President’s Corner #10: The MR Value Proposition

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This coming Sunday, February 18, 2018, colleagues will gather in Washington, DC for a workshop on High-Value MRI. This workshop, which will be co-provided by the ISMRM and the RSNA, is the brainchild of our own Jim Pipe, past president of the ISMRM and architect of our ongoing MR Value Initiative1, who has been ably assisted by a thoughtful cadre of organizers and other stakeholders2. The two-and-a-half-day program will be focused squarely on one thing: The MR Value Proposition.

We the practitioners and boundary-pushers of magnetic resonance may not always be inclined to question the value of what we do every day. The rest of the world has no such hesitation. In a healthcare landscape increasingly organized around efficiency, and tectonically tilting toward value-based metrics, it is generally viewed as irresponsible not to question the return on investment of any medical test or procedure. As a consequence, the value of imaging has been the subject of lively discussion in political and economic circles, amongst both the payers and the recipients of healthcare reimbursements, in industries that rely upon imaging for their business models, and, to a lesser extent, in academia.

Those of us who depend upon clinical revenues for our livelihoods and our research support are increasingly confronted with a challenge: over the course of the last decade, reimbursements have continued to get smaller as our imaging datasets grow ever larger. How are we to meet this challenge? The way I see it, we have two fundamentally different choices: image less, or image more.

Image less: According to one perspective, it is past time to trim and tailor our time-honored imaging protocols. For all the pride we may feel in the progress of MR technology, information content, imaging speed, and workflow efficiency, it is clear that day-to-day practice is not as streamlined as it could be. Many pulse sequences don’t necessarily lead to actionable information, or to changes in outcome for our patients. So perhaps it is time to drain the sequence swamp. Or, to put it more positively, perhaps it is time to focus on answering well-defined clinical questions definitively. Here, there is an essential role for innovation.  For example, we can prioritize the development of abbreviated MR examinations that may not utilize the full range of contrast mechanisms available, but that contribute substantively to diagnosis and management in a rapid and cost-effective manner. Abbreviated examinations have already seen noteworthy success in the area of breast MRI, to cite one example, and other areas are sure to follow. Of course, it is worth noting that, if we can demonstrate sufficient clinical value for MR to become a first-line test in areas where it has traditionally been only a follow-up option, we may end up increasing the net utilization of MR.

Image more: That is one perspective. According to another perspective, though, it is important that we not limit our collective innovation to a process of abridgement of existing imaging protocols. It is highly unlikely that we will weather the current economic storm by cutting alone – by imaging less and less, even if we do so to better and better effect. ‘No-one ever led by cutting,’ a wise and well-informed mentor of mine recently said to me. As the history of the Industrial Revolution and the current Information Age amply illustrates, the world is ultimately changed by innovation that introduces new value into the balance. The invention of MRI, after all, created dramatic new value for medicine and human health, and our field of MRI has a long history of productive reinvention.  This perspective suggests another imperative: to create new value. To answer not only existing but also new clinical questions. To change workflow entirely. To give physicians and patients not merely what they think they need, but what they never imagined they could have. Here, of course, lies another opportunity for innovation. To cite just one example, active research in our field is currently being devoted to the acquisition of rapid, continuous, comprehensive and quantitative data streams which would appear, at first glance, to be quite the opposite of focused, high-value exams. Despite their apparent complexity, such approaches hold the potential to streamline imaging workflow dramatically, cutting through the operational complexity of traditional MR protocols, and eliminating wasted non-scanning time. Such approaches may also be well suited to AI algorithms designed to extract key features from multidimensional datasets, enabling personalized assessment of individual patients as well as far-ranging research in large populations. We should not hesitate to embrace such new paradigms, along with more tailored approaches, so long as they truly prove to change the MR value proposition. We should also work together to figure out how to apply rigorous standards of value to such studies, early and often. Finally, any conversation about value would be incomplete if we did not acknowledge that MR is not only a clinical endeavor – it is also a powerful tool for basic discovery. There is undeniable value in the generation of new knowledge for a wide array of disciplines, and few tools have shown as wide a reach as MR. Let us also not forget that basic discovery has, time and again, led to clinical translation and generation of still further unanticipated value.

So then. Shall we image less or image more? That is the question. Or is it? Recall the lessons of Complementarity (see previous President’s Corner posts #6 and #7). Both perspectives will be represented at the High-Value MR workshop, and perhaps both perspectives are correct. The key is not to forget one perspective while under the sway of the other. When all is said and done, I think, we should investigate not only how to image less, or how to image more, but how to image differently, and, ultimately, better.

A great deal of work remains in order to lay the groundwork appropriately for value-based MR research and practice: establishment of concrete metrics of value and comparative effectiveness, conversations with insurers and policy-makers, and alignment of incentives and funding mechanisms for research and development focused on high-value imaging (see the recent US government roadmap for medical imaging research and development, for example).

There is at least one more imperative for all of us in the context of the MR value proposition, and this is to tell our story. It falls to us to communicate the value of MR to those who do not understand it or take its wealth of capabilities for granted. It is up to us to promote the benefits of MR to the public, to diverse scientific disciplines, and to diverse clinical specialties that touch upon our community. This is something about which we can no longer be complacent.

You will not, perhaps, be surprised to learn that both the objective of increasing value and the imperative of telling our story is represented in the new ISMRM strategic plan, a draft of which will soon be released for public commentary and collective iteration. The plan will be a living document, aimed at engendering conversation about our dynamic role in a rapidly changing world. Regardless of how the coming changes play out, one thing is clear: we want to add value. We want to provide key actionable information that changes the way patients are treated.   We want to move the needle in understanding our world, and in liberating ourselves from disease.

For those of you who are not registered for the upcoming workshop on High-Value MRI, sign up now! As of the time of this writing, there are still some spaces available. Even if you are unable to attend, consider joining in the value conversation in other ways.  In private moments, too, considering asking yourself, as the world would ask you, how what you do is of value, and how you might prove and improve that value. If you have ideas, please tell us here at the ISMRM, and we will find a way to share.

Next time: Your new ISMRM strategic plan

1 Were I to have consulted Jim prior to posting this piece, he would likely have petitioned me to strike his name from the text, so as to let the workshop and the initiative stand on their own merits. Since I believe we all owe Jim a debt of gratitude for his advocacy, to us and to the world, on this topic, I will forbear to do so. Sorry Jim. And thank you!

2 Better, Jim? Seriously, thanks to the organizing committee of the High-Value MRI workshop, to the ISMRM Central Office for its expert stewardship of all the related practicalities, and to everyone in our Society who faithfully bangs the drum of value.