ACR CHAIR’S MEMO
JAMES A. BRINK, MD
Providing Higher Value Care Through
Population Health Management: What Is the
Radiologist’s Role?
Medicine is not an exact science, and
the uncertainty of medicine relates
heavily to a long-held view of medicine
as an art. Jeffrey Campbell [1] stated
that “developing a tolerance and
healthy respect for uncertainty, as well
as recognition of the prominent role
it plays in a patient’s experience of
illness, is a fundamental component
in our ability to provide effective and
empathetic care.”
Although the uncertainty of medi-
cine factors heavily in the care that is
provided to an individual patient, the
Triple Aim for Health Care Reform [2]
calls for better care for individuals,
lower costs through improvement, and
better health for the population. It is
this need to provide better health for
the population where the uncertainty
of medicine becomes most problematic.
In its “Roadmap for Provider-Based
Automation in a New Era of Health-
care,” the Institute for Health Tech-
nology Transformation [3] states,
The goal of population health
management.is to keep a
patient population as healthy as
possible, minimizing the need
for expensive interventions such
as emergency department visits,
hospitalizations, imaging tests,
and procedures..Population
health management requires
healthcare providers to develop
new skill sets and new
infrastructures for delivering
care..Automation makes
ª 2016 American College of Radiology
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population health management
feasible, scalable and sustainable.
A key tenet in these descriptions
of population health management is
the need for automated or semi-
automated tools to assist with data
integration, analysis, reporting, and
communication to improve the health
of a population on a broad scale.
Although population health man-
agement is not yet adopted broadly
throughout our country, the Medicare
Access and CHIP Reauthorization
Act set the stage for value-based pay-
ments and put 9% of our fee-for-service
revenue at risk by 2022. At the Massa-
chusetts General Hospital, population
health management has been imple-
mented and continuously refined for a
number of years. The internal perfor-
mance framework (IPF) defines the
measures and tools needed to succeed in
this arena. The IPF elements are divided
into three buckets focused on quality,
medical expense trend, and strategy.
The quality measures focus much on
the classic topics one would expect in a
population health management portfo-
lio: diabetes, depression, bronchitis,
asthma, weight loss, and so on. Efforts at
reducing medical expense trend consti-
tute the second bucket in the IPF. In
Massachusetts, state law requires medi-
cal expense trend to stay below a 3.6%
increase annually. Some efforts in this
category are focused on reducing leakage
of imaging studies performed in our
health care system to outside networks.
The third bucket in the IPF focuses
on quality and efficiency strategies,
including opportunities to engage
specialists in population health man-
agement. Here, radiologists can parti-
cipate equally with their specialist
colleagues from a wide range of disci-
plines. Suggested activities for specialists
include virtual visits, active referral
management, patient-reported outcome
measures, procedure order entry and
decision support systems, clinical care
bundles, care redesign, and variation
reporting and control.
Active referral management
through an e-consult program gives
specialists input through e-mail-based
e-consults rather than in-person visits,
allowing patients to avoid long waits.
Virtual follow-up visits enable patients
to receive routine follow-up care in
their homes or offices, increasing
clinical capacity for new, urgent, and
complex patients. Procedure order en-
try and patient-reported outcomes
guide patients and physicians through
common procedures by providing risks
and benefits at the point of clinical
care and decision making. Specialty
care management enables care man-
agers to address complex care coordi-
nation needs. Care bundles enable
efficient care delivery for defined
episodes of care. Finally, variation
reporting and control provide sufficient
guidance and data to physicians and
practices about their laboratory, phar-
macy, and radiology ordering patterns
to reduce practice variation.
759
 Variation reporting and control is
where I believe radiologists have the
greatest opportunity for contribution to
population health management. I am
never more embarrassed for our pro-
fession than when profound variation
in how we do our business is brought to
our attention. On June 17, 2011, the
New York Times ran an article titled
“Medicare Claims Show Overuse for
CT Scanning” [4]. On the basis of data
available at the Hospital Compare
website, the Times concluded that 200
hospitals “administered double scans
[ie, CT scans performed with and
without intravenous contrast material]
on more than 30 percent of their
Medicare outpatients.” The national
average is 5.4%, and best practice for
the thorax is probably less than 1%.
The authors concluded that “double
scanning is more likely to occur at
smaller, community hospitals” and
identified one such hospital that
performed double scans in 89% of its
Medicare chest patients.
Practice variation in radiology can be
achieved at both the front end of the
imaging chain through clinical decision
support (CDS) provided to ordering
physicians, guiding them to the appro-
priate imaging examination (ACR
Select). In addition, computer-assisted
reporting provides best practice clinical
guidelines to radiologists as they interpret
imaging examinations and can reduce
variation at the back end of the imaging
chain, particularly when radiologists are
making recommendations for clinically
significant findings (ACR Assist).
CDS for order entry has been in use
at the Massachusetts General Hospital
since 2004. It has become very much a
part of the culture of this institution.
Although several studies have docu-
mented the benefit of CDS for reducing
The author has no conflicts of interest related to the material discussed in this article.
James A. Brink, MD: Massachusetts General Hospital, 55 Fruit Street, FND-216, Boston, MA 02114-2698; e-mail: jabrink@
partners.org.
760
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variation in order entry, I will highlight a
few examples that typify the high level of
acceptance and value for CDS within
this institution. One senior primary care
physician reported that several years ago,
she started showing patients what deci-
sion support says when they insisted
on imaging examinations she believed
to be inappropriate. In exasperation, she
would turn the computer screen in her
office toward patients to show the results
of decision support for their symptoms.
These patients now ask what decision
support says when they are discussing
whether an imaging examination is
warranted for their clinical scenarios.
Some departments have adopted
the rate with which inappropriate im-
aging examinations are ordered as an
ongoing performance practice evalua-
tion metric. Indeed, the degree to
which decision support has become
integral to the culture of this institu-
tion is most encouraging as we try to
manage the health of our population,
and it typifies the automated or semi-
automated tools that are needed to
achieve such benefit on a broad scale.
Although decision support for ra-
diologists is at least a decade behind
decision support for referring physi-
cians, the expected benefits from such
systems are equally exciting. By
providing clinical guidance at the point
of radiologic care, radiologists can draw
on tools to help guide them to a uni-
form description of findings and, more
important, a uniform recommendation
for a clinical scenario. First described in
2011 [5], CDS for radiologists allows
imaging-based care algorithms to be
integrated directly into the dictation
platform, enabling their use at the point
of care. If radiologists apply the same
algorithms to the same imaging sce-
narios, then variation in radiologists’
Journal of the American College of Radiology
reports will be reduced, including
variation in the description of imaging
findings, characterization of lesions,
and recommended next steps.
The ACR sees the value of these
tools in reducing practice variation for
the benefit of our population’s health
and has committed substantial resources
to further develop and distribute deci-
sion support for referring physicians as
ACR Select and decision support for
radiologists as ACR Assist. The goal of
both of these systems is to find the sweet
spot of appropriate imaging utilization
that maximizes our population’s health
at an appropriate cost. Overutilization
risks increased cost and decreased health
because of the needless workup of
false-positive and incidental findings.
Underutilization decreases population
health by not providing the benefits of
medical imaging and image-guided
intervention to those that would
benefit most from our services. I am
confident that with these semi-
automated CDS systems, radiologists
can participate in population health
management through meaningful
reduction in practice variation. The art
of medicine is not dead, it’s just different.
REFERENCES
1. Campbell JI. Art and the uncertainty of
medicine. JAMA 2014;312:2337-9.
2. Berwick M, Nolan TW, Whittington J. The
Triple Aim: care, health, and cost. Health Aff
(Millwood) 2008;27:759-69.
3. Institute for Health Technology Trans-
formation. Population health management: a
roadmap for provider-based automation in a
new era of healthcare. New York: Institute for
Health Technology Transformation; 2012.
4. Bogdanich W, McGinty JC. Medicare claims
show overuse for CT scanning. The New York
Times. June 17, 2011. Available at: http://
www.nytimes.com/2011/06/18/health/18
radiation.html?_r¼0. Accessed June 3, 2016.
5. Boland GWL, Thrall JH, Gazelle GS, et al.
Decision support for radiologist report recom-
mendations. J Am Coll Radiol 2011;8:819-23.
Volume 13 n Number 7 n July 2016