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o We Expect Too Much From Our ITendors? What Can We Do About It?

ndrew Menard, JD, Steven Seltzer, MD, Ramin Khorasani, MD, MPH

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hat a time to be a radiologist!hether you are a battle-hardened

eteran or new to the field, you facedaunting landscape combining

conomic pressures, clinical opportu-ities, and political uncertainty. It islear that imaging has become a vitalomponent of diagnostic and thera-eutic medical practice, and advancesn molecular imaging and image-uided procedures promise to con-inue to expand the importance ofmaging at both ends of the clini-al spectrum. At the same time,igh-cost imaging has becomehigh-priority target for payers

nd policymakers, commoditiza-ion threatens our professional in-ome, and quality and safety ini-iatives (although vital) imposeurdens on our productivity. Fi-ancially, it seems clear that bothechnical and professional feesill fall, and the future of the fee-

or-service reimbursement models uncertain at best.

MBAs and economists will pointut that radiology is not the firstndustry to face such fundamentalhallenges. Using one of the strate-ies to mitigate these risks, likeany other industries, radiologistsay look to IT to help automate

rocesses to improve productivitynd satisfy the demands thathreaten to swamp their core busi-ess. Busy practitioners in 2010ight reasonably expect to find so-

histicated software tools sup-orted by major vendors that willeet their functional requirements

t a reasonable cost, allowing themo keep most of their attention fo-

used on practicing medicine. But q

fter a quick search, those practitio-ers might well be disappointed.A recent article in Health Affairs

1] reported that only 2% of hospi-als would meet the requirementsf the federal government’s “mean-ngful use” criteria. The gulf be-ween today’s broadly available ra-iology IT tools and the optimalolutions needed for tomorrow’sigh-quality, safe, and efficientractice is likely to be equally sub-ptimal. Crossing that gulf willequire more than blaming our ITendors for their current offer-ngs. Clinical radiologists and ourT vendors may have to modifyheir interactions to accelerate theeeded IT enhancements to en-ble meaningful use in our diverselinical practices.

UNCTIONALEQUIREMENTS FOREEDED RADIOLOGY

NFORMATIONECHNOLOGY SOLUTIONS

o have an appreciable impact onhe challenges facing a radiologyepartment every day, a vendoreeds to offer solutions that are ro-ust, flexible, and intuitively us-ble, while satisfying most or all ofhe demands that clamor for atten-ion, including patient safety,ealth care quality, clinical effi-iency, compliance (legal and regu-atory), payer documentation, bill-ng, record keeping, and therowing demands of a rapidlyhanging health care delivery sys-em facing major reform (eg, re-

uirements for meaningful use pro- v

© 2010 Published by Elsev0091

osed by the federal government touality for incentive payments forhysicians [2,3]). The systemsust work well in the various set-

ings in which the radiologists prac-ice (academic or private practice,or inpatient, outpatient, or emer-ency department patients). Dril-ing down a little deeper, a solution

ust enhance the department’sorkflow (meaning that the solu-

ion must be less costly in terms ofime and effort than the oldethod it would replace), allowing

he radiologists to focus on practic-ng medicine rather than beingonsumed by interactions withheir computer. But meeting eachf these legitimate requirementsay impose a series of small tolls on

hysician and departmental work-ow. If this toll is too high, the soft-are solution will face resistance

nd may fail, as many hospitals andoftware vendors have learned.

We should not be surprised thatell-designed systems are rejectedy busy physicians. Software engi-eers, even those working for theost experienced health care ven-

ors, may be too far from the mov-ng target of clinical practice to an-icipate the demands that shapehysician behavior day to day oreemingly minute to minute. Theseendors make some progress whenhey hire physicians as internal ex-erts, but these individuals are rap-dly incorporated into the culturend priorities of the vendor. Atresent at least, radiology practicenvironments and requirements areoo broad and variable for any one

endor to develop and deliver off-

ier Inc. on behalf of American College of Radiology-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.09.002

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he-shelf solutions that are satisfac-ory for all needed functions inost practices. Of course, there are

lso challenges of standards-basedntegration providing ample op-ortunity for finger pointingmong all stakeholders when thingso wrong rather than collectiveroblem solving. The best IT prod-cts then are often seen as naggingoothaches; over time, the painevel tends to increase until theractice opts for another solution,tarting the cycle again.

Home-built radiology solutionsre perhaps even less optimal. Be-ides generally representing an at-empt to express paper processes inoftware (rather than fundamen-ally improving practice), home-uilt systems risk ignoring the im-ense value of the industrial

earning curve. Sophisticated soft-are systems are often too complex

o create, support, and continuallynhance (using proven industrialngineering standards) through thefforts of a few talented peoplerom a radiology practice. Andhere is the nagging worry of USood and Drug Administrationompliance for some software sys-ems. There are opportunities tohange this paradigm within thepen-source community [4], but toate, such efforts and solutionsave not been broadly adopted inur clinical practices.

HANGING OURPPROACH

o solve this multivariate problem,adiologists and radiology groupsight reconsider their relationshipsith their IT vendors, moving from

he transactional customer-vendoraradigm for largely manufacturedoftware solutions (albeit withome customization) toward a col-aborative development-services re-ationship. (In this respect, the de-

elopment of software systems for p

adiology is similar to the develop-ent of advanced imaging technol-

gies.) In such a collaborativeelationship, the radiology groupould engage the vendor in an itera-

ive process designed to accelerate thereation of an optimal solution ratherhan simply selecting and “makingo” with existing products. Some

arge radiology practices (academicnd private) have already createduch relationships, and the approachay be valuable to many more radi-

logy groups and vendors.The goal of the collaborative

rocess is to accelerate the creationnd evolution of more optimal so-utions by allowing the clinical pro-ess and workflow knowledge resi-ent in the radiology practice tohape the software solution thatest fits the specific radiology envi-onment. The vendor would pro-ide its bench of talent, processes,echnologies, and experience, accel-rating both the development ofhe solutions and iterating these so-utions as radiologists provide feed-ack from actual use.In some cases, the iterative pro-

ess may have unexpected value as aadiology process improvementystem and even a risk managementtrategy. Besides allowing the par-ies to continuously improve theoftware solutions provided by theendor, the “feedback and iterate”rocess may become bidirectionals insights created through the in-eractions lead to streamlininghanges in the radiology group’sorkflow. This bidirectional feed-ack loop encourages the forma-ion of a virtuous cycle that opti-izes both the software solution

nd radiology workflow. In oururrent environment of uncertaintynd potentially rapid change, suchvirtuous cycle may help radiologyroups adapt and survive. For theseeasons, it may be suboptimal for

rivate practice groups to rely solely a

n software solutions crafted byendors working closely with largecademic practices. Such solutionsay not fit, and private groups may

nd themselves unprepared for ma-or environmental changes. It is alsoqually likely that insights contrib-ted by broader participation ofrivate practice groups will en-ance the value of IT solutions forcademics.

It is important to recognizehat this process imposes newosts on radiology groups. Creat-ng optimal solutions will requireadiologists to invest their ownime, energy, and creativity, di-ectly affecting clinical revenue inhe short term, hopefully to gen-rate dividends in productivityver the long term. These costsay be heavily front loaded, but

eriving continuing value will re-uire a continuing investment.It is also worth considering the

currencies” that radiology groupsnd vendors would exchange in thisaradigm. A fair exchange of values mandatory for compliance rea-ons, as well as from the economicerspective. Besides the dollars ra-iology groups will pay vendors,hey will contribute the time, ex-ertise, ideas, and insight of theiradiologists and staff members. Ineturn, they will receive solutionshat are better tailored to theireeds and, hopefully, feedbackrom vendor experts that helproups improve radiology work-ow and processes. Balancinghese currencies will require bothides to call in their lawyers tonalyze issues such as fraud andbuse and intellectual property,ut over time, standardized ap-roaches may emerge.Our specialty has long valued

ollaboration with industry on a va-iety of initiatives (eg, advanced im-

ging technologies). The funda-

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ental driving force behind suchollaboration has been the percep-ion and reality of value betweenractitioner and industry. A newollaborative model for developinghe required IT solutions is sorelyeeded to help us cope and flourish

n this era of unpredictable and

apid change.

EFERENCES. Jha AK, Desroches CM, Kralovec PD, Joshi

MS. A progress report on electronic healthrecords in U.S. hospitals. Health Aff (Mill-wood). Available at: http://content.healthaffairs.org/cgi/content/full/hlthaff.2010.0502v1.

. Office of the National Coordinator forHealth Information Technology. Health ITPolicy Council recommendations to national

coordinator for defining meaningful use.

Available at: http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_888532_0_0_18/FINAL%20MU%20RECOMMENDATIONS%20TABLE.pdf. AccessedSeptember 15, 2010.

. Khorasani R. Health care reform through mean-ingful use of health care IT: implications for radi-ologists. J Am Coll Radiol 2010;7:152-3.

. Nagy P. Open source in imaging informatics.

J Digit Imaging 2007;20(suppl):1-10.

ndrew Menard, JD, Steven Seltzer, MD, Brigham and Women’s Hospital, Boston, Massachusetts.amin Khorasani, MD, MPH, Brigham and Women’s Hospital, Center for Evidence-Based Imaging and the Department ofadiology, 1620 Tremont Street, Boston, MA 02115; e-mail: rkhorasani@partners.org.