In 2007, the Institute for Healthcare Improvement (IHI) debuted its performance optimization framework for health care organizations, the Triple Aim. It is anchored in the acknowledgment that health care simultaneously faces spiraling costs, novel challenges, and questions of accessibility to broad segments of America. IHI proposed a framework encapsulating these concerns within a trio of responses, or aims: enhancing patient experience, improving population health and reducing costs.
Ten years later, IHI President and CEO Derek Feeley responded to calls from the world of health care to expand that framework into a Quadruple Aim system, one that would incorporate an additional goal that varied according to the institution proposing it.
“For many organizations, the fourth aim is attaining joy in work,” Feeley wrote then. “For others, it’s pursuing health equity. Some organizations highlight other priorities. The Military Health System, for example, has added readiness as their fourth aim.”
Feeley had no objections to institutions expanding their performance improvement aims, provided that work results in measurable action, keeps the focus on patients and doesn’t undercut the already elusive goals of the initial three aims.
“Feel free to interpret the Triple Aim in a way that makes sense for you and your organization and what you need to achieve but do so in a way that is deliberate and strategic,” he wrote. “Whether you choose to work on the Triple Aim or the Quadruple Aim, understand that you can’t ignore joy in work or equity and expect to secure Triple Aim outcomes.”
In the time since the response to the triple aim ostensibly was expanded, many organizations have embraced health equity and addressing staff burnout as critical to health system optimization, leading to the emergent citation of a Quintuple Aim structure by early 2022. However-many-pronged the attack on systemic challenges a health care institution employs, its achievement requires clarity of approach and consistency of execution.
Dr. Cheryl Petersilge, CEO and founder of the Chagrin Falls, Ohio-based enterprise imaging consultancy Vidagos, said that the idea of achieving the quadruple aim (or triple or quintuple aim), as it applies to the medical imaging space, involves establishing continuity across the many segments of a health care organization that typically operate independently from one another.
“If you think about total quality assurance and imaging, you’ve heard of the comprehensive longitudinal medical record and continuity along the continuum of care,” Petersilge said. “One way you optimize medical decision-making is by making sure all the information is available to the provider at the time they’re making the decision. That’s what improving the patient experience is all about.”
“Images have been extremely siloed,” she continued. “They haven’t been accessible to providers outside of their office space. You’re either making medical decisions without the information, or you’re delaying care. It should be that all of the information is available at the time and location of care, whether it’s generated in your institution or not.”
Electronic medical records (EMR) and electronic health records (EHR) can help facilitate that information delivery and access, if implemented and overseen properly, Petersilge said. As a co-chair of the Society of Imaging Informatics in Medicine (SIIM) Enterprise Imaging Community, she not only appreciates the distinction between the two, but emphasizes that a medical imaging ecosystem is a peer system to EMR, and not subordinate to it. That’s a critical distinction when departments vie for consideration in an enterprise health care structure.
“If you look at both, there’s way more volume of data in the imaging record than there is in the EMR,” Petersilge said. “What medical specialty touches the greatest number of patients? It’s radiology, the big gorilla of enterprise imaging. So why would you consider that record to be an ancillary system? For a radiologist, and now many other imaging professionals, it is imaging system first: you’re paying for those tools, maximize the use of those tools for the imaging professional.”
Rather than working to fit the functionality of specialty imaging modalities and their respective software clients into an EMR-driven workflow, Petersilge argued that working within a modern enterprise imaging structure provides the opportunity for much more sophisticated, imaging-specific processes. These systems set the foundation for workflow automation, as well as the incorporation of imaging-specific AI, and help to support the transition from free text information to discrete data. Doing so will ultimately support overarching institutional goals like those in the quadruple aim, ensuring that patients are best served by optimizing the workflows of the imaging specialists and better utilizing the information they generate.
“You should look at the two systems and say, ‘Which one offers the better functionality for my imaging professional?’” Petersilge said. “That, to me, is huge. One of the areas I focus in on is re-thinking how you search for and access these studies when you’re perusing the electronic record.”
By the same token, she points out that institutions can leverage the patient data that they already have on file to begin to understand and address population health goals. Although not every patient on file will have undergone a medical imaging study, a trove of information among those who have nonetheless exists, which could help project and analyze broader health trends and even pre-clinical disease states.
Better and more seamless information-sharing across departments and institutions also improves the quality of life for health care professionals. Clinicians who can readily access and analyze imaging studies remotely enjoy an experience superior to those who must compile patient information from different data sources. (“Thirty percent of CDs don’t open,” Petersilge pointed out). Smoother data sharing and access also helps to reduce imaging costs by eliminating redundant or inappropriate imaging, and can support offsite care centers when properly networked and centralized.
“If you consolidate them, you can have one central team that can manage all those imaging systems, and standardize so you have workflows that can come off the shelf,” Petersilge said. “It becomes much easier to handle existing modalities, deploy new pieces of equipment and integrate new modalities as they are introduced into the workplace.”
Centralizing supports for medical imaging teams isn’t only important for managing distributed locations or interdepartmental communication; it can also help coordinate remote employees, of which Petersilge points out there are more than ever in a post-COVID (novel coronavirus) work environment.
“Within radiology, many departments went completely remote during COVID; many are preserving at least a portion of their workforce as remote,” she said. “With the radiologist shortages, that’s new. It allows you to retain staff, and for the staff to be more mobile and thus achieve greater work satisfaction.”
Enterprise imaging can also be structured in such a way as to reduce costs while supporting a flexible workforce, particularly by centralizing equipment management and support, Petersilge said.
“If ophthalmology has been managing its own equipment, or goes directly to the vendor, bring them into the enterprise imaging fold,” she said. “They get benefit of IT professionals to help them. I have seen a couple organizations that have been working without an image management system, and it’s a pain point for organizations: they can’t see all the images at once; they can’t see the images in the office with a patient.”
Finally, Petersilge said that in order to truly understand how to analyze and manage these concepts requires moving the health care system to a value-based structure that “really embraces wellness over episodic care” with incentives that lead toward rewarding those outcomes.
Loannis Panagiotelis, chief marketing officer for MR at GE HealthCare, said that his company has endeavored to address patient access to medical imaging and system productivity by increasing adoption of technological solutions that enable shorter scan times and sharpen image technology. AIR Recon DL, a deep-learning-based image reconstruction algorithm, removes image noise and artifacts from scans, leveraging raw image data to scan patients faster without compromising image quality. Panagiotelis claimed the technology, which has been years in development, can sharpen images by as much as 60 percent and cut scan time in half.
To date, GE HealthCare has sold more than 3,000 AIR Recon DL licenses, and installed some 2,000 systems; as of December 2022, the technology already had been used to scan about 5.5 million patients. With that level of adoption, Panagiotelis believes more patients will benefit from its advantages sufficient to address scanning backlogs, patient discomfort in the imaging suite, and even help make radiologists more comfortable during reads.
“We made sure that as many people as possible can benefit,” Panagiotelis said. “We made [AIR Recon DL] available for all our systems – entry-level, mainstream, higher, new systems, legacy systems – and for all anatomies. That has been a grand success.”
Panagiotelis said that the improvements to throughput and efficacy of imaging that AIR Recon DL supports have expanded the reach of MR into studies that formerly were believed to be too complicated or time-consuming for the modality, including prostate screening, musculoskeletal imaging, and gerontological studies.
“It’s become simple and accurate, and that’s why this is taking off,” he said. “It becomes easy for the people to go and have these examinations. We believe it is impactful, but at the same time we are not compromising the procedure. The sharpness of these images is increasing because of the ability to combine studies with new types of contrast without compromising the overall duration of the scan.”
Taken together, the myriad technological advances that work to improve operational efficiency, simplify ease of use of the imaging systems, reduce acquisition time, and enhance workflow “all brings the costs down,” Panagiotelis said. “We go over this process multiple times a year, collect customer feedback, and try to define our products to meet their needs. There are different customer segments, but increasing patient access, clarity of scans — everybody needs these things.”
Leveraging evolving technologies to improve holistic industry metrics like population health requires not only a deep understanding of the processes that underpin medical imaging systems themselves, but also an insight into the communities in which health care institutions operate, and the residents within them that they serve. Finding solutions to improve their specific needs “is really where the big effort is being made,” Panagiotelis said.
“There’s a lot of elements, a lot of effort that we need to take in order to bring the solutions to the market,” he said. “There are multiple elements of technology that we are trying to develop simultaneously that, in the future, may prove of particular benefit for patients in the field of psychiatry — fMRI, fiber tracking, neuroscience imaging. If MRI can enter this field, this will be a major breakthrough.”
“The things we’re trying to do today to make it easier and cheaper, include new techniques that make invisible pathologies visible,” Panagiotelis said. “We want to introduce an element of prognosis, not only an element of diagnosis.”
Dave Bennett, CEO of the Lake Success, New York-headquartered interactive patient solutions developer pCare said that achieving optimal health outcomes hinges upon the recognition that the best patient care is achieved in a workplace that values staff wellness, too. Notwithstanding the extant labor issues in a landscape that is still defined largely by the impact of the novel coronavirus (COVID-19) pandemic on the business of health care, Bennett argues that stresses on the system as a whole can be distilled, in some respects, to stresses on individual professionals.
“How do we really tackle these sort of things and actually improve outcomes?” he said. “How do I focus on attending to their needs – physical, mental, professional and others – while keeping them engaged to focus on cost containment, patient engagement, improvement in outcomes?”
“On top of that, what’s most critical is the financial health of some of the largest health care organizations in the country,” Bennett said. “They’re really in financial jeopardy right now. We’ve seen an escalation in costs, largely labor, and the simple fact of supply and demand. You have a demand for a large number of skilled-trade health care professionals, and that supply is waning. The industry is challenged by those, and that’s why challenging burnout is critical.”
Losing veteran staffers also means depleting institutional memory when they take their years of experience with them upon departing, to say nothing of losing people who’ve learned how to manage staff, control costs, and reinforce institutional culture, to say nothing of the time investment required in training their replacements. However, Bennett argued that some of the stopgaps to addressing such issues, like digital innovation tools, can support the culture shifts that are necessary to optimize the patient experience, thereby supporting overall institutional goals.
“Health care is extremely conservative in its nature,” he said; “health care has to be cautious and take its time, almost to a fault. The speed with which we adopt these things is also an issue, and can have profound impact on organizations. We’re always looking for things that can be force multipliers; something that can be put in place to increase effectiveness.”
Bennett believes that remote technologies that have become more commonplace in the past decade – including advance patient registration, texting with practitioners, patient health portals – will accelerate further, from advanced adoption of telemedicine to increased delivery of virtual services, from rounding to patient navigation to staff intercommunication; all things that can be accomplished offsite as well as within a facility. Personalizing care to enhance the patient experience can also help health care staff to more seamlessly align their own experiences with institutional goals.
“The engineering of people is equally important,” Bennett said. “How does this technology fit into their workday? Is it doing things that are very critical? I hear all too often from health care professionals that this is a hard job. We need to be able to recognize that our staff is making this possible.”
“This digital transformation, and how it aligns with the four aims, is the ability to create mechanisms that go beyond patient satisfaction information, and how to use feedback to be able to recognize those staff for their great jobs,” he said. “We need to elevate our staff and let them know that we really care, they’re doing a fantastic job and they are really making a difference. Health care is a constantly moving target with technology, but there are some core things at the bottom, and that’s the human experience, and how it crosses over everything from patients to clinicians to outcomes.”
