Thursday, November 29, 2012

The Siemens RSNA Press Conference
...and some thoughts on IT

For the third year running, Siemens has somehow acquired the idea that I'm a true journalist, a member of the press, and invited me to their annual RSNA Press Conference. In return, I'll report to you what was said.

Presiding over the conference was Dr. Hermann Requardt, (PhD in Physics!) CEO of Siemens Healthcare, with Dr. Gregory Sorensen, (Neuroradiologist) CEO of Siemens Healthcare North America, in the supporting role. 

Dr. Requardt blended optimism with realism, noting that the healthcare market continues to expand, although we must continue to temper this with cost containment and determine ways to achieve the balance. The US was (and probably will continue to be) the lead market in this business, the target market most receptive to innovation. However, the European market is flattening, and the Far East is ramping up healthcare spending. But, "if you can't pay your physicians, you can't buy new MRI's," says Dr. Requardt, and that's certainly true. Even so, Siemens orders were stable from 2011 to 2012, with revenue and profit increasing slightly.

Probably stung by the barbs thrown at healthcare spending, especially directed at imaging, Siemens acknowledges a dramatic need for efficiency, and doesn't want to be seen as part of the problem, but rather the solution, "which is innovation," according to Dr. R. One somewhat surprising part of the solution: less expensive, entry-level, "good enough" scanners manufactured in China by Siemens are being sold world-wide, and actually moving quite well here in the good old US of A. (Dr. Sorensen later said that HALF of these "good enough" scanners are sold to the US, and conversely, their high-end machines sell well…in China.)

Siemens grasps that the mountain of data thrown at radiologists is nothing short of disruptive, terming it a "Data Tsunami". The solution is to be found within IT, which becomes the enabler for productivity.

Siemens is making the best of the Accountable Care movement, viewing it as a US-driven movement from "what's wrong with the patient" to "what's going to help the patient," assuming that outcome-optimized medicine will be based on knowledge.

Dr. Sorensen then gave a brief overview of Siemens' past, present, and future. It turns out that Siemens is the largest and oldest company in the world, dabbling in everything from power plants to power Doppler ultrasound, yielding a background of durability and long-term outlook. He revealed this year's Breakthrough Innovations:
  • The First Wireless Ultrasound probe, allowing for cordless scanning, say in the operating room. You can see Dr. Sorensen holding the probe above. 
  • Their new full-field mammography offering will have the lowest available dose, 30% lower than the competition. 
  • New Angio suite. 
  • Interpretation software for AmyVid, Lilly's new amyloid PET agent. Apparently, the interpreting physician will be blinded as to patient history for this scan. (Not that we get one anyway)
  • Siemens will soon offer the "highest performance" 3T MR, the Prisma. 
For the future, Dr. Sorensen notes that 20-40% of US healthcare is wasted, often because we pursue diagnostic dead-ends. "The value of knowing is paramount, and the worst treatment is the treatment you didn't need."

Siemens optimistically (can you say wishful thinking?) believes ObamaCare will sharpen the US market, though they think we will still stay in the lead. To this end, they must improve upon their value-based product, with the hope that demand for high-end products will continue.

The team lastly traced the cyclic nature of health care spending with respect to the growth and contraction of any particular national economy: “From Underinvestment to Cost Cutting.” We’re clearly beyond the fat years, and into the last stage. And it seems that there is usually a time-lag between recovery of an economy, and recovery of the health care industry. I’m not holding my breath on that one.

I want to revisit the point about IT being the solution, the enabler of healthcare. (I'm assuming they don't know some of MY IT people, although I realize that isn't what Dr. Requardt meant.)

The sentiment was also reflected by Paul Chang, M.D., in his Eugene P. Pendergrass New Horizons Lecture, "Meaningful IT Innovation to Support the Radiology Value Proposition."  (Note that the information on lectures to follow is from the RSNA Daily Bulletin.) PACS, according to Dr. Chang, is a "commodity-level service". To really show the value we rads provide, we need IT. First, IT provides advanced workflow to help quality in radiology, and help all the clinicians get their needed information as well. Rads used to collaborate with clinicians daily, looking over the old-style films. PACS has done away with that to a considerable extent. We need to follow the examples of the new social media, says Dr. Chang, like Facebook and Twitter, which leverage the technology of the Web to share content and collaborate virtually. We need to improve how we mine data from our reports and the EHR in general, an area where we are woefully behind. And, we need to demonstrate our value directly to the patients, using IT to connect to them as well as to the clinicians. "We have to become irreplaceable and add measurable, demonstrable, and differentiable value to our clinical colleagues in this aligned environment," said Chang. "We have to be perceived as irreplaceable in this aligned model and have to provide evidence ... and demonstrate to that aligned enterprise that we truly add value," Chang said. "In other words, we need to be a differentiable value innovator."

Next, let's consider the contributions of Dr. Keith Dreyer, who gave another New Horizons Lecture, "The Future of Imaging Informatics: Meaningful Use and Beyond". The development of PACS and so forth was driven, said Dr. Dreyer, by the imaging necessities under the soon-to-be historical fee-for-service payment system that incentivizes volume while being neutral on value, with a focus on maximizing productivity and volume and reducing the cost of doing business. Since the US Government wants to lower costs, we are now steered toward bundled payments and accountable care organizations that "shift risk from the payers to the providers...and even to us..."  Meaningful Use arose from the need to monitor this transition. "Radiologists need to adapt, not only for incentives, but because this is where the future of healthcare is headed. Previously, technology was driven toward improving productivity while reducing costs, but in the new model, the push is to improve the quality of care, access and safety, with the assumption that those improvements will reduce costs."

"At the expense of some productivity, we're going see a dramatic increase in quality that will be measurable by metrics that we'll be required to measure but also an increase in relevance," said Dreyer.

"They really haven't been optimized for performance metrics such as quality, safety, access, and outcomes," he said.

If radiologists were incentivized by outcomes, they would likely want, for example, to open up a chat session with referring clinicians who have questions on a difficult case they recently read to guide them through it. If the motive was patients first, they might wish to have a system that extended that chat functionality to patients, Dreyer said.

Meaningful Use ". . . provides a fertile ground for innovation in radiology access, communication, and utilization..."

We should add the opening statements of Dr. George Bisset III, RSNA president, as quoted on

"What I mean is owning our patients' problems," he said. "I mean being more fully invested in them, thinking of them as 'our' patients as much as anybody's -- owning their fears and their frustrations; owning their need for clear, understandable information; and owning their health behaviors and capacity to make good health-related decisions. I believe it's time to redefine what we mean by patient care, viewing it not so much as a product we deliver but as a virtue we live and breathe as we go about our daily duties."

Bisset sees the current healthcare chaos as a "golden opportunity." The changing environment of value-driven healthcare is an opportunity to address radiologists' invisibility. He advised paying attention to small details -- even relatively routine exams such as mammograms or chest radiographs may be alarming for some patients. Spend a little time in the waiting room and ask patients what can be done to improve the experience, he added.

To create a patient-centered practice it boils down to four principles, according to Bisset:
  1. Dignity and respect: Healthcare practitioners should listen and honor patient and family perspective and choices.
  2. Information sharing: Healthcare practitioners should communicate and share accurate, complete, timely, and unbiased information with patients and families in ways that are affirming and useful.
  3. Participation: Patients and families should be encouraged and supported in participating in care and decision-making at whatever level they choose.
  4. Collaboration: Patients and families should be included as partners on an institution-wide basis. Healthcare leaders should collaborate with patients and families in policy and program development, implementation, and evaluation. They should also collaborate in healthcare facility design, their professional education, and in the delivery of care.

Well, then. From the luminaries of radiology, you have a relatively bright vision for the future, thanks to IT, and an attitude (marketing?) shift that portrays us as more caring than the clinicians themselves. I hope they're right, of course. But here's where I go off the rails. Since I'm NOT a radiology superstar, or even a dwarf star, I can have a contrary opinion, and no one will notice. And so, contrary I shall be.

I won't quite say that we are seeing the death-throes of radiology, because I think we will always have something to add. WE have become the master diagnosticians, and are often called upon to solve problems before the patient even gets off the gantry. We DO provide value, we DO deliver quality. Of this I am certain. Could we do better? Yes, of course. Of the the viewpoints presented, I'm frankly most in line with Siemens, who wishes to provide IT solutions which will truly help us improve what we do. And to make money in the process. This is what capitalists do, and those who do so the best are those who are flexible and provide what is needed at the proper time. Siemens IT products are quite advanced, and worthy competitors in the world market. (Yes, we chose TeraRecon over syngo.via, but the latter has HUGE potential which I think will be realized in the next few years.)

I have nothing but the highest respect, even awe, for Drs. Dreyer, Bissett, and Chang, and again, I hope their optimistic vision is correct. However, I'm feeling much less certain. Basically, they are saying that first, we need to use IT to comply with the new laws and new paradigms, "quality" metrics and otherwise, brought to us by ObamaCare, and secondly, that we need to do a better job of selling ourselves, and we should use IT tools to make this happen. Frankly, these are not, or should not be, fundamental changes. We should already be communicating to our clinicians, we should already be using advanced visualization and other accoutrements to improve our reads. But...there are HUGE pitfalls awaiting us, and thinking that IT will save us is perhaps naive. I'm very wary, for example, of the ACO concept, where we will be placed in the dichotomous positions of gate-keeper to prevent excess scans, and whipping boy when we DO advise against a scan some clinician (or patient for that matter) thinks he needs. Having a direct Facebook-style connection to our patients sounds good and right, until a patient latches on to us and is incapable of understanding what we are trying to tell them, and becomes belligerent  (Been there, done that, by the way.) Dr. Bissett's comments are well-taken, but for the most part are things we should be doing already, with the possible exception in my little mind of the ultra-high level of communication to the patients, especially of troubling results.

How do we measure our contribution to the patient's outcome, relative to the treatment they receive? Could we provide more quality? No doubt. Many scans could be read better, and we would like to make fewer errors.  But all I'm seeing here are ways to seek out and punish those responsible for "bad outcomes". Incentive to improve? Maybe. But certainly no mechanism is provided. Well, I'll take that back. With the pressure to produce removed, we can perhaps just read one or two studies per day, and we damn well better get those right. Oh. That won't fly either, will it?

As an iconoclast, I'm seeing these measures as being reactive to the new governmental restrictions, and not proactive. We are trying desperately to prove our value, when it's continuously proven every minute of every hour of every day. Radiology isn't going away, but reimbursements are going to plummet, and all of the electronic arm-waving and attempts to add even more value to what we do isn't going to change that. At best, those who play this game better than others will be more likely to be enslaved purchased by their hospitals, soon to be the only game in town, to the exclusion of predatory entrepreneurial groups who can micromanage and tailor their minions to produce whatever metric is desired at that moment.

Innovation is life in this business, as with many others. I'm certainly not rejecting the concept, and I do embrace IT (the technology, not the personell) as our path forward. However, I fear that none of this will change how we are perceived by the government and by our colleagues. At 3AM, the ER docs know quite well how valuable we are, but we will always be the folks with the expensive toys that (in the delusions of many) overspent the healthcare dollar and backed the entire field into the corner in which we now find ourselves. All the computers and all the IT men can't put our reputations together again. Sorry.

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