As I sit here trying to think of a way to wrap up a year of tremendous change in radiology, health care, and the economy at large, I understand that there is no way to turn 2009 into a neat package. Nevertheless, sifting through a year’s worth of content developed for Radiology Business Journal—and our electronic journals, ImagingBiz.com, Radinformatics.com, and Medical Imaging Review—it is quite clear to me that radiology needs to make a fundamental shift. The specialty must become patient centered. I am not referring to the dreaded (for some) ACR® recommendation to make five patient contacts per day. This is clearly impossible for radiologists who are interpreting studies in centralized reading centers. Neither am I thinking of patient-direct marketing, once considered useless but now a part of many practices’ marketing programs. I am thinking of the future: After more than a century of attending—and sometimes pandering—to the referring physician, it is time for radiologists to put patients first and assume the responsibility of their expertise. Why? Because this deference to the referring physician appears to be preventing radiologists from doing many of the things that they will need to do to add value to their services with patients and hospital clients in the emerging health care economy. One thing of which we are certain is that we will need to do more with fewer resources—even if health-reform efforts are not successful in expanding health care coverage to more US residents. The imaging specialist: Radiologists, radiology departments, and imaging centers should be at the forefront of the utilization-management movement, but for years now, they have demurred due to unwillingness to offend referrers. Now is the time to push for computerized physician order entry systems with embedded imaging-appropriateness software, by lobbying at the federal and state levels to include this potentially powerful informatics software within the definition of meaningful use of American Recovery and Reinvestment Act funds. Radiologists need to push back if a study is not necessary or appropriate. Imaging appropriateness is in the best interests of patients. The radiation-safety expert: What happened at Cedars-Sinai Medical Center in Los Angeles, California, was a black eye for Cedars-Sinai, but it was also a very public reminder that imaging technology needs to be in the hands of experts. In the interest of full disclosure, I bypass many other institutions and imaging centers to get to Cedars-Sinai’s outpatient imaging center (and will continue to do so). From my perspective, the imaging leadership and service at Cedars-Sinai are sterling, and the radiology department is second to none. As radiation exposure becomes an issue in the United States, radiology must be the frontline defense on behalf of patients in adhering to as low as reasonably allowable imaging protocols. In addition, excess imaging is, in many cases, excess exposure and excess expense. The medical-informatics expert: One professional mandate that the referral-based business model is not preventing is the deployment of PACS by the practice. Many of the practices in our ranking of The 50 Largest Radiology Practices (page 24) have deployed PACS and are using teleradiology for distributed reading solutions. This is in the interest of both the practice (by enabling it to cover sites that could not support FTE radiologists) and patients (by allowing subspecialization). Radiology should take this one step further and become a champion of the almost-moribund regional health information organization movement. Having access to all prior studies is in the best interest of the patient, and this also is what is required to ensure that patients do not get duplicate examinations. This is not just in the interests of patients, but in the best interest of health care economics. The imaging consultant: As hospitals shoulder the inevitable increased financial pressure, there will be a growing interest in understanding and managing the individual costs of DRGs. Some DRGs are quite imaging intensive, so radiology has an opportunity to collaborate with other specialists in developing evidence-based imaging protocols within individual DRGs for maximum appropriateness and efficiency. If there is imaging involved, radiologists should be at the table—even if it is cardiac imaging. At the risk of offending referrers, all radiology services also need to be prepared, and have systems in place, to deliver results to patients who ask for this consideration. Increasingly, women’s imaging centers are making this service available, but there are many other life-threatening instances in which patients should not be kept waiting for results. I am fortunate to have great union-paid insurance (including dental coverage) through my spouse, but medical bills and telecommunications are in a dead heat as our second largest monthly expense. What are you doing to inform patients of their burdens at the time of service? The best imaging center organizations are building Web interfaces with insurance companies so that patients understand their responsibilities, and hospital radiology departments need to do this as well (and please don’t ask for it all up front.) I can’t shake the feeling that this is a time of unprecedented opportunity—and danger—for radiology. Radiology practices, hospital radiology departments, and imaging centers that put patients’ needs first will find themselves in the vanguard as the specialty moves into an uncertain future. Cheryl Proval, Editor cproval@imagingbiz.com