is a Professor and Vice-Chairman, Radiology Informatics, and
Medical Director, Pathology Informatics, University of Chicago
Pritzker School of Medicine, and the Medical Director, Enterprise
Imaging, for the University of Chicago Hospitals, Chicago, IL.
In radiology informatics and information technology (IT), we are
constantly challenged to provide a sustainable infrastructure that
supports the needs of the radiology department and enables imaging
throughout the healthcare enterprise. In the early days, many of us
thought that radiology informatics was defined merely by
digital image management and its promise to eliminate X-ray
film. Once we accomplished that goal, we realized that
optimization of workflow was even more important.
Too often, electronic practice tools are viewed as turnkey
solutions. In reality, installation of a picture archiving and
communication system (PACS) or a speech recognition system will not
fix a “broken” radiology practice. The improper
application of electronic-based systems can make
deficiencies in workflow even more glaring.
Unless we are willing to dramatically re-engineer the radiology
department and our own attitudes and practices, we will not only
fail to successfully leverage and exploit these advanced imaging
tools, we may threaten the perceived value of radiology and
participate in its marginalization or commoditization.
From a strategic perspective, our true goal is to build a
technology infrastructure that ensures the relevance and value of
radiologists in taking care of patients. Those of us in informatics
and IT need to incorporate into our strategic planning a view of
radiologists as value innovators.
The concept of value innovation was first introduced
by Michael Porter in his 1985 book,
Competitive Advantage: Creating and Sustaining Superior
Value innovation is the never-ending task of re-examining what we
provide that is of value to our customers. We must always ask
ourselves: Are we relevant? Do we add value? And we must
continuously re-engineer our workflow and our attitudes
to add that value.
In a modern economy, there are 2 ways to compete. If your
product or service is perceived as a commodity—that is,
undifferentiated from competing products or services—the only
legitimate basis on which to compete is price. Toilet paper, for
example, is a commodity.
Another way to compete is to provide a product or service that
is perceived as having additional value that can be differentiated
when compared with other products and services. An iPod (Apple
Inc., Cupertino, CA), for example, is perceived to have more value
than other MP3 players.
The question is, as radiologists, are we providing a commodity
that can be outsourced anywhere or are we providing true value?
The answer depends on how we see ourselves and what kinds of
service we provide. In arriving at that answer, it is important to
ask customers what is important to them and how well we're
succeeding in meeting those needs.
Once we have defined those axes of value, it is
possible to plot a value curve. Figure 1 shows value curves for 3
different types of radiology practices.
The value curve for a typical academic radiology practice shows
very high value in the number of imaging services provided.
However, academic practices tend to fall short when it comes to
other components that are valued by customers, such as examination
ordering and patient comfort.
The services provided by a competitive, successful
community-based practice are quite different from those provided by
an academic practice, and they result in a characteristic value
curve that is also different. The “competitive” practice may not
deliver as many imaging services, but it excels in services that
are perceived as being of value to the customer, including
examination ordering and scheduling, patient comfort and
convenience, and report turnaround time.
True value innovators go even further, identifying where they
are on the value curve, where they want to be, and the gaps in
between. Then, and only then, do they acquire technology that best
suits and addresses those gaps, whether it be PACS, teleradiology,
a radiology information system (RIS), voice recognition, structured
reporting, Web-based physician order entry, multimedia Web reports,
or patient Web portals(Figure 2).
The iPod effect
Before identifying gaps in value, it is important to understand
who the customer is. In the context of radiology, our customers are
our referring physicians and, ultimately, our patients. Today,
patients are active health consumers, and, like other consumers,
their characteristics have changed over the last 10 to 15 years.
Let’s call it the iPod effect.
From functional point of view, the iPod could be considered an
inferior product. For example, it doesn't come equipped with FM
radio, and it locks users into a particular application, iTunes.
Yet the totality of the experience is viewed as seamless,
attractive, and very positive. The reason the iPod is successful is
that it addresses 3 major drivers of the modern-day
consumer-characteristics that drive our modern-day healthcare
consumer as well.
The first driver of the iPod effect is real-time
delivery, or “I want it now.” In the past, if customers ordered a
music CD and received it in the mail a few days later, they were
happy. Then it became possible to place an online order before
midnight and receive the CD by express delivery the next day. Now,
we can go to iTunes and download music onto the iPod immediately.
Real-time delivery of service and product is a critical driver and
one of the reasons the iPod has been so successful.
When it comes to medical care, that same expectation is valid.
Many of us in hospital-based radiology practices have confronted
the increasing demand to provide same-day service. A patient comes
in in the morning for a magnetic resonance imaging (MRI) study or a
positron emission tomography/computed tomography (PET/CT) scan, and
the patient wants the interpretation in his or her oncologist’s
hands that afternoon, so therapy can begin immediately (Figure 3).
Clearly, the drive for real-time delivery of service is going to
continue and is one of the reasons certain technologies such as
speech recognition have become so important.
The second iPod characteristic is no-compromise service. From
the elegant interface to the seamless integration with an
industry-leading, comprehensive iTunes library, the iPod offers
users a listening experience that is without peer.
In healthcare, patients have developed similar expectations. In
the past, there was an asymmetrical distribution of healthcare
information-that is, the doctor always knew more than the patient.
This is no longer the case. Who is more motivated to know
everything about a disease than the person who has the disease?
With the resources available on the Web, many patients are
extremely knowledgeable. After all that research, they want
optimized, no-compromise service. As a result, we can no longer
differentiate ourselves as physicians who add value by simply
knowing more than our patients. Instead, we must take on the role
of consultant and manager, becoming the person who helps shepherd
the patient through a complex process. Patients will no longer
settle for second-best.
The last driver is personalized service. With the iPod, we can
select our own music. We no longer have to listen to someone else’s
selection on the radio. With amazing advances in genetics and
proteomics, physicians will be able to provide customized therapy
for patients. That same driver is going to be relevant in
radiology. For example, optimized image protocols that are tailored
to the specific patient will require much more capable
integration of information systems.
Another major driver in radiology is the concept of pay for
performance, or “no outcome-no income.” Can radiologists
successfully play this game? I believe we can. However, critical
requirements for success will include massive improvements in
efficiency, productivity, and cost-effectiveness—in other
words, optimized information throughput.
Electronic-based technology and informatics can be important
enablers of value innovation, if we’re willing to re-engineer our
processes. When it comes to improving efficiency in
information throughput, we must go beyond such simple measures as
enhancing patient throughput or reducing report turnaround
The turnaround time that really matters encompasses the entire
service chain. It spans from the time a physician decides to order
a study to the time at which information is available from that
study to help the clinician create a patient management plan. To
truly improve turnaround time, we must re-evaluate examination
ordering and scheduling, patient registration, examination
acquisition, examination interpretation, report authoring, and
It is clear that we must do away with film and paper.
Instead, we must embrace electronic-based informatics systems. To
do this, we need much better integration of electronic information
systems and modalities within those systems. To date, a lack of
integration is one of vendors’ biggest failures.
Time-motion studies repeatedly show that technologists waste too
much time typing information from one electronic system to another.
We also need greater integration in communicating context. It makes
no sense for technologists to have to tell a RIS that they have
completed a study. “Performed procedure” steps and other kinds of
technology can do that automatically.
In addition, we will need to make major improvements in how we
communicate. Simply sending out reports in a timely fashion willno
longer be adequate. We must be much more engaged and
In considering the difference between communication and
collaboration in radiology, it is useful to think about the
evolution of the Web. Radiologists typically use a PACS the way
people used an old-fashioned Web 1.0 application. We sit in a dark
room, and information or images come to us. Our clinicians are not
interacting with us, and we’re not collaborating with them. This is
one reason radiology can be easily commoditized and
Today, kids don’t use the Web to passively receive information
in isolation from one another. They use such applications as Skype
(SkypeTechnologies, Luxembourg), instant messaging, MySpace
(MySpace, Inc., Los Angeles, CA), and YouTube (YouTube, LLC, San
Bruno, CA) to foster virtual collaboration and active
Radiologists and vendors must re-evaluate applications from this
Web 2.0 perspective, re-engineering them in a way that fosters
collaboration with clinicians (Figure 4). The goal is to match the
appropriate communication method to a specific clinical
context. Messaging, Web conferencing, multimedia reports, and other
electronic communication models can all be very helpful.
Radiology must be willing to continuously re-engineer and
reinvent itself to fully exploit electronic technology. Information
systems canplay a significant role in helping
radiologists to evolve from being simple providers of information
to true collaborators. If we choose to make this transition, we
will avoid being marginalized and commoditized. Instead, we will be
able to show that we add true value to patient care.