From Stewardship to Leadership: The Evolving Role of Radiology in Care Transformation

Headshot of Pamela T. Johnson, MD, FACR

Pamela T. Johnson, MD, FACR

Pamela T. Johnson, MD, FACR, vice president of care transformation for the Johns Hopkins Health System, vice chair of Quality & Safety in Radiology and professor of Radiology & Oncology at Johns Hopkins Medicine, and Founder of the High Value Practice Academic Alliance, and Norman J. Beauchamp, Jr., MD, MHS, executive vice president for Health Sciences at Michigan State University (MSU), and past dean of the MSU College of Human Medicine, contributed this post.

According to the Organization for Economic Cooperation and Development 2017 Health Statistics, the United States spends more on healthcare than any other country. It does so despite having one of the younger populations and a relatively low consumption of healthcare services, as reported in the book Priced Out: The Economic and Ethical Costs of American Health Care. A recent article in the Journal of the American Medical Association estimates 2019 healthcare expenditure at $3.8 trillion and wasteful expenditure as high as $935 billion.

If we can reduce the magnitude of the dollars lost in waste, we can help safeguard healthcare affordability and ensure more resources to spend on social determinants of health such as education, job creation and neighborhood environment. The question many would ask is, “When will they do something about this?”

As medical providers, we are accountable for three of the six categories of waste: failure of care delivery, failure of care coordination and overuse or low-value care. Recognizing a responsibility to refine care delivery, clinicians across the country are implementing performance improvement initiatives to increase efficiency, effectiveness and affordability of medical care.

Imaging has become a cornerstone for diagnosis and management decision making, but utilization does not always adhere to appropriate use criteria, despite an expansive library championed by the American College of Radiology® (ACR®) – including the ACR Appropriateness Criteria® evidence-based guidelines. Overuse adds unwarranted risk and cost for the patient. Unnecessary imaging can be reduced by bolstering adherence to appropriate use criteria through education, clinical decision support and provider feedback reports.

Torso shot of Norman J. Beauchamp, Jr., MD, MHS

Norman J. Beauchamp, Jr., MD, MHS

An equally important goal in imaging stewardship efforts is to increase use of radiology exams that can reduce more costly elements of care, like hospitalizations, surgery and chemotherapy. Examples include evidence-based breast and lung cancer screening, diagnosis of coronary artery disease in stable chest pain with coronary CTA and surveillance of abdominal aortic aneurysms. Despite evidence that imaging improves outcomes for these clinical conditions, many patients are not benefitting from the radiology due to lack of adherence to best practice guidelines and disparities in care delivery.

Value-based care transformation prioritizes quality, safety and outcomes while reducing cost of care. Diagnostic radiology effectiveness assessments have been limited to process measures like report turnaround time, and our existing peer review platforms do not effectively determine how interpretations affect management decision making. We need more robust clinical measures for imaging quality, which reflect how our interpretations affect patient outcomes. Efforts to develop quantitative, scalable measures are evolving and, as a profession, it is incumbent on us to once again demonstrate accountability.

Radiologists’ potential to lead care transformation goes beyond improving imaging appropriateness and developing imaging-related outcome measures. With knowledge of all aspects of medicine and surgery required for board certification and an understanding of the importance of diagnostic and management efficiency and effectiveness, radiologists are uniquely poised to lead all of care transformation. This begins by serving on the teams directing care transformation in your medical center, and if there are no dedicated committees, creating one by inviting faculty from medicine, surgery, emergency medicine, pediatrics, etc., to partner on imaging, lab and medication stewardship as a start. Value-based performance improvement requires multispecialty collaboration to be successful.

Our field has a unique opportunity to substantively impact our society in a time of great need by refining care. We chose this field because we could have a scalable impact on the care of a great number of patients every day. Our specialty is defined by being interprofessional, collaborative, innovative, patient-centered and ever-evolving. Let’s apply our aptitudes and values to the imperative of care transformation.

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Peer Learning is Paving the Way Toward Continuous Improvement

Headshot of Jennifer Broder, MDJennifer Broder, MD, vice chair of Quality and Safety, Lahey Hospital and Medical Center Department of Radiology, and Vice Chair, American College of Radiology® (ACR®) Commission on Quality and Safety, contributed this post.

Continuous improvement is the dedication to the proposition that we can always become better. One of the necessary features of continuous improvement in our clinical work is ensuring that we have a system in place to identify our clinical errors, consider why they happened and learn from them. For many years in radiology, a formal documented random score-based peer review model has been used as one of the tools to accomplish this.

What we all know, though, is that while this score-based peer review model was running in the foreground, in the background during the course of our daily work we have been tapping each other on the shoulder, leaving each other notes in our mailboxes or sending emails saying, “Hey, take a look at this. Thought you would want to know.” More often than not, that communication was for cases that had  presented challenges, potential misses, things that people felt we would  struggle to discuss as “teachable moments.” We would privately look, wince, learn and gather the courage to move on.

Over the past few years, there has been a group of radiologists who have been asking the questions: What if we could reduce the shame associated with the identification of those errors? What if we could bring all that learning out into the open so that not just one radiologist learns from their mistake, but we all learn together? Would that help us collectively improve our performance? If so, could we do without the scoring aspect altogether? The model of peer review that has resulted from those conversations has been named “peer learning” and is described in the 2016 sentinel article Peer Feedback, Learning and Improvement: Answering the Call of the Institute of Medicine Report on Diagnostic Error published in Radiology. In a peer learning model, cases with learning opportunities—whether discrepancies or great calls—are identified during the course of one’s regular work day, submitted to a central coordinator with description, but without scoring or other expression of judgement, and then the feedback is shared with the interpreting radiologist for feedback. The coordinator chooses the highest yield cases to share with the rest of the community, most often anonymously during departmental cases conferences. Further, the learning from these conferences is then channeled into generating systems improvements.

Across the country, we’re seeing an increasing awareness of peer learning and adoption across diverse practices — whether your practice is small or large, academic or private, diagnostic or interventional, we are seeing that peer learning can be implemented anywhere. Enthusiasm for the model is growing rapidly.  Almost 370 people signed up for the recent American College of Radiology® Implementing Peer Learning webinar, during which nine panelists from various practice settings across the country joined me to help answer people’s questions about how to gain support for the transition and manage the practice details of program implementation.

Transitioning to peer learning takes some work, but it well worth the effort, and there are many more resources to help you. For instance, there is also the 2017 article Practical Suggestions on How to Move From Peer Review to Peer Learning which helps guide implementation and video recordings from the ACR-sponsored National Peer Learning Summit.

  • Does your facility practice peer review or peer learning? How do you think a shift toward peer learning will impact the culture at your institution?

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Working Together – and with Others – to Move Radiology Forward

Headshot of Dr. Howard B. Fleishon with dark gray background

Howard B. Fleishon, MD, MMM, FACR, chair of the American College of Radiology® (ACR®) Board of Chancellors, contributed this post.

The ACR is working with more than 50 other national medical societies to avert reimbursement cuts due to the Medicare Physician Fee Schedule evaluation and management (E/M) code changes that will soon go into effect.

The COVID-19 pandemic has already caused a major disruption and financial hit to various specialties within the healthcare provider community – including radiology. As patients begin to return for care, the recovery for many practices may be slow. Any further reimbursement reductions may jeopardize their ability to serve their patients.

As you may know, the ACR has created and gathered a number of microsites with resources to help us through this largely unprecedented national health event.

Now, many areas are beginning to reopen. Please know that we continue to work on your behalf to help you and your practice recover from COVID-19 and provide the best care to your patients.

Together, we are weathering the storm. And together, we will move the profession forward – whatever the future may bring.

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