Re-engineering radiology
in an electronic world:
The radiologist as value innovator
To avoid becoming a commodity, radiologists must continuously ask how they can add
value to patient care—and how technology can help achieve that goal.
Paul J. Chang, MD
I
n radiology informatics and infor-
mation technology (IT), we are con-
stantly challenged to provide a sus-
tainable infrastructure that supports the
needs of the radiology department and
enables imaging throughout the health-
care enterprise. In the early days, many
of us thought that radiology informatics
was defined merely by digital image
management and its promise to elimi-
nate 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 real-
ity, installation of a picture archiving
and communication system (PACS) or a
speech recognition system will not fix a
“broken” radiology practice. The im-
proper application of electronic-based
systems can make deficiencies in work-
flow even more glaring. Unless we are
Dr. Chang is a Professor and Vice-
Chairman, Radiology Informatics, and
Medical Director, Pathology Informat-
ics, University of Chicago Pritzker
School of Medicine, and the Medical
Director, Enterprise Imaging, for the
University of Chicago Hospitals,
Chicago, IL.
December 2008
willing to dramatically re-engineer the
radiology department and our own atti-
tudes and practices, we will not only fail
to successfully leverage and exploit
these advanced imaging tools, we may
threaten the perceived value of radiol-
ogy and participate in its marginaliza-
tion or commoditization.
From a strategic perspective, our
true goal is to build a technology infra-
structure 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 strate-
gic planning a view of radiologists as
value innovators.
Value innovation
The concept of value innovation was
first introduced by Michael Porter in his
1985 book, Competitive Advantage:
Creating and Sustaining Superior Per-
formance.1 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
www.appliedradiology.com SUPPLEMENT TO APPLIED RADIOLOGY
perceived as a commodity—that is,
undifferentiated from competing prod-
ucts 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 dif-
ferentiated 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 out-
sourced anywhere or are we providing
true value? The answer depends on how
we see ourselves and what kinds of ser-
vice 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 dif-
ferent types of radiology practices.2 The
value curve for a typical academic radi-
ology practice shows very high value in
the number of imaging services pro-
vided. However, academic practices
tend to fall short when it comes to other
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RADIOLOGIST AS VALUE INNOVATOR

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 success-
ful is that it addresses 3 major drivers of
FIGURE 1. This graph illustrates the value curves for 3 different types of radiology practices. The
value curve for a typical academic radiology practice (pink) shows very high value in the number
the modern-day consumer—characteris-
of imaging services provided, but it tends to fall short when it comes to other components that are tics that drive our modern-day healthcare
valued by customers, such as examination ordering and patient comfort. A competitive, success- consumer as well.
ful community-based practice (yellow) may not deliver as many imaging services, but it excels in The first driver of the iPod effect is
services that are perceived as being of value to the customer. Value innovators (green) identify real-time delivery, or “I want it now.” In
where they are on the value curve and where they want to be, and then they acquire technology
that best suits and addresses those gaps. (Graph created from data in Schomer et al.2)
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
FIGURE 2. This chart summarizes the various electronic technologies and the services they
confronted the increasing demand to pro-
enable. (PACS = picture archiving and communication system; RIS = radiology information vide same-day service. A patient comes
system; VR = voice recognition; SR = structured reporting; POE = physician order entry; in in the morning for a magnetic reso-
PWP = patient Web portal; MWR = multimedia Web reports.) nance imaging (MRI) study or a positron
components that are valued by cus- True value innovators go even further, emission tomography/computed tomog-
tomers, such as examination ordering identifying where they are on the value raphy (PET/CT) scan, and the patient
and patient comfort. curve, where they want to be, and the wants the interpretation in his or her on-
The services provided by a competi- gaps in between. Then, and only then, do cologist’s hands that afternoon, so ther-
tive, successful community-based prac- they acquire technology that best suits apy can begin immediately (Figure 3).
tice are quite different from those pro- and addresses those gaps, whether it be Clearly, the drive for real-time delivery
vided by an academic practice, and they PACS, teleradiology, a radiology infor- of service is going to continue and is one
result in a characteristic value curve that mation system (RIS), voice recognition, of the reasons certain technologies such
is also different. The “competitive” structured reporting, Web-based physi- as speech recognition have become so
practice may not deliver as many imag- cian order entry, multimedia Web re- important.
ing services, but it excels in services ports, or patient Web portals (Figure 2). The second iPod characteristic is no-
that are perceived as being of value to compromise service. From the elegant
the customer, including examination The iPod effect interface to the seamless integration
ordering and scheduling, patient com- Before identifying gaps in value, it is with an industry-leading, comprehensive
fort and convenience, and report turn- important to understand who the cus- iTunes library, the iPod offers users a lis-
around time. tomer is. In the context of radiology, our tening experience that is without peer.

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 RADIOLOGIST AS VALUE INNOVATOR

In healthcare, patients have developed

similar expectations. In the past, there A
was an asymmetrical distribution of
healthcare information—that is, the doc-
tor 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 dis-
ease? With the resources available on the
Web, many patients are extremely knowl-
edgeable. 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 con-
sultant and manager, becoming the per-
son who helps shepherd the patient
through a complex process. Patients will
no longer settle for second-best.
The last driver is personalized ser-
vice. With the iPod, we can select our
own music. We no longer have to listen B
to someone else’s selection on the radio.
With amazing advances in genetics and
proteomics, physicians will be able to
provide customized therapy for pa-
tients. That same driver is going to be
relevant in radiology. For example,
optimized image protocols that are tai-
lored to the specific patient will require
much more capable integration of infor-
mation systems.

Information throughput
Another major driver in radiology is
the concept of pay for performance, or
“no outcome–no income.” Can radiol-
ogists successfully play this game? I
believe we can. However, critical re-
quirements for success will include
massive improvements in efficiency,
productivity, and cost-effectiveness—
in other words, optimized information
throughput.
Electronic-based technology and in-
formatics 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 turn-
around time.
FIGURE 3. (A and B) Features such as “Find a Physician” simplify and speed the task of deliv-
ering urgent radiology findings into the proper hands—in this case to both (A) a referring
hematologist and (B) the primary care physician.
The turn-around time that really mat- acquisition, examination interpretation,
ters encompasses the entire service chain. report authoring, and report delivery.
It spans from the time a physician de-
cides to order a study to the time at Collaboration
which information is available from that It is clear that we must do away with
study to help the clinician create a pa- film and paper. Instead, we must em-
tient management plan. To truly improve brace electronic-based informatics sys-
turnaround time, we must re-evaluate tems. To do this, we need much better
examination ordering and schedul- integration of electronic information
ing, patient registration, examination systems and modalities within those

December 2008 www.appliedradiology.com SUPPLEMENT TO APPLIED RADIOLOGY ©

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RADIOLOGIST AS VALUE INNOVATOR
A about the evolution of the Web. Radiol-
B way that fosters collaboration with clin-
FIGURE 4. (A and B) Multimedia reports enhance collaboration with clinicians.
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
8 ■ SUPPLEMENT TO APPLIED RADIOLOGY
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 commu-
nicate. Simply sending out reports in
a timely fashion will no longer be
adequate. We must be much more
engaged and collaborative.
©
www.appliedradiology.com
In considering the difference be-
tween communication and collabora-
tion in radiology, it is useful to think
ogists 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 eas-
ily commoditized and marginalized.
Today, kids don’t use the Web to pas-
sively receive information in isolation
from one another. They use such applica-
tions as Skype (Skype Technologies, Lux-
embourg), instant messaging, MySpace
(MySpace, Inc., Los Angeles, CA), and
YouTube (YouTube, LLC, San Bruno,
CA) to foster virtual collaboration and
active participation.
Radiologists and vendors must re-
evaluate applications from this Web 2.0
perspective, re-engineering them in a
icians (Figure 4). The goal is to match
the appropriate communication method
to a specific clinical context. Messag-
ing, Web conferencing, multimedia
reports, and other electronic communi-
cation models can all be very helpful.
Conclusion
Radiology must be willing to continu-
ously re-engineer and reinvent itself to
fully exploit electronic technology.
Information systems can play a signifi-
cant 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 commodi-
tized. Instead, we will be able to show
that we add true value to patient care.
REFERENCES
1. Porter ME. Competitive Advantage: Creating
and Sustaining Superior Performance. New York,
NY: Free Press; 1985.
2. Schomer DF, Schomer BG, Chang PJ. Value
innovation in the radiology practice. RadioGraphics.
2001;21:1019-1024.
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December 2008