As the Diagnostic Imaging World Shifts, Time for Radiologists to “Get Out of the Dark Corners of the Reading Room”

Dec. 9, 2015
UPMC’s Rasu Shrestha, M.D. shares his perspectives on the vast changes roiling the world of imaging: it’s time, he says, for radiologists to “get out of the dark corners of the reading room and lead dialogue”

The world is changing very, very rapidly these days for anyone whose work encompasses or touches on radiology or imaging informatics, and that includes radiologists, administrators in radiology groups and hospitals, referring physicians, and all the healthcare professionals whose work connects to or directly involves imaging informatics.

In his November/December cover story on imaging informatics, HCI Editor-in-Chief Mark Hagland interviewed a number of healthcare leaders and industry experts on all the policy, operational, clinical, and information technology changes sweeping the industry these days. Among those he interviewed was Rasu Shrestha, M.D., chief innovation officer at the 20-plus-hospital, 3,600-plus-physician UPMC (University of Pittsburgh Medical Center) health system in Pittsburgh. This autumn, Hagland discussed with Shrestha—who not only oversees imaging informatics at UPMC, but also continues to practice part-time as a radiologist, and further, is the current chair of the Scientific Programming Committee for Informatics within the Radiological Society of North America (RSNA). Below are excerpts from that interview, published here just days before the start of the annual RSNA Conference, to be held Nov. 29-Dec. 4 at Chicago’s vast McCormick Place Convention Center.

Rasu Shrestha, M.D.

How do you view the current landscape around imaging and imaging informatics right now, as all the “tectonic plates” seem to be shifting at once?

From my perspective, there are at least two massive dynamics in the healthcare industry right now that aren’t just altering the landscape; in fact, our tomorrow in terms of how we practice medicine and operate, will be different from our yesterday. Healthcare reform and consolidation are those two dynamics,” he says. “So there’s a massive amount of consolidation going on among  providers, practices, payers, and vendors—Merge bought by IBM for over a billion dollars, for example. And this consolidation brings challenges of interoperability, efficiency, the need for us to do more with less. Then with healthcare reform, the train’s left the station. And it’s critically important to us: it brings challenges of volume to value. It particularly challenges to us practicing radiologists, because we’ve been so volume-focused.

How are you and your colleagues approaching all of this at UMPC in particular?

With regard to how we’re meeting change here at UPMC, we look at consolidation and healthcare reform as offering us opportunities, first, to engage in patient-centered care; and second, to focus on newer care models. And as a payer and provider organization, we’re not just talking about it; we’re living and breathing it today. So these newer care models we’re developing and incentivizing our physicians, that’s real for us. And third, embracing new technologies—we’ve been doing that for three decades now. And it’s time for us to double down and really leverage technologies, and eliminate the silos.

So what does all this mean for imaging informatics in particular?

Imaging data is different from wave-form data, which is different from other forms of data. And working with all of those image and data forms at once requires that everyone, including radiologists, participate in re-visioning how to store and share data, including images, of all kinds, across and beyond the enterprise.

How will radiology practice change in the next five years?

With regard to some of the challenges I referenced around consolidation and healthcare reform, those are all very, very, real. What’s interesting about radiology is that we’re no strangers to pushing the needle, to pioneering change. DICOM first came about in 1983—it was the ACR NEMA (National Electric Manufacturers Association) 1.0 standard. So it’s been around for a while. And when we came up with the 2.0 standard some years later, it became DICOM. So DICOM has been around for a while. And well before people started embracing meaningful use and going live with EMR and CPOE [computerized physician order entry], we had PACS [picture archiving and communications systems], we had RIS [radiology information systems], we had 3D imaging and post-processing. We’re no strangers to change in radiology; the problem that we have is that we’ve been stagnant. Complacency is one of the biggest impediments to innovation and change. Now is the time for us to wake up and lead change and continue to push the needle.

Radiology continues to be important in the healthcare paradigm. And we’ve moved from being a departmental system to an enterprise asset. The opportunity for us to take the new dynamics and leverage our advantage by really pushing patient-centric care and informatics across the enterprise and position radiologists not just as a bunch of clinicians reading images in a dark room and pushing out reports; but rather, being consultants to our colleagues. It’s not just about us performing a study and producing a report, but being a part of the value chain. If we only focus on the read-flow process, then it’s unfortunate, because it’s well after the “scene of the crime,” as I put it. The potentially bad study that shouldn’t have been done in the first place, doesn’t really look at our value.

What can radiologists do, per the mandate set for January 2017 around referring physicians being required to use clinical decision support and appropriateness criteria tools?

[Editor’s Note: In early November, just as the November/December cover story and print issue was going to press, senior officials at the Centers for Medicare & Medicaid Services announced that they were delaying this mandate, without providing a timeframe for its implementation. HCI will update its readers on developments in that area, as new information becomes available.]

It’s important for them to get out of the dark corners of the reading room and lead dialogue within their hospitals and group practices, and more importantly, lead dialogue in the industry for what is important for care delivery—there will also be requirements for value-based reimbursement—90 percent of traditional Medicare payments are supposed to be transferred into value-based payment by 2018.

So it’s not only innovation in the technology space, but also in the reimbursement space. And that will fundamentally change how care is delivered. It will force us to look at how we deliver care. And the onus is on us to not be forced to do this, but to lead change…

It seems clear that the sharing of images in health information exchanges (HIEs) has generally lagged seriously behind the sharing of non-image-based data. What are your thoughts on that?

That again speaks to radiologists needing to help take the lead. If you look at radiology or imaging, the way we’ve been positioned or have positioned ourselves, is that in many ways, we’re at the end of the flow in t3rms of the patient. By the time an order gets put in for imaging of the head and neck and it goes through the RIS and PACS system, and we prepare a report, we’re looking at diagnosing a headache, for example. So we’re coming in at the end of a long chain of activity. So to leverage data bidirectionally and leverage data out of EMRs and HIEs, and the other way around, too, for us to share guidance and information upstream into these care streams, both of those are very important.

So it’s not just data interoperability, but data liquidity. How do we make sure to create freer-flowing data in a contextualized manner, in multiple care systems? That’s important. And in the context of imaging, we’ve short-changed ourselves by not focusing on a specific area, so when it comes to HIEs it’s really important to find out, is there a relevant prior? First is awareness of a prior, because we won’t even need to order a new study. So that’s waste and unnecessary radiation. So, first, there needs to be awareness of any relevant prior; and if one is available, access to the reports; and third is access to the images. So those are things we can be relevant to, and push for, it’s really critical.

What about merger and acquisition activity on the vendor side—how is that activity influencing everything else?

The landscape is littered with vendors and companies that have been acquired and essentially have been under-utilized for their capabilities. And there are multiple reasons consolidation has been happening in the vendor space. You’d hope that these consolidations are going on for the right reasons—not just for market dominance. But what the industry (vendors) really needs to look at is, not just acquiring companies for the asking of doing so, but how do they really grow exponentially as companies? And that’s really critical.

The other thing is, time and again, we’re seeing specific challenges when it comes to interoperability. So before the consolidation rage happening vendors were really incentivized not to interoperate—more towards closed systems and proprietary standards, so they could show off their capabilities. But now this notion of interoperability is becoming so important with provider consolidation. So we don’t need more standards; we need clearer guidelines around these standards, better discipline around adherence to the standards, and clearer measures. Because we’re not really measuring interoperability right now. Everyone believes in the idea of it. But clearer measures, so we can actually hold vendors and payers accountable.

Even remote-read groups are consolidating these days, correct?

Yes, and there are lots of reasons for that, including efficiencies of scale, whether it’s remote-read entities and other organizations. And the end of the day, it’s important for us to comprehend that it’s not just about getting a report out. It’s important for us to have more contextualized data around the patient story. And when we’re talking about that, and taking about collaborative care, where we’re being incentivized to collaborate, that can’t really happen in a silo, when you’re shooting off reads to remote-read organizations. So I see that as a huge opportunity for more traditional radiology groups and hospital organizations to say, hey, we have all the resources we need to do these things. We have tools we can leverage around better communication.

What would your advice be for CIOs, CMIOs, directors of imaging informatics, and others involved in imaging informatics, in the next few years?

I think it’s really important for us to understand at the end of the day that it’s less about interoperability and meeting standards, etc. It’s three things. One, it’s really about the patient. And it’s easy to say that. But those who have endured frustrations in their own care or the care of loved ones, really understand that. Number two, interoperability and adherence to standards—it must be done. And three, at the end, it’s less about technology and more about leadership. We have the technology. Facebook, Apple Pay, and so many technologies already exist that could potentially be leveraged in some way. It’s not about the technology, it’s about the leadership. We have to make this happen.