Patient Centered Screening for Lung Cancer

This month the Journal of the American College of Radiology features an outstanding article describing barriers to lung cancer screening in the context of behavioral economics. This article offers a nice complementary perspective to Porter’s Five Forces where lung cancer screening barriers are analyzed using an industrial economic model.

The pictured ACR Lung-RADS matrix is deceiving in its simplicity.  This graphic represents decades of research, advocacy, and hard work from ACR members, staff, government, and academic partners. In my experience, most radiologists focus on the column labeled “Management”. However, few customers, either internal or external, appreciate the weight behind the management recommendations. Their attention, understandably so, tends to focus on the immediate desire to determine malignancy. Radiologists may do well to adopt a patient centered perspective and shift their focus to the column labeled “Probability of Malignancy”. After all, this information speaks to the underlying clinical concern.

Prediction and decision making is fraught with errors; breaking down future management into probabilities is the best way to combat errors and biases. Equipped with the probability information, customers are able to make the most informed decision about future management, thus combating the biases identified in the JACR article. Patients with a high deductible health plan can make rational decisions about when to schedule their next screening exam, if at all. Incorporating the probability information into a standardized Lung-RADS template requires no additional work for the radiologist after a one-time IT investment.

Shared decision making and patient centered care are important concepts changing the landscape of medicine. By increasing patient engagement, we expect better compliance and outcomes. Most customers do not expect radiology participation in this effort yet engagement with a radiologist has a unique power to impact patient experience. By delivering a more patient centered approach to lung cancer screening, we can impress our customers with the unexpected value of our expertise. Delivering probability information to our customers can enhance the value of radiology, rational acceptance of collective management recommendations, and improved morbidity and mortality.

The Importance of Human Resources in Customer Service

A contracted mobile CT scanner brought in to support a VA hospital CT construction project sits idle in a parking lot due to a lack of human resources. With a rumored cost to taxpayers of approximately $45,000/month there are no technologists available at the institution to run the scanner and provide veteran access to this important imaging service. Furthermore, the absent human resources has prevented timely access to CT services during second/third shifts, and weekends, affecting the Emergency Department and inpatient veterans who need scans. Many of these after-hours studies are being outsourced to a local private hospital, requiring the added cost of ambulance transportation.

Meanwhile, daytime scans are being performed on an in-house low quality 16 slice hybrid SPECT/CT machine, potentially displacing veterans who need nuclear medicine exams.

As the idle mobile CT unit continues to collect dust in the parking lot one employee quipped, “I hope that thing is gone before the snow flies or it will burn.”

Let’s hope it is another mild winter. More attention needs to be paid to the relationship between VA Human Resources and veteran access.  As Human Resources is the link between internal customers (employees) and external customers (veterans and their families), their mission is critical.

A Duty to Scan

Imagine a Veteran’s Hospital where taxpayers have provided tens of millions of dollars of CT and MRI equipment. Imagine that hospital has a 8-12 week backlog of veterans who would benefit from these exams and salaried radiologists ready to interpret the images and pass that knowledge back to the organization’s customers.

Continue to imagine there is a bottleneck; the technologists needed to move veterans through the scanners are not available. Does that Veteran’s Hospital have a duty to hire as many technologists as possible and maximize the capacity of those scanners? Does the hospital have a duty to scan, and is it negligent not to do so? If a principle mission of the Veteran’s Hospital is responsible stewardship of taxpayer resources, the answer is yes. Let me explain.

Currently our Veterans Administration has the ability to outsource clinical duties to private hospitals when demand cannot be met internally. However, when they do so in Radiology, taxpayers must reimburse a small piece of the investment that the private hospital made in their own scanner. This is known as the technical component of the fee and that private hospital will send a bill to the taxpayer that includes it. If the scanner at the VA were being run at peak capacity this technical component paid to the private hospital would be justifiable. However, if there is idle capacity in the hardware at the Veteran’s Hospital, taxpayers are effectively buying something that they have already purchased.

Stewardship of taxpayer resources would suggest there is a duty to scan within the VA system and that outsourcing of imaging is only appropriate when that VA equipment is being run on weekends and second shifts. It is critical to have an administration and Human Resources department that understands this duty.