Rethinking Our Value Chain

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 - Ethan B. Foxman, MD
Ethan B. Foxman, MD

If you are reading this editorial, then very likely your daily work is part of the overall value chain of radiology that starts with ordering an imaging study and ends with the creation of information delivered to patients, caregivers, healthcare systems, and payors. You should feel a great sense of pride that more than 500 million times a year in North America alone the work you do provides patients (and healthcare providers) with information that is essential to their care and integral to the functioning of all of healthcare.

Yet, radiology lives in a paradox. Our profession utilizes near-miraculous technology to view the source of illness in a living person, but then manages the flow and delivery of that information within a locally disjointed and non-standardized information-technology (IT) infrastructure. This disaggregated information technology is the world you know well. It is the array of variously functional and dysfunctional applications you use to add value to your part of the radiology value-chain every day.

Consider how this world of disaggregated technology works for a radiologist: It means that you might have to manually enter information from your PACS into your voice-dictation system, including accession numbers, patient and exam demographics, comparison studies; your report and templates may or may not be standardized to those of others in your practice and certainly not with others in your industry; peer review, 3D image post-processing, and radiation dose registries may or may not be part of your standard workflow.

It means that routine generation of clinical performance analytics is spotty across all of radiology, including turnaround-time metrics, real-time RVU-output and load-balancing metrics, and Physician Quality Reporting System (PQRS) compliance; demonstrable quality metrics and population-health management are either lacking or require heroic efforts to generate; patient portals and other tools that empower patients to schedule, view, and distribute examinations may or may not be available—and likely not integrated with other systems.

In short, our locally amalgamated systems of imaging viewers, voice dictation, image archiving, and all of the various enhancement tools bolted on along the way create an underperforming value chain that chronically frustrates patients, providers, healthcare systems, payors, and those of us working in radiology. This reality also leads to a clear imperative: We need to redesign the complete arc of the radiology value chain. Our reward will be a system that simultaneously increases quality, decreases costs, and improves service.

The local value chain

Where can we start? Opportunities for improving the radiology value chain reside in the macroeconomic and microeconomic zones of radiology. In the macro zone, we can anticipate growing vendor awareness of the need to build integrated systems. In the micro zone, or the zone that we individuals work in on a daily basis, the imperative is for us to be critical of the workflows and processes that support the value chain of our world. This is not a new imperative but rather one that has to be reenergized in light of the unprecedented pressures of radiology to demonstrate quality, reduce cost, and improve services.

Furthermore, we have to understand that improving our local value chain does not entail tradeoffs between quality, cost, and service—the three dimensions of performance of any value chain. Consider a simple example: Tightening the integration between PACS and standardized templates in a voice-dictation system simultaneously improves dictation speeds (cost reduction), ensures incorporation of dose reporting and appropriate PQRS metrics in all exams (quality improvement), and represents information in a standardized and familiar configuration for referring physicians (service). Even with existing technology, the indicated value chain enhancement is often possible but underutilized.

This simple example is meant not as a specific directive, but rather as a clear illustration that cost, quality, and service do not compete against each other when a value chain is optimized. In fact, each is simultaneously enhanced.

There is good reason to be optimistic that the existing field of disjointed information systems will give way to more integrated, higher-performing systems. Just as our profession and industry rode the wave of technology in the 20th century that revolutionized image acquisition through the proliferation