LIVE from RSNA 2016: Radiology Thought-Leader Eliot Siegel, M.D., on What Value Really Means

Nov. 28, 2016
At RSNA 2016, Eliot Siegel, M.D., one of the leading lights in the imaging informatics world, shares his perspectives on the broad question of value in radiological practice—and what healthcare IT leaders can to do help move the needle

If the transition from film-based radiological practice to PACS- (picture archiving and communications system) facilitated practice that started nearly 30 years ago was historic, the radiology world is on the threshold of a far more profound set of changes, Eliot Siegel, M.D. believes. Dr. Siegel made his comments at a media breakfast sponsored by the Amsterdam-based Philips, on Monday at the annual RSNA Conference, sponsored by the Oak Brook, Ill.-based Radiological Society of North America, and being held at Chicago’s gargantuan McCormick Place Convention Center.

Dr. Siegel was one of several speakers at the Philips media breakfast on Monday morning. At that event, Philips executives explained in some detail about their strategic goals for the company, echoing what other vendor executives have said about the present moment in radiology. “We have to be faster, easier to use, and more reliable; we have to change the economics around equipment,” said Rob Cascella, executive vice president and CEO of Philips Diagnosis and Treatment. “So we’re building in things like intelligence, decision support, and predictive analytics. We want to make the clinician more effective. And from an operating perspective, we want to make the group more effective.”

And, following the roundtable discussion involving Philips executives and radiologists, including Dr. Siegel, Yair Briman, the Haifa, Israel-based senior vice president and general manager of Healthcare IT Philips, told Healthcare Informatics Editor-in-Chief Mark Hagland that “We see the opportunity of how much more value we can add to patient care. So the revolution” that’s happening right now, Briman said, “is really in moving from the hardware—though we continue to innovate there as well, for example, around SPECT-CT—but it’s really in the information and in how you manage that information. We need to help radiologists become more effective, especially in their use of time. So being able to provide radiologists at the point of practice with a range of protocols for diagnostic image analysis, all fully automated, will be one of the areas in which we can provide tools”—such as for calculating the volume of tumors—“that will improve not only productivity but also clinical quality.”

Eliot Siegel, M.D.

At the media breakfast, Dr. Siegel, who is the chief of imaging at the VA Maryland Healthcare System, vice chair of radiology at the University of Maryland School of Medicine, an adjunct professor of computer science at the University of Maryland, and of biomedical engineering at the University of Maryland-College Park, noted that “This year marks the twenty-fifth anniversary of when we purchased the world’s first all-digital system. We had the first fully filmless digital imaging hospital system, the PACS. It was really cool just not to lose the films. Back then, that was a really major thing, though we take that granted today. We actually had our department enclosed in an enclosed glass cage, and everyone came in to see the radiologists reading at stations. Twenty-five years later,” he continued, “I’m not sure we’ve achieved all the things we had hoped to. Sure, we have images anytime and anywhere we want to. But we were hoping we could really use the computer and coordinate with the electronic medical record, and really have the radiologist be a consultant.”

What’s more, Siegel emphasized, “The radiologist’s role is not just to make findings, but to have the judgment. Computers can do some findings, but the radiologist needs to put all those things together. And it’s a complex nexus of information we need—using our judgment, combined with the findings on the image. So what I want from the next generation of systems, is to be able to take advantage of all the amazing things we had hoped for 25 years ago, with a whole new generation of information systems to support us. So I was excited to work with Philips to try to bring this to our healthcare practice.”

Among the issues Dr. Siegel sees as persisting, most are around workflow and clinical decision support of some sort or another. “Some of the challenges I have in my own job,” he said at the media breakfast, “number one, we have many different workstations we need to do my job, I want to consolidate that. I want to be able to combine genomic data and personalize the way I take care of patients, and have that information in front of me, information from the EMR but also from other sources. And I want that information available in real time. As I go to read a study, I want all that clinical information available at that moment. It’s that ‘mission briefing’ concept that was mentioned a few moments ago. And I want to be able to deal with the complexity and volume of information systems right now.”

Among the numerous issues that need to be sorted out for radiologists, Dr. Siegel said, are, reducing the number of workstations necessary for radiologists to do their day-to-day work, and moving forward to leverage technology to optimize radiological practice. “In my academic practice,” he noted, “I have residents and fellows spending hours gathering information, looking at old studies, and talking to the patients. So I have that information. They’ve gathered information about old studies and about the patient’s history. What I want is for my computer system to essentially emulate that team, and bring that information to me. Not everyone is privileged to work in an academic environment and have all those people working for them. I’d like for computer systems to do that, to emulate that—to bring us genomic data, past studies, and EMR-derived information. Over time, we need to be able to work smarter.  And being able to get information in that ‘mission briefing’ form. makes things better. And having all that information on the patient really changes the diagnosis and how I work. Give me the lab information, the patient’s problem list—I want to know if the patient has an underlying condition, for example. And that information can be built up over time, both from the EMR and from additional information added.

In short, Siegel said, “Give me contextual information based on what I already had and knew about the patient. There are a whole bunch of intermediate steps. We haven’t really progressed in 25 years, and I’m super-excited about moving forward and having the train leave the station.”

Shortly after the media breakfast, Dr. Siegel sat down exclusively with Healthcare Informatics to consider the broad-level changes taking place in U.S. healthcare right now, and questions around the kinds of value that radiologists and radiology can bring to patient care. Below are excerpts from that interview.

How do you see radiologists in this emerging healthcare, in which the purchasers and payers of healthcare are demanding more value from providers, and in which such things as additional Medicare physician payment cuts could be looming on the horizon? Rasu Shrestha, M.D., of UPMC, talks regularly about the challenge for radiologists of adding value to patient care.

It’s interesting, because if I go to a cocktail party and say I’m a radiologist, people think I’m the rad tech. And if you watch “House,” everybody does everything. There’s a lot of ambiguity around what the radiologist is, not only in the lay public, but even among physicians, and even among radiologists themselves. And I don’t think that even other clinicians necessarily understand what radiologists do. Sometimes, the assumption is that the radiologist looks at images, and extracts findings, for others to figure out. But I was taught that the radiologist was a consultant. And I’m at the nexus: I get information form the oncologist, the surgeon, the lab. If I’m the oncologist, I think I’m the nexus; the same with the pathologist. But when people talk about radiologists as a commodity, they’re talking about the radiologist as someone who simply extracts findings.

But doing that is a really tiny part of what we do. And when Rasu and others talk about value, the question is, what are we doing to contribute to the overall mission, to maintain health, treat disease, and reduce suffering? And one of the key questions radiologists have been struggling with for years, is, what is the relationship of what I’ve just done in writing a study, to the overall treatment of the patient?

And as we look at where we are in the value chain and how we should be reimbursed in an environment where people are looking at us for value—as you know, I’m vice-chair of radiology at the University of Maryland, and we’re connected by a bridge to the veterans’ hospital. And in the one environment, at the University of Maryland, we’re still in a pay-per-study environment; on the other side, the VA side, we’re in a salaried environment. And the same doctors act extraordinarily differently in the two different environments. For example, at the University of Maryland, my virtual colonoscopy procedure competes with the GI physicians and others, because they do the [regular colonoscopy] studies, whereas at the VA, the enthusiasm is for radiologists to do virtual studies, because of that lack of competition. So there are all sorts of different areas where, depending on the reimbursement model, the same doctors act differently.

Here’s another example: the most sensitive study for infection of any type is PET. But CMS has traditionally not reimbursed for PET for investigating inflammatory processes or infection. So at the University of Maryland, I might do a tagged white cell study [a white blood cell scan] that potentially is more dangerous for the patient, because we’re removing cells and replacing them. But at the VA, I’m able to pick and choose what is the optimal study for the patient. So reimbursement changes things. We kind of cross the bridge and move from one model to the other [those radiologists who practice at both hospitals]. There are advantages of both.

What do your radiologist colleagues say about this strange state of affairs, involving different economic incentives at different facilities at which they practice? Do they say that it’s a crazy situation? That it’s the way the world works? That we could do better as a healthcare system?

You hear all those types of responses. Physicians roll with what they’re presented with. But we have our own practice, we cover private hospitals, we work in the academic facility, and in the Department of Veterans Affairs hospitals. And living in those three environments, you get a chance to see that medicine truly is practiced in different ways, and what’s optimal for the patient could vary.

What should the incentive system be, ideally, in your view?

Clearly, in my mind, the incentive system should reward for value. The system should incent physicians to provide the maximum value for patients. Physicians need to be properly reimbursed. The biggest challenge is that it’s hard to determine what value represents and what quality represents. One example of this is that we currently do conventional chest radiography via regular x-rays. Chest, ankle, abdominal, etc., x-rays are all done with digital radiography. Well, it turns out that I can buy a 16-channel CT scanner from Philips at a price comparable to digital radiography or conventional x-ray. And I can operate that CT at the same dose, and can put my patient into that CT scanner, which costs about the same, and do CT at the same dose, with a similar price, and similar throughput, because I’m not giving the patients contrast—and at the VA, in a value-based environment, I have the ability to make that decision. In another environment, at the University of Maryland, I could not convert digital radiography to CT, because CMS [the federal Centers for Medicare and Medicaid Services, through the Medicare program] would say that that’s not indicated; you should be doing a regular x-ray. And I can say, the scanner costs the same or less, from the same company, with way more information and at the same dose. But the system is not based on value; instead, it’s based on the reimbursement models we have. So I could not do this at U of M on the Philips CT scanner. I’d have to bill for CT, but would get pushback on appropriateness, so in the VA, based on value, I would have more flexibility. There are problems in the VA. But in my own magic wand environment, I would be able to do what’s right for the patient, and include calculations on cost and value. But the payer model is a frustration. That’s why I’m doing it on the VA side.

What should our audience of CIOs, CMIOs, and their fellow healthcare IT leaders understand about all this?

That 2016 brings about a really interesting inflection point in radiology, where we have the capability to reinvent the way we practice. This is why I’m excited about working with Philips. They’ve come to us and said, we’d like you to help reimagine how you consume information from the EMR and other sources, and figure out how to create a consolidated view. So I’m a customer of the CIOs; and  I want their information presented in the context of the workflow and what I’m doing, to better take care of our patients. And the measurements I make on my Philips workstation, I don’t want to just utter words represented on a screen, like a robot, into a radiology report. Because once that happens, unless you type in a patient’s name, know a specific date, call up the report, read the report, there’s nothing that’s helping to consolidate this into a better process. So CIOs need to help transform processes, so that when you’re looking for and collecting information, it’s easier to them to access and use that information. So Philips is helping us reimagine the way we move forward, just like 25 years ago, we transitioned from film to digital. Now the challenge is to work collaboratively with CIOs and everyone else, so we become part of the whole of the integrated process with everyone else in hospitals. And that’s really what we’re trying to do.

And what should CMIOs and other clinical informaticists know, specifically?

The message I would have for CMIOs is that radiologists don’t just interpret findings, but are trained as image specialists. What constitutes image quality? And what level of color fidelity and other quality do I want from systems? What’s the best way to extract information? What’s changing now is that images are now considered to be a part of the electronic medical record, from a legal perspective, etc. It used to be a question as to why one should or shouldn’t save diagnostic images, it was or wasn’t for legal purposes. Truly from a legal and medical perspective, images really are part of the electronic medical record. And I would tell my CMIO colleagues that radiologists have a level of expertise for images in general, not just for radiology, and that we truly want to have our data made more accessible. And we have a lot of needs to be able to consume those sorts of data as well.

And what would you say to those HIE [health information exchange] leaders, who are struggling to incorporate image-sharing into their networks?

I really think healthcare should take a lead from the financial sector, and create true interoperability. Clearly, people need interoperability [to do online banking], and the financial sector needs that. One of the parts of HIPAA [the Health Insurance Portability and Accountability Act of 1996] that people don’t always remember, is the idea of a universal healthcare identifier. We don’t have that in the U.S., and these HIEs have to figure out who the patients are. And that’s a huge challenge for those HIEs. So one of the interesting trends in the future is to what extent will patients have their own PHRs. And also, all my information will all be in one place.

So it will require striking a delicate balance between protecting security and privacy, and supporting optimized patient care. I’m just afraid that the pendulum has swung so far in one direction; if these data silos are so isolated, I’m afraid we won’t learn from the lessons of the past. We’ve come a long way in the last 20 years with privacy and security, and we really ought to be able to incorporate things into healthcare. And I personally would love to see patients take more ownership in their own records and in their own care.

The OpenNotes movement is really helping to accelerate patient engagement.

Yes, and I would love for the EMR and the PHR [personal health record] to be truly image-enabled, too. That would be a great step forward.