imaging that can easily be wrapped with a DICOM header for quick storage and access. Together, it means fewer tools for radiology to have to engage with. LAHEY HOSPITAL & MEDICAL CENTER STREAMLINES WORKFLOWS Lahey Hospital & Medical Center is one of the world s premier health care organizations and a physician-led, nonprofit group practice with 5,500 staff across multiple locations. Subspecialty departments include Orthopedics, Neurology, Urology, Oncology, Cardiology and more. Lahey made the move from legacy on-premise tools to Ambra Health to tackle their rapidly growing outside image management needs. STREAMLINED IMAGE WORKFLOWS Managing over 2,000 new studies each week, Lahey quickly outgrew the legacy on-premise image management. Adam Medina, Radiology System Administrator, observed that we d had trouble with facilities pushing data to us and there was little insight into the problems. At 2AM you need to know where data is, but it was getting hung up. With frustrations growing, Lahey made the shift to the Ambra cloud, and immediately saw benefits. When we had problem discs and TOMO images that we couldn t get in, the first question I d ask is have we tried using Ambra. We ve never had a failure, it just flows in and can be viewed across the facility right away. ADAM MEDINA, LAHEY HOSPITAL & MEDICAL CENTER RADIOLOGY SYSTEMS ADMINISTRATOR Simplifying the Radiology Tech Stack If you re like other radiology teams, you re likely dealing with many systems day-to-day. The simple rule is, the more systems, the less your productivity, and greater the cost. 10

11 A typical process and technology stack that supports radiology includes CD burning tools, couriers and shipping fees, CDs and VPNs, on-premise VNAs, disaster recovery solutions, as well as infrastructure and resources to keep it all running and some semblance of integration. With the move to more portals for both referring physician and, patients, the stack is set to grow. Shifting to a cloud image sharing platform eliminates the hodge-podge of different apps, and reduces infrastructure costs, while improving image flow, patient, referring physician, radiology and administrative experience. Application Impact Hardware Impact Image Exch. App. Maint. 15% CDs, Shipping Etc. 55% Application Impact Now Op-Ex Hardware Impact Eliminated TOTAL COST SAVINGS 60% Operational Impact Film Library & Distribution 30% Operational Impact Minimized SaaS Image Management Platform 30% Image Distribution 9% CURRENT PROPOSED 11

12 CAREWELL URGENT CARE SIMPLIFIES TECH STACK CareWell Urgent Care, based in Massachusetts and Rhode Island runs 15 locations, with 260+ physicians, nurses, and administrative staff. They typify a trend toward more comprehensive urgent care, and have a substantial investment in on-site imaging, mainly centered around x-ray capabilities. A key part of their model, is having a close relationship with outside radiology, and driving fast turnaround times. With over 15,000 x-rays last year, and expectations to grow by another 20,000 in the near term, and an overall 300%+ growth in image volume, ensuring reads are handled timely, efficiently, and scalably is strategic priority. SYSTEM SIMPLIFICATION By using the cloud, they ve simplified their systems down to one unified point of access and eliminated friction from image transfer. Using cloud image sharing to digitally route imaging to outside radiology subspecialties, CareWell works hand in hand with major hospital systems like UMassMemorial Medical Center s Radiology Department, with imaging instantly routed to 60+ radiologists across different subspecialties, increasing efficiency and quality of interpretations. Partnering more effectively and efficiently with outside radiologists, and streamlining our patient journey are all critical to supporting our growth. We couldn t continue to do what we re doing without cloud PACS. TERRY GIOVE, VICE PRESIDENT OF OPERATIONS, CAREWELL With better routing, CareWell has also seen a significant acceleration in image turnaround, cutting turnaround from days to hours, and enabling CareWell to communicate results back to patients rapidly. Looking to the Future Patient-Centered Radiology Per the Advisory Group, 86% of patients want online access to both their medical images and the associated written report, and many are looking for prompt access. Web-based patient portals enable radiologists to better connect with patients, however there are important considerations for radiologists too, with patients increasingly likely to be reading the reports that were geared to being read by referring physicians. Some radiologists may not be comfortable sharing findings with patients without the involvement of their primary care physicians. 12

13 Artificial Intelligence and Deep Learning No, AI likely won't replace radiologists anytime in the medium term, if ever. But deep learning and is considered one of the breakthrough technologies of the decade and has the potential to optimize radiology workflow. One practical example of using AI is to rapidly detect pulmonary embolisms in CT scans, prioritizing them to the top of the queue so that radiology can look at them immediately, give that report back to the emergency room physician, and facilitate faster treatment. There's this fear that machine learning and artificial intelligence will replace physicians, but I really think it'll augment what they do. DR. SAFWAN HALABI, MEDICAL DIRECTOR RADIOLOGY INFORMATICS, STANFORD CHILDREN'S HEALTH Conclusion Radiology s role is changing. The growth of teleradiology, an increasing gap between image production and interpretation, elevated awareness of radiology s role with patients, and of course new regulations such as MACRA, are all driving a new radiology landscape. Technology innovations like cloud medical image management, workflows, worklists, and routing imaging across the radiologic value-chain, can redefine radiology s role in patient care. It means putting a spotlight on the processes and measurement that integrate radiology into patient care. Stronger, more agile image sharing is a MORRIS PANNER, CEO, AMBRA powerful enabler for this more distributed model. Easy to search image archives enable radiologists with unprecedented access to priors, all to reduce redundant imaging and improve quality. It s a new landscape that provides both challenge, and opportunity. ABOUT AMBRA HEALTH Ambra Health is a healthcare cloud company dedicated to making digital medical image management accessible to all, from anywhere. Our powerful cloud-based suite streamlines the medical image exchange process and connects patients, care providers, and facilities worldwide. We work with some of the largest hospitals and health systems such as Stanford Children's Health, Weill Cornell Medicine and Memorial Hermann as well as private practices, imaging centers, clinical research organizations, and health information exchanges. Discover what the power of the cloud can do for your healthcare enterprise at 13