Q&A with Duke University Health System Vice Chairman of Radiology, IT, & Clinical Informatics Christopher Roth, MD: “Enterprise Imaging Has Part to Play in Addressing Shrinking Margins”

In a perfect world, the only thing imaging professionals would have to consider is how to improve clinician workflow and thus, satisfaction, along with patient safety. Of course, the world is far from perfect, as demonstrated by healthcare’s shrinking margins. So those professionals must do their part to keep the enterprise as robust as possible. When it comes to imaging, Duke’s Dr. Christopher Roth talks about increasing good dollars in and decreasing bad dollars out. On the good side, he cites efforts to improve patient scheduling and, thus, throughput; while on the bad side he talks about ways to decrease storage costs and reduce application expenditures by consolidating vendors. In this interview with healthsystemCIO Founder & Editor-in-Chief Anthony Guerra, Roth covers these issues, point of care ultrasound considerations and many others.

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Bold Statements

… it’s a really big space, and it’s really hard to do everything well. So any organization is going to have to prioritize what they choose to do well.

… there’s a lot of opportunity out there, a lot of interest out there, a lot of shiny things that are appealing to our physicians that we want to be able to really look hard at and say, ‘What’s going to work? What matters to us? What is it we want to pay the most attention to, and what’s going to deliver the most return on the human time and dollars that we want to deploy?’

It’s a core issue and it’s been around for a long time, and it’s certainly something that floats up to the CMIO or CIO level that, ‘Hey, it’s taking me a really long time to do my job. I’m tired. I’m not feeling like I want to be part of this organization if you’re not going to support me.’ And that becomes a recruiting and retention-type issue, and it’s hard to find good clinicians these days. 

Anthony: Welcome to healthsystemCIO’s interview with Dr. Christopher Roth, Associate Chief Medical Officer for the Imaging Service Line and Professor of Radiology at Duke Health; and Vice Chairman of Radiology, IT, and Clinical Informatics with Duke University Health System. I’m Anthony Guerra, Founder and Editor-in-Chief. Dr. Roth, thanks for joining me.

Dr. Roth: Thank you, Anthony.

Anthony: All right, great. So we’re going to have a fun chat today. Let’s start off by telling me a little bit about your organization or organizations and your role.

Dr. Roth: Sure, thanks. I have been a neuroradiologist for 15 years at Duke. I transitioned into IT around 2011 and I’ve been progressively doing more and more around the organization within radiology and beyond. The beyond part is a little bit interesting because the perception of radiologists that they’re stuck in a room and they don’t really go too far outside of that, I think that’s growing increasingly uncommon. In particular, because many of the imaging technologies that we use are very similar in some ways to some of the other things that are happening elsewhere in the system. And we have some best practices, some good ideas that we can share with all of those places around the health system that really haven’t had the decades of experience that we have.

So part of what my job has evolved into, both as the vice chair of radiology for my department and also leading the imaging service line, which is the group of imaging specialties, when it comes to considering both the technology but also the quality and safety and capital requirements, people, access, growth, all the different things that we’re trying to do, is to really go out and share best practices in imaging across the entire health system so that we can all learn from each other and be sure we’re taking care of patients well.

Anthony: Very good. You mentioned the service lines, and I think there’s some macro things that we’re looking at when we look at this issue. So imaging, would you say imaging is essentially being done everywhere now in every service line? It can be as simple as photos taken with a phone camera, point-of-care ultrasound. But is there anywhere imaging isn’t being done? I guess that’s something to talk about.

Dr. Roth: Yes, so I would say imaging is pretty much done everywhere, but I would bucket imaging as clinical multimedia capture and use. Because you can imagine audio/video in sleep labs or in the operating room or in a clinic. If you’re asking some patient to do something on a physical exam, you might capture a small piece of video to show the way they walk or to show the way their face moves when they try to make an expression that shows the impact of a stroke or something like that. It is both audio/visual and also still images.

If you consider that, I think we all have different ways to capture multimedia today and use it in our daily lives. And it’s easy to imagine applying all of those to healthcare. So a lot of the providers that are in the health system today have different ways to capture and create such multimedia and we’re using it regularly.

Anthony: Let’s talk about your strategy. I want to accomplish two things. I want to understand some of the things you’re working on and things you’ve accomplished both in the last year and that you’re working on and moving forward. So I want to bring to light some of the interesting things that you’re doing, but I have a suspicion that you’re way farther ahead than many, many, many hospitals and health systems. And so, I also want to do a component of this discussion on how to get started, like real basic stuff. Would you agree that – I mean, there has to be a huge spectrum of imaging maturity going on in healthcare. Anyway, wherever you want to jump in there.

Dr. Roth: Thank you, I appreciate it. So one of the things that we are working on, obviously, when you consider technology, you have to consider the impact to the clinical operations and the business. The clinical priorities for us today are people, how are we getting patients into our health system, how are we growing, do we have any big safety issues that we need to address, improving our financial positions, capital budgeting, operational budgeting, margin improvement, what are we doing with payers, things like that. And then you think about it from the perspective of what can technology bring to the table to improve all of those things.

So in terms of imaging, we’ve got a number of different irons in the fire. If you talk about access, it’s how can you get imaging out directly to patients in patient portals. How can you get them education, so they know what is on their images and what their report really means. To what extent can you improve what you’re doing with technology with respect to tech space, AI, artificial intelligence. What ways can you save money with respect to moving gobs and gobs of data, whether clinical or innovation/research to the cloud in a way that meets your cybersecurity profile expectations, in a way that meets your expectations with respect to clinical speed and efficiency. How can you help patients set up appointments for themselves and really take ownership of their care. All of those are imaging-related things, whether you consider diagnostic imaging, such as is common in radiology, cardiology, obstetrics, ophthalmology. You can consider the documentation-type images and the evidentiary images or multimedia that all of us are capturing, too. For example, the photograph in the OR, the photograph in the ED with dermatology or plastics in clinic spaces. Endoscopy, point-of-care ultrasound, it’s a really big space that’s up there, and it’s really hard to do everything well. So any organization is going to have to prioritize what they choose to do well.

For us, I think there’s a number of things that we’re focused on, certainly patient access, new clinics. I would add a cloud migration of much of our data in the next year or two. Cybersecurity is always on everybody’s mind and being sure that systems we have are secure. Point-of-care ultrasound when it comes to enterprise imaging for us is a big one. We have not done a terrific job historically with how we do point-of-care ultrasound across all of the different environments where it is done. So that is one that is very front of mind for us. The rush of text-based and pixel-based AI is happening now, and there’s a lot of opportunity out there, a lot of interest out there, a lot of shiny things that are appealing to our physicians that we want to be able to really look hard at and say, ‘What’s going to work? What matters to us? What is it we want to pay the most attention to and what’s going to deliver the most return on the human time and dollars that we want to deploy?’

So that’s a pretty big answer, but it reflects the fact that imaging is a really horizontal technology space and clinical operations space across all of the health systems that do imaging, which is pretty much everybody.

Anthony: Yes, very good, very good. You mentioned prioritizing what they want to do well or what to work on. Does it start with, where are our clinicians having trouble? Where are they getting frustrated? For example, if you have a clinician who wants to get a well-rounded view of the patient, and there’s imaging studies that have been done that reside in different PACS requiring multiple logins in order to get that view. I mean, that’s something that frustrates doctors. Is that one of the core issues here, because we have these silos in the ologies, so to speak. We have data silos, we have imaging silos, we have multiple systems, and that requires, again, multiple logins, and that’s frustrating for a clinician. Is that a core classic issue in this space?

Dr. Roth: It’s a core issue and it’s been around for a long time, and it’s certainly something that floats up to the CMIO or CIO level that, ‘Hey, it’s taking me a really long time to do my job. I’m tired. I’m not feeling like I want to be part of this organization if you’re not going to support me.’ And that becomes a recruiting and retention-type issue, and it’s hard to find good clinicians these days.

I think that is some of it, but even at a macro level higher than that, the decisions that we are tending to make right now are largely, in many cases, dictated by finance. It’s an uncomfortable conversation to have. But there are lots of products out there that help physician workflow to a degree, but there are much bigger wins out there financially that touch on getting patients through the door, touch on getting new clinics in very active areas of your community, that focus on delivering faster patient care and really help the bottom line. And I think something that’s happened as COVID dollars have gone away, inflation has happened. Nurses are costing more money, everybody, everything construction wise and in terms of technical infrastructure, costing more money. I think there are a lot of health systems out there that are acutely feeling the financial crunches that they have, and their operational capital budgets are beginning to reflect the fact that things are tightening up in ways that were uncommon before the pandemic.

So while you say clinical efficiency matters, I think that is some of it, and burnout is a real thing that can impact recruiting and retention. I think the bigger one than physician workflow today is how can we maximize the resources that we have? How can we be sure that we’re saving money where we can, turning off systems that we’re not using effectively? How can we get patients through the door? Things that will ultimately bolster the bottom line and allow a really robust period of growth for hopefully the next couple of years.

Anthony: Ok, so if the mandate is to cut costs and increase revenue, how does that translate into the imaging space? What should imaging professionals focus on?

Dr. Roth: Yes, so I mean really simply, it’s more new dollars in and less bad dollars out. So let’s break it down that way. More new dollars in is – how can I support new clinics that my organization is strategically targeting? How can I rebuild my scheduling system, my electronic health record? If you’re in a diagnostic imaging space, instead of seeing patients every 30 minutes, you see them every 20 minutes. How can I speed up how quickly the staff can work through their work every given day so that they’re able to turn patients around quickly?

I think those are some of the obvious dollar-up ways, and when you think about cost down, what are we talking about? We’re talking about what systems are you using today, but really not that many people are logging into them and maybe you can replace them or downsize them because they’ve become obsolete. To what extent can you move your data off premise and to a cloud provider such that you’re not having to buy new storages and pay people within your organization. You’re instead thinking about software as a service and cloud services to be able to scale storage costs for the really high amounts of data that all of us are getting today. If you just take a step back from that for a minute, over the last 15 years, radiology volumes have gone up by about 300 percent and the data in each imaging study has ballooned. So you’re actually accelerating how much you are capturing every single year in terms of imaging data. And by the way, that applies to cardiology and other imagers as well. So how can you cut costs on the staff that you have or redeploy those staff to other things? That’s one of the things that we’re doing. We’re not getting rid of staff. What we’re doing is, in many cases, redeploying those people to other things. So if you’re going to bring in an AI application that makes images faster, or gets to a diagnosis faster, we are taking those people that used to do old jobs and putting them in refreshed jobs covering AI applications.

We are thinking about, how can we consolidate our vendor partners. So today, we have a huge number of point-of-care ultrasound modalities across 21 different vendors because we had not taken a consistent holistic approach until the last couple of years in terms of having some preferred vendors that we would work with. So what that means is you wind up with, if a clinician goes from point A to point B, they’re faced with an unfamiliar device. They may not know how to use that device well. They may not feel comfortable using it. So we are trying to get some standardization with the modalities so that those providers can capture what they need to and tie with point-of-care ultrasound specifically, put a documentation platform right behind it, so that those physicians who today, in many, many, many cases across the country, are taking an ultrasound image and put a transducer on a patient, capture an image and make a decision but don’t document, don’t bill, they don’t store that image. We have found that that is not best practice. We want to find a way to capture those images, capture the documentation so that we can bill and support the bottom line a little bit. So I think there are a lot of opportunities out there. I listed a number of them, that’s certainly not an exhaustive list but those are some of the ones that we are paying a lot of attention to today.

Anthony: Yes, lots of stuff that we can go into there. You mentioned the – do we use the term POCUS? Do we like that? Does that work?

Dr. Roth: I think it’s fine. That’s fine.

Anthony: You mentioned POCUS everywhere. Everyone’s got their own. But you talked about the concept of a documentation platform behind it, would this be something, and again, you’re educating me here a little bit, would this be something other than a PACS system or other than an EHR, some other system?

Dr. Roth: There are ways that you can capture images. There’s basically two ways that imaging happens out there in the world, and I’ll just break them down quickly. So one is an orders-based workflow. An orders-based workflow is like what physicians would be familiar with in radiology. There’s an order in a clinic that goes to a location where that order is going to get fulfilled. It may be an echocardiogram. It might be an x-ray. It might be an OB ultrasound, whatever it happens to be. And then there are images captured in documentation. That’s the very familiar aspect of how imaging happens traditionally. What has emerged over the last five or 10 years are different ways to do encounters-based imaging. And what an encounters-based imaging way is, is there’s not an antecedent order in many cases, because it’s hard to know what order you might put in and the number of orders you would have to build across photography, across point-of-care ultrasound, across endoscopy of different organ systems and different body parts just gets to be overwhelming.

So what an encounters-based workflow for imaging does is the imaging is captured first, it goes to a system, it may be within the health record, the electronic health record, or it may be a third-party system where those images stay briefly and then documentation happens either in the EHR or that third-party system to describe what it is that happened during that imaging encounter. I did an upper endoscopy, and I found a polyp in the trachea. I did a point-of-care ultrasound, and I found an effusion around the heart, and I drained it. Different things like that, and then you build the documentation to go to the electronic health record, billing to happen in the electronic health record, but you’re starting with the images rather than starting with the order. So your question of point-of-care ultrasound is a really complicated one, because different people in every organization, you use point-of-care ultrasound differently and you need to meet them wherever it is they are.

At our organization, we got our physicians, our risk management, we got compliance, we got clinical engineering together. This was last July, and it was a group of about 30 or 35 people, and we had a meeting a week about point-of-care ultrasound. It was really intense, and we hit on some really big, complicated topics. Who are our preferred vendors? What are the requirements of a point-of-care ultrasound exam, which by the way we landed on: you have to store an image or a video clip from that, and you have to have a discrete result in the electronic health record. And those, while simple sounding, are actually technically difficult to do and very much uphill for the physicians who might be doing it. But we as an organization made the case that, look, we have risk management problems, there are compliance issues potentially. You want to think about the much bigger picture of point-of-care ultrasound and how it impacts the entire organization. That same group looked at credentialing and privileging of physicians. It’s not technical in any way for a CIO group like this, but it is very much an issue when there are providers who feel empowered enough to pick up an ultrasound but may not be adequately trained to make those clinical decisions. And that’s something that came up in the meeting that we had.

So those kind of things, point-of-care ultrasound is very much a technical consideration, but it’s also a very operational consideration that has a bunch of sacred cows in it that all of these sites need to consider before they really approach the technical standardization of workflow. So while yes, there are systems that will support documentation and billing of point-of-care ultrasound, they have to be able to apply to an ICU or an OR setting where a patient is trying to die on you, all the way to a family practice clinic where somebody is just walkie-talkie normal and you’ve got plenty of time to do the documentation in an entirely different manner.

Anthony: We only have a couple of minutes left. There’s so much here. Okay, quick question, I’m throwing in two more questions. Number one is, and again, where I’m coming at this from is CIO, CMIO, I’m very interested in understanding the optimal relationship between IT leadership and imaging leadership on the clinical side as you go through this. What are your thoughts there? Do you feel like you’ve got like one foot in each world, like you are almost the CMIO-type person but specifically for imaging?

Dr. Roth: Yes, I think that’s true. The thing with imaging is it’s all technical. It’s all informatics. Everything that is imaging today has some flavor of electrons flowing through a pipe that has an on switch somewhere, it has a storage somewhere, it has documentation needs. It’s different than supporting an ambulatory clinic. It’s different than supporting an OR, because in imaging, by definition, everything is informatics. So one of the fortunate parts of the role that I have is that I do have a good backing in informatics as a board-certified informaticist, but also, I have a clinical leadership position that allows me to be sure that the different ways that we’re providing imaging care across our organization are architected well.

So not every organization is going to have somebody who understands that. But I think it’s critically important that there is at minimum good communication between the technical folks who support the imaging – who understand the imaging space and the imaging IT space – with clinical leadership who can help make the decisions around purchases, around build, around how work is going to happen in each of these clinics – if somebody isn’t able to cross into both worlds like I do.

Anthony: All right, very good. I think I’m going to sneak in one final question. Do we want to think of this as getting all roads to lead back to the EHR? I mean, is that the holy grail that the clinician is in the EHR, the patient record, and it’s right there, or one click, they can see everything. They can find that PoCUS study that was done with the documentation, is that the true north?

Dr. Roth: Absolutely, it absolutely is. That has not changed. All of us put in EHRs many years ago because of HITECH and it is still the place, it is still the source of truth, it is still the place that everybody gathers to figure out what on earth is going on with this patient so you must be able to get all of that clinical multimedia, whether it’s still images – still images that are from a camera phone or from a scope or from a DICOM modality – audio, video, whatever it is. It all has to live ultimately in the electronic health record. But you have to be able to supplement the electronic health record with the right information, whether it’s imaging metadata or reports, to be able to accommodate those workflows that are highly variable across all of our organizations.

Anthony: Right, because just looking at the pure cold image may not be helpful at all to a clinician. They need that metadata, that reading, why was this ordered, who ordered it, what was the result, did anybody analyze this? They need all that, correct?

Dr. Roth: And I would add, there are more and more stakeholders in the electronic health record for all of our organizations. Payers increasingly want to know what imaging has gotten done, and in some cases, they want to be able to access that image to preauthorize a follow-up study. It has been something we’re trying to figure out. Patients as part of a patient portal, we have tried to empower our patients with letting them know not just what their report is, that’s years ago. Let’s give them access to those images. Let’s help them actually transfer images from site A to site B if they have to change where their care happens. Give them the necessary tools to understand what their imaging actually shows. Referring physicians, we’re all getting more connected to our community referring physicians. You have to find different ways to connect people around imaging insofar as they need it when they need it.

Anthony: That’s wonderful, Dr. Roth. I want to thank you so much for your time today. I really appreciate it.