Radiology Business Journal June/July 2012

June/July 2012

www.imagingBiz.com

California’s Dose PuzzleIs Radiology’s ProblemRadiology in a Defragmented Health System: The Hoag Experience page 30

Inside the Virginia Mason Production System:Lean Radiology page 52

Climbing the Hospital’s Leadership Ladder:Three Stories From Radiology page 57

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June/July 2012

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California’s Dose PuzzleIs Radiology’s ProblemRadiology in a Defragmented Health System: The Hoag Experience page 30

Inside the Virginia Mason Production System:Lean Radiology page 52

Climbing the Hospital’s Leadership Ladder:Three Stories From Radiology page 57

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June/July 2012 | Volume 5, Number 3

4 Radiology BusiNess JouRNal | June/July 2012 | www.imagingbiz.com

COnTenTS

FeaTureS

18 California’s Dose Puzzle Is radiology’s Challenge By Cheryl Proval As California CT providers race toward the July 1 deadline to comply with the Medical Radiation Safety Act (formerly SB 1237), physicists, informaticists, and vendors attempt to close the chasm between radiation- dose measurements and the ephemeral definition of patient dose.

30 radiology’s role in a Defragmented System: The Hoag experience By Julie Ritzer Ross At Hoag Memorial Hospital Presbyterian, a reimagining of the delivery of care—and by proxy, radiology— is underway.

45 Waste not, Want not: Inside the Virginia Mason Production System By Cat Vasko Virginia Mason’s radiology department applied the principles of the Toyota Production System to revolutionize clinical and operational processes.

57 ascending the Hospital’s leadership ladder By Matt Skoufalos By focusing on the job at hand, elevating those around them, and seeing beyond the radiology department, two radiologists and one former department administrator have achieved key hospital-leadership positions.

37 The Top Five Medical-imaging IT Projects of 2012 By Cheryl Proval The winning entries in the 2012 competition are presented here. Supported by an innovation grant from

46

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6 Radiology BusiNess JouRNal | June/July 2012 | www.imagingbiz.com

COnTenTS June/July 2012 | Volume 5, Number 3

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Radiology Business Journal is published bimonthly by imagingBiz, 210 W. main St., Suite 101, tustin, Ca 92780. uS Postage Paid at lebanon Junction, Ky 40150. June/July 2012, vol 5, no 3 © 2012 imag-ingBiz. all rights reserved. no part of this publica-tion may be reproduced in any form without written permission from the publisher. PoStmaSter: Send address changes to imagingBiz, 210 W. main St., Suite 101, tustin, Ca 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

DeParTMenTS

8 adView Putting lung-cancer Screening Through the actuarial Wringer By Cheryl Proval

10 The bottom line real Options in Diagnostic radiology By Richard Heller III, MD, MBA

12 Priors 12 reimbursement | The MPPr and the –59 Modifier: buyer, beware 14 Communications | The anthropology of radiology: building Trust in the Digital age By Greg Thompson

26 numeric | Pulling Sub Duty: Medical Directors’ Pay and Call Compensation

62 advertiser Index

64 Final read bursting the radiology bubble By Curtis Kauffman-Pickelle

37 14

Please address all subscription questions to Jean laviCh at [email protected].

8 Radiology Business JouRnal | June/July 2012 | www.imagingbiz.com

fatal than other cancers, resulting in a higher number of life-years saved by screening.

The team had already completed its research when the National Lung Screening Trial (NLST) Research Team3 published results showing that the use of three annual CT screenings in a high-risk population, aged 55–74, resulted in a 20% reduction in cancer-related mortality (compared with the use of three annual screening chest radiographs). The Milliman team had actually used a higher proportion of early-stage cancers detected, as well as a higher mortality reduction.

They speculated that the NLST results might have been even higher if the design of the trial had not required it to be terminated when the 20% improvement threshold was reached.

As care is integrated and incentives are realigned, one hopes that reports of such long-view research on where our health-care dollars can yield high returns in health and wellness will not fall on deaf ears. Currently, however, insurance-company actuaries are likely to be most interested in two numbers: the researchers’ estimates of the annual cost of care with screening ($11 billion) and without screening ($15.4 billion). In the minus-zero-sum game moving forward, radiology will be called on to answer the hard questions: Where is the waste that will free up dollars for expenditures that can yield high health-care returns?

Cheryl [email protected]

References1. Pyenson BS, Sander MS, Jiang Y, Kahn H, Mulshine JL. An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost. Health Aff (Millwood). 2012;31(4):770-779.2. New York Early Lung Cancer Action Project Investigators. CT screening for lung cancer: diagnoses resulting from the New York Early Lung Cancer Action Project. Radiology. 2007;243(1):239-249.3. Kramer BS, Berg CD, Aberle DR, Prorok PC. Lung cancer screening with low-dose helical CT: results from the National Lung Screening Trial (NLST). J Med Screen. 2011;18(3):109-111.

An article by M i l l i m a n a c t u a r i e s 1 in the April

2012 issue of Health Affairs details an interesting accounting exercise that is likely

to cause private insurers to take notice. Using a method employed to evaluate new insurance features, the researchers created an actuarial model designed to estimate the cost (and cost benefit) of lung-cancer screening for US smokers and former smokers, aged 50–64, with at least 30 pack-years of smoking.

The results were surprising from a cost perspective, particularly when viewed in the context of what other screening tools cost. The baseline scenario modeled the cost per life-year saved at $18,862, which compares favorably with the costs (in 2012 dollars) of cervical-cancer screening ($50,162–$75,181), colorectal-cancer screening ($18,705–$28,958), and breast-cancer screening ($31,309–$51,274).

To calculate the cost of screening for this population—an estimated 18 million US residents (30% of the total US population aged 50–64)—the researchers used published protocols for initial and follow-up screening. They assumed that initial low-dose spiral-CT screenings of patients would initiate diagnostic evaluation about 31% of the time, and that repeated annual screening exams would initiate diagnostic evaluation about 9% of the time (somewhat more often than indicated in other published data).

Based on results of the New York Early Lung Cancer Action Project,2 they assumed that actual cancers would be detected in 0.6% of initial screenings and 0.2% of repeat screenings. They built the cost of an annual episode of care methodically (estimating the cost of a low-dose CT lung-cancer screening exam based on the ratio of cost differences between screening and diagnostic mammography) and then applied this to a thoracic CT exam.

The annual cost per screened patient was converted into a per-member, per-month cost. For the purpose of pricing the rider, the authors assumed that 50% of the

target population would actually use the screening program; this is consistent with colorectal-cancer–screening compliance. The cost of the program was spread across the entire commercially insured population.

At the center of the cost-benefit calculation was a stage-shift model with a two-year offset, whereby an intervention (screening) shifted the distribution of stages of cancer—in this case, the earlier detection of lung cancer, leading to earlier treatment and lower treatment costs, as well as improved survival. Multiple scenarios were created, including a status-quo scenario (based on what currently happens without screening); a baseline scenario (to show what happens with screening); and several other scenarios that featured different key assumptions, including the number of people screened, the percentage of early-stage cancers detected, and the cost of screening.

All of these scenarios assumed that 100% of the target population would be screened. This is unrealistic, the authors acknowledged (and is not the assumption used to price the insurance rider), but a 100% assumption made it easier to calculate costs and benefits, as well as to compare results for alternative protocols and across diseases. The analysis did not consider societal effects such as productivity, tax contribution, disability, life-insurance costs, or the cost of additional survivors entering the Social Security and Medicare programs.

Costs and BenefitsThe team estimated the average annual

cost of lung cancer screening to be $247, assuming that 75% of screenings would be repeat screenings and that the insurer cost (spread over a commercial population) would be $0.76 per member per month. The baseline scenario resulted in an additional 130,000 lung-cancer survivors in 2012.

Reasons that the cost of lung-cancer screening was lower than that of breast-, cervical-, and colorectal-cancer screening were that much of the evaluation of suspicious nodules occurs without biopsy and that the target screening population is smaller. Another reason for the lower cost of lung-cancer screening is that symptomatically detected lung cancer often is more quickly

Putting Lung-cancer Screening Through the Actuarial WringerFinding the payoff in health-care expenditures defies simple arithmetic

AdView

As radiologists, we work in the options trade without even realizing it. Every day, we help clinicians make the

best decisions by providing them with opportunities termed real options. These options are analogous to their financial counterparts, such as options on stocks. For example, when you buy a stock option, you have bought the right (but not the obligation) to purchase the stock later, at a preset price. If you think that a stock’s price is going to double from $5 to $10 per share, you could buy the stock itself at $5—or (for a fee) you could purchase just the option to buy the stock later, at perhaps $7 per share.

If the stock’s price per share then rose to $10, you would buy it at $7 and gain $3 per share (less the small fee you paid for the option). If the stock’s price went down to $2, however, you wouldn’t exercise the option. You would lose your fee, but if you had bought the stock, you would have lost much more: $3 per share.

Real options also provide a nonobligatory right to undertake an initiative later. Instead of building an expensive plant now, a company could use real options: Wait six months and perform research on market trends. In six months it would have still have the opportunity, or right, to build the plant, but not the obligation. If research indicates that the plant is a poor investment, the company would have avoided significant losses.

For real options to have value, two criteria must be met. First, the decision to be made is irreversible (you can’t unbuild the plant). Second, delaying the decision is feasible. If both of these criteria are met, then real options are likely to have value. Many of the decisions that we make in medicine meet both of these criteria.

For example, a surgeon might think that a patient has a renal-cell carcinoma, based on clinical findings, and wish to take the patient to the operating room. Surgery is the initiative, and it meets both

criteria for real options. It is irreversible, even if nothing but exploration is done. The other criterion (possibility of delay) also is present. While timely surgery is prudent, immediate exploration is unnecessary.

Instead, the patient could be examined using CT or MRI. Imaging provides the surgeon with real options: the right (but not the obligation) to go to the operating room after imaging. If the imaging exam is negative—or shows pathology not requiring an operation—surgery can be avoided.

ProtoCols and algorithmsIf this example seems obvious, it’s

because we deal in real options every day. What is the use, then, of thinking about options, if we already understand them? There are at least two ways that thinking about real options, in a formal way, can be useful. The first is to help us understand why clinicians order certain exams; studies that provide more useful options to referring clinicians have greater value.

Specifically, studies that can also diagnose alternative pathology are more useful than exams that provide only a single answer. In the diagnosis of pulmonary embolism, for example, both CT and ventilation/perfusion scans provide reliable and important information, but CT has largely taken over the role that ventilation/perfusion scans once dominated.

Is it because CT exams are more accurate? That has been a point of controversy, but real options help explain why CT has become the leader in pulmonary-embolism diagnosis. With a CT exam, you get the yes/no answer to the question of pulmonary embolism’s presence, but you also get other information that aids the clinician. Is there pneumonia or an aortic dissection?

The second reason that it can be helpful to think of real options is that they influence the design of exam protocols and imaging algorithms. The value that we (as radiologists) provide is in the form of information. That information gives our referring clinicians the opportunity to make

the best decisions for their patients’ care. When designing exam protocols and

imaging algorithms, we should maximize the options that the exams provide the clinicians. This can involve optimizing an individual exam to provide the greatest number of potential diagnoses. At our hospitals, we administer both intravenous and enteric contrast for appendicitis CT exams. We wish to offer our clinicians the maximum number of reliable diagnoses from a single exam.

In addition, it is extremely useful to think about how imaging exams reduce the cost, discomfort, and side effects of other exams. This is particularly true in pediatric radiology. For example, we routinely do ultrasound if there is a clinical suspicion of intussusception. If the ultrasound exam’s result is negative, we will have avoided the radiation exposure and discomfort associated with a reduction enema, and we might also find an alternative explanation for the child’s symptoms.

The greater the uncertainty about the value of an initiative, the greater the importance of real options. If a surgeon were completely sure that a patient had appendicitis, he or she would go straight to the operating room. The more unsure that a clinician is of the diagnosis, the more important imaging becomes. In the same way that delaying the construction of a manufacturing plant while performing market research provides an option, delaying exploratory surgery while performing imaging provides an option.

The next time that you are thinking about which exam to recommend, remember that we’re in the real-options business. Exams that provide more options provide more value. Your clinicians will thank you, and your patients will benefit.

Richard Heller III, MD, MBA, a partner with Radiology Imaging Consultants, is the chief of pediatric radiology at Advocate Hope Children’s Hospital and Advocate Christ Medical Center, Oak Lawn, Illinois.


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Real Options in Diagnostic Radiology

by RichARD helleR iii, MD, MbABy framing imaging services in terms of providing real options, radiologists can help clinicians make the best decisions for their patients

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Radiology practices took a blow when CMS invoked the Multiple Procedure Payment Reduction (MPPR) for professional-

component services provided to the same patient in the same session by the same physician on the same day, beginning in January 2012. The specialty narrowly avoided an even greater indignity—that the MPPR be applied to such studies read by any member of the practice—primarily because of the administrative difficulties of enforcement, not because the efficiencies that CMS cited as justification for applying the 25% reduction for second and subsequent studies read by any practice member were a figment of someone’s imagination.

As recently described by Silva,1 the MPPR policy has saddled practices with three administrative challenges: defining a separate professional-component session; distinguishing, for purposes of billing, between the same professional-component session and a different professional-component session; and handling the compliance issues associated with the policy.

Silva reports that CMS has acknowledged that separate professional-component sessions can occur on the same day for a single patient, in which case using the –59 modifier in coding is recommended to indicate a distinct procedural service. CMS, however, has not provided clear guidance on when a service is distinct.

Silva has drawn two main truths from the scant guidance that has been provided: First, the professional-component MPPR is never applied when two different radiologists provide separate interpretations; second, when two interpretations are provided at the same time, the professional-component MPPR is always applied. He writes, “Therefore, the only instance in which interpretations

performed by the same physician on the same date would be considered separate is when the interpretations occur at ‘widely different times.’”1

Whether the studies are acquired using different modalities or on different anatomic areas for disparate reasons, time between interpretations is a common characteristic of guidance from both CMS and the ACR® on the subject. Silva suggests that an interval of eight hours between interpretations would be an appropriate example of separate services, but shorter time intervals might not. “In the end,” he writes, “practices will be required to establish some objective criteria for the definition of separate sessions.”1

After a separate session has been defined, the practice then will be challenged to identify those sessions that warrant the –59 modifier at the time of billing. The options are prospective identification—by the radiologist, at the time of reporting—or retrospective identification by a coder. The ACR acknowledges that both of these options are likely to be insufficient, both because many radiologists would rather not take the time to identify the relevant sessions and because coders will not always know

that another same-day exam exists. Silva proposes a series of what-if

scenarios that underscore the difficulty of identifying time of interpretation: Is it when the radiologist begins dictation or finalizes it (for those radiologists who do batch dictation)? What if the interpretation was communicated to the referring physician much earlier than the actual dictation took place? he asks, suggesting that the probable approach will be a combination of the two identification options.

Keeping CompliantLest a practice be tempted to forfeit

25% of all second and subsequent studies due to the difficulty of identifying separate sessions in same-patient, same-day, same-physician encounters, Silva suggests that they consider that 25% of a $100 Medicare professional-component payment for advanced imaging is, after all, $25. Another option that would probably pay for itself (as cumbersome as it sounds) would be to hire a coder to catch all exams to which the –59 modifier could be appended.

Neither of these extremes are recommended because of compliance considerations. It has been documented that CMS does not expect use of the –59 modifier to be a frequent occurrence, and its frequent use could attract increased scrutiny on the part of recovery contractors.

Nor does Silva recommend that practices direct same-day, same-patient studies to different radiologists (for an end run around the professional-component MPPR). Silva writes, “. . . although different physicians interpreting studies bypasses the MPPR, purposefully operationalizing changes in workflow for this purpose would be a noncompliant act.”1

Silva believes that CMS has a broad


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By gReg thompson

High-tech communication in 2012 is undeniably fast and efficient, but does it build trust? Among referring physicians who rely

on radiologists, the question transcends the objective nature of science and drifts into the subjective world of personal relationships.

Allison Tillack, MA, a student in the MD/PhD program at the University of California–San Francisco, is not afraid to tackle such topics in her dual role as clinical scientist and medical anthropologist. The fourth-year medical student hopes to be a radiologist one day, and she is determined to integrate technical expertise with a patient-focused approach that belies the solitary-radiologist stereotype.

Tillack, who is now finishing her dissertation, sensed that old-fashioned face-to-face communication would build the most trust, but she needed evidence to back her intuition. Thanks to a vendor-sponsored 2011 RSNA Research Medical Student grant, she had the opportunity to interview and observe a variety of physicians for six months, asking them to reflect on the elusive bonds of trust and how they were formed.

Widely used PACS have revolutionized radiology, but trust and communication have occasionally fallen by the wayside. “Back in the film days, reading rooms were the information clearinghouses of the hospital,” Tillack says. “If you wanted to know what was going on, chances are someone would be down there talking to the radiologists. All the teams would talk to the radiologists, and that’s where patient problems were solved. Now, there really is not a space for that.”

Such conversations still occur in patient-care areas, but Tillack laments

that radiologists are not usually present. In some cases, patient information might not be adequately relayed via electronic means. “This patient information is critical to how radiologists read the images and construct their differential diagnoses and recommendations,” she says. “The fact that they are not often in on these informal hypothesis-making sessions can be detrimental.”

What’s neW is old

Despite increasing complexity in the imaging world, referrers in Tillack’s study appreciated an old-fashioned commitment to communication. They wanted radiologists not only to produce interpretations and link imaging findings to clinical information, but also to communicate actively with their physician colleagues.

How does this communication inspire that elusive trust? When Tillack asked a pulmonary/critical-care attending physician about certain radiologists, he responded that he didn’t really trust the night radiologists—and didn’t even read their reports. Because they were

generalists, he said, they were not as good as the subspecialists working days.

He named a particular thoracic radiologist (available in the daytime) as someone who had his full trust, stating that his own interpretations matched those of the radiologist, which were correct. In addition to being pleasant and receptive to questions, this trusted radiologist did not hedge, gave differential diagnoses, correlated findings with clinical information, and described what he saw.

Another pulmonologist expressed similar opinions about how he learned to trust the same radiologist, telling Tillack that it took only a short time. The radiologist called him about a patient and recommended bronchoscopy. This radiologist wants clinical interaction, which builds trust, and he is proactive in contacting clinicians. His helpful interpretations provide more information and are more definitive than those of the other thoracic radiologists, the pulmonologist told Tillack.

While an affable disposition never hurts, Tillack found that even radiologists who are not particularly friendly can still be extremely trusted and valued. As one third-year resident in emergency medicine observed, a particular night radiologist is good, but is irritable when overloaded. Nonetheless, he always calls the resident when there is important information involved—while other night radiologists do not. That failure to call can interfere with the care of emergency-department patients, so the resident trusts the grouchy-but-responsible radiologist because he looks out for the clinical team.

estaBlishing a pResenCeWhile the benefits of the digital

the anthropology of Radiology:Building Trust in the Digital Age

c o m m u n i c a t i o n s

range of radiologist-specific baseline data that it can use to judge whether a practice is gaming the system. He also suggests that practices spend the time needed to create the policy that will enable them to come into compliance, as CMS has

indicated an interest in applying the MPPR to the technical and professional components of all imaging tests, as well as to the technical component of all diagnostic tests.

—Cheryl Proval

Reference1. Silva E 3rd. The PC MPPR: implications for practices. J Am Coll Radiol. 2012;9(5):311-312.

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priors

revolution and PACS are clear, Tillack hopes that software manufacturers will create some innovative ways for radiologists to reinsert themselves into patient care. Companies are developing video-chat systems that would allow referring physicians, viewing images at a workstation, to click on a consultation box and video chat with radiologists.

Such a service could help, but boosting face-to-face conversations by reorganizing the medical space might also help radiologists form more personal relationships. “Moving reading rooms

to patient-care areas could potentially change the referrer–radiologist relationship,” Tillack suggests. “Make a welcoming space—not among cubicles, and not behind a door with an access code—a place where clinicians can stick their heads in and radiologists can easily go down the hall and ask patients a few questions. This could help to facilitate the integration of radiology into everyday patient care.”

Even with PACS, or perhaps in spite of it, Tillack found that trust is still a major consideration for referring physicians and radiologists. Without face-to-face interaction, the opportunity to gauge each other’s expertise—and whether clinical decisions are well thought out—is no longer there.

“Health care is being centralized, but with telemedicine, it is getting harder and harder to have those personal relationships,” Tillack says. “A lot of the emergency-department physicians were very hesitant to put a lot of faith in the interpretations they were getting from a teleradiologist—or someone they could not find in the building, if they had questions. They could call those people, but that daily give and take does not always happen over the phone. These personal ways to assess trust were still important.”

Tillack contends that the most useful radiology reports ultimately should not simply contain a description of imaging findings, but should place these findings within the clinical context—and make recommendations to help guide patient care. Radiologists who generate these kinds of clinically informed reports will be sought for consultation, and their opinions will be more highly valued.

neW gloRy days Tillack has no desire to go back to

the good old days of radiology, and she appreciates the speed and efficiency of the modern PACS. Lost films, for example, are no longer a problem. “The downside is that radiologists have a huge amount of pressure to keep up with the list and deal with that volume,” she says, “and clinicians have come to rely on incredibly fast imaging.”

The culture shift allows referrers to access images, but that brings up a familiar concern. As referring physicians get more comfortable with images, some might not value the radiologist’s expertise as much as they should. Trust (through communication) can maintain the perception—and the reality—of a radiologist’s usefulness. While the renewed focus on communication might drift into the subjective world of personal relationships, this realm might very well shape the future of radiology.

“When I talk to referring providers, the people they trust and value have a great grasp of radiology and clinical medicine, but are also open, kind, and pro-communication people,” Tillack concludes. “Many radiologists really want to be active as physician consultants, and interventional radiology has opened eyes about what the profession can do for patient care. Focusing on all of these human elements can ultimately improve relationships with referring physicians and bolster patient care.”

Greg Thompson is a contributing writer for Radiology Business Journal. This article first appeared in the June 2012 issue of the online journal Radinformatics.com.

Radiologists who held medical directors’ positions with hospitals and health systems collected a median of $32,353 annually, and

those who took weekend call earned a median of $2,000 in call compensation, according to a survey1 conducted

and published by the Medical Group Management Association. Medical directors’ compensation, at the low end, was $20,000; at the 90th percentile, it was $122,840.

The specialists with the highest earning power for medical directorships included

emergency-department physicians, family physicians, infectious-disease specialists, nephrologists, pathologists, cardiovascular surgeons, and hospitalists. Factors that drove higher compensation were the amount of responsibility that a directorship entailed and the number of hours spent

pulling sub duty:Medical Directors’ Pay and Call Compensation

n u m e r i c

the great eightEight characteristics of a useful

radiology report emerged in research conducted by Allison Tillack, a student in the MD/PhD program at the University of California–San Francisco. With a clear theme of effective communication running throughout, the most frequently identified characteristics are that the report:

• suggests a diagnosis, or a short listof possible diagnoses; • provides a detailed description of findings; • provides information that guidesthe patient’s care; • includes unexpected/subtlefindings; • answers the clinical question that prompted the study; • offers recommendations for furtherimaging studies;• separates significant and incidentalfindings; and• doesn’t hedge or waffle aboutconclusions.

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doing this work, as well as responsibility for emergency issues and for the quality and appropriateness of care.

Ownership of the practice was also a factor. Radiologists in practices owned by hospitals or integrated-delivery systems earned a median $25,000 for directorship services, while independent radiologists collected a median of $43,290 annually.

According to the survey results, it paid to head the complaint department: Nonsurgical-subspecialist medical directors responsible for patients’ complaints earned more than twice as much as their peers who were not responsible for patients’ complaints. Most medical directors spent between four and eight hours per week on the associated work; pathologists and family physicians reported spending the most time on their medical-director positions.

Compared with their peers, radiologists received call compensation (see figure) that was on the high end of the scale, at a median of $1,000 per day (or $2,000 per weekend). Only invasive interventional cardiologists (at $2,500), family physicians who handled obstetrics

Figure. Median call compensation (daily rate) for selected specialists; adapted from the Medical Group Management Association.1

$2,000

$1,800

$1,600

$1,400

$1,200

$1,000

$800

$600

$400

$200

$0

$1,500

$650

$100$234

$1,000$854

$1,740

Anesthesiologists(all) Cardiologists

(noninvasive)Family physicians

(no obstetrics) HospitalistsRadiologists

Orthopedists(all)

Neurosurgeons

($2,200), and neurosurgeons (at $2,850) earned higher median rates for weekend call.

Three sources of funding were identified by survey participants: hospital only, medical group only, and hospital plus medical group. It appears, however, that radiology groups primarily are footing this bill, at least in the MGMA sample: The only radiology-compensation segment considered statistically significant by the survey sponsors attributed compensation to the medical group only.

The medical-directorship data were based on 266 completed surveys; the call-compensation findings were based on 308 completed surveys. For more information, contact MGMA Survey Operations at (877) 275-6462, extension 1895.

Reference1. Medical Group Management Association. Medical Directorship and On-Call Compensation Survey: 2012 Report Based on 2011 Data. Englewood,

CO: MGMA; 2012.

As California CT providers race toward the July 1 deadline to comply with the Medical Radiation Safety Act (formerly SB 1237), physicists, informaticists, and vendors attempt to close the chasm between radiation-dose measurements and the ephemeral definition of patient dose

RepoRting Ct Dose | Challenges and Issues

The imaging informaticists, physicists, physicians, and vendors’ representatives who gathered at the Society for

Imaging Informatics in Medicine regional meeting, Practical Imaging Informatics, in Long Beach, California, on March 22, 2012, didn’t arrive in covered wagons, but they did have much in common with the state’s pioneer settlers. On September 29, 2010, California’s SB 1237 was signed into law as the Medical Radiation Safety Act,1 effectively putting all providers of CT exams on notice that beginning July 1, 2012, they would be required to begin reporting technical parameters and radiation dose for each study.

Prompted by an outpouring of popular dismay over reported episodes of overradiation in California and elsewhere, the legislation does not mandate how much radiation is permissible—just that the dose be recorded in the PACS and the radiology report, and that incidents of overradiation be reported. The public, however, is unlikely to be much interested in the nuances of the law, according to J. Anthony Siebert, PhD, professor of radiology at the University of California–Davis, who moderated the “Radiation Dose Monitoring in California” sessions. “Individual patients see this, and now, they are wondering what their dose is,” he says.

Therein lies the rub. While there are measurements of volumetric CT dose index, dose–length product, effective dose, and absorbed dose (among others), there currently is no way to calculate and send the patient’s dose to PACS automatically, robustly, and accurately. California providers of CT exams and radiation therapy are bound to comply

18 RadIology BusIness JouRnal | June/July 2012 | www.imagingbiz.com

By Cheryl Proval

California’s Dose Puzzle Is Radiology’s Challenge

v California’s Medical Radiation Safety Act requires all providers of CT exams to begin including the technical parameters and radiation dose for each study in or attached to the radiology report beginning July 1, 2012.

v Radiation dose has several meanings and can be expressed in multiple ways,

Preload: Previewusing different units. There is no single dose measurement that does the greatest job of describing risk, and there is currently no way to send the measurements to the RIS automatically.

v While providers seek solutions, they are taking inventory of processes and operations, resulting in significant dose efficiencies in some departments.

www.imagingbiz.com | June/July 2012 | RadIology BusIness JouRnal 19

with the new act; the challenge is how to do so. Even the most advanced and conscientious providers are struggling to overcome the limitations of technology, informatics, personnel, and the science of dosimetry.

With radiation dose increasingly on the radar of regulators and payors nationwide, imaging stakeholders are well advised to join the pioneers in California who are seeking answers to a very complex problem: What is the best way to calculate patient dose?

Along with Siebert, four other presenters addressed this question. Bette Blankenship, MS, DABR, is a medical physicist at Sharp Memorial Hospital (San Diego, California). Christopher Cagnon, PhD, DABR, is chief of radiology physics at the University of California–Los Angeles (UCLA) Medical Center. Michael McNitt-Gray, PhD, DABR, FAAPM, is a professor in the department of radiological sciences of the David Geffen School of Medicine at UCLA. Together, these three presented “Radiation Dose in a Clinical Environment: Benefit and Risk—The User’s Perspective.” Lisa Russell, inspector, compliance and enforcement, for the California Department of Public Health (CDPH), then presented “The California Dose Reporting Law: Implications and FAQs—The Government’s Perspective.”

With enactment of the Medical Radiation Safety Act, California providers have been pushed beyond the debate over the relative risks of medical radiation. In referring to the issue of radiation exposure, Seibert notes that many of the reported incidents have been due to human (rather than technological) problems, in terms of using the equipment properly and safely. He does, however, acknowledge

the stochastic risks of ionizing radiation seen with extremely high doses, as at Hiroshima and Nagasaki, Japan.

“What are the risks of cancer induction and the stochastic characteristics of ionizing radiation?” he asks. “It’s a weak carcinogen—but remember, it is a carcinogen. We have to understand that epidemiologists love to take very, very low risk multiplied by really, really large numbers of patients, and then you have all of these virtual cancers and virtual deaths that occur. Is that a reality? Well, we don’t really know, but we do have to pay attention to it.”

The issue is unlikely to go away; in fact, Cagnon predicts that the next big regulatory flashpoint in imaging will be fluoroscopy.

“There’s been a shift in users of fluoroscopy from the traditional realm of radiology and radiation oncology into operating rooms and physicians’’ offices,” he notes, also citing a shift in the types of procedures (from diagnostic to therapeutic). “In the catheterization laboratory, what was once a five-minute procedure can now be hours long,” he adds.

What physicists Measure“Everyone wants to know what

his or her dose is,” Cagnon says. “It’s a frequently used term, and it’s frequently used incorrectly.” Radiation dose has several meanings and can be expressed in multiple ways, using different units. There is no book of standard doses for

While California CT providers scramble to patch together solutions to meet the demands

of the Medical Radiation Safety Act, the physics community does have a vision of a more elegant solution to dose reporting, as articulated by Michael McNitt-Gray, PhD, DABR, FAAPM, a professor in the department of radiological sciences at the David Geffen School of Medicine at the University of California–Los Angeles (UCLA).

Phase 0: McNitt-Gray calls where we are now phase 0. Resources include the patient protocol page and a DICOM Radiation Dose Structured Report (RDSR), which is information that could be dictated into the radiology report.

Phase 1: By July 1, 2012, McNitt-Gray hopes that all UCLA CT systems will be able to produce a DICOM RDSR or a patient

Reporting Dose the Right Wayprotocol page, with some informatics assistance, to generate an HL7 message that would automatically insert the information into the radiology report.

Phase 2: The next step would be to adjust the DICOM RDSR by body region and size, and automatically insert that into radiology report. “We are not going to get there by July 1, but we are going to get there,” he vows.

Phase 3: To arrive at an even more biologically relevant number, the dose measurements would include organ dose to the radiosensitive organs—a goal seen as a possibility.

Phase 4: McNitt-Gray admits that he does not know where this step will take the radiology community, but he is certain that there will be another step.



medical exams. Dose received by a patient spans a wide range, depending on what is done, the procedure parameters, and the equipment used. There is no single dose measurement that does the greatest job of describing risk.

What physicists measure, Cagnon explains, and what machines report, is almost always referred to as exposure. Physicists expose an ion chamber to ionizing radiation and then measure the charge that results. This charge is known as kinetic energy released in matter, material, or unit mass (kerma). Some machines report air kerma or kerma area (dose area) product.

The measurement methods for exposure and dose, however, have the least relevance for patients. More biologically relevant measurements that

can be more useful for calculating risk—absorbed dose, dose equivalent, and effective dose—require some calculation by the physicist.

While absorbed dose might be more relevant, it, too, has its limitations. To emphasize that dose is independent of the volume of material irradiated—and is, therefore, not a definitive measure of risk—Cagnon likes to ask his radiology residents the following question: If a single 10-mm CT slice generates a dose of 2 cGy, how much will 20 consecutive slices generate?

The answer is the same—2 cGy—but the biological risk of the multislice study is, of course, greater. “Dose only tells us how much energy was absorbed by the material/tissue that was actually irradiated; it doesn’t tell us how much

tissue was irradiated or provide the total (integral) radiation dose received by an object,” Cagnon explains. “We all know that the actual biological risk is greater, but the dose, which is what everyone uses, does not necessarily tell you that,” he adds.

Dose equivalent, another measurement used by physicists, refers to the fact that various forms of radiation have different biological effects. Dose equivalent equals the absorbed dose multiplied by a quality factor. This factor is around 1 for beta particles, gamma rays, and x-rays. For protons, it is much higher, at 5; for alpha particles, it is 20.

Effective dose requires another calculation that takes into consideration the biological sensitivity to radiation of the body part irradiated. For instance, Cagnon explains, a very high dose to the fourth finger might burn the skin, but the effective dose would be considered quite low because there aren’t any biologically sensitive organs in the finger.

Ironically, an argument could be made that patients subjected to the high-dose head-CT exams featured in widely publicized photographs of hair loss—photos that helped launch SB 1237—were actually the subjects of effective doses that were quite low. “The brain is not considered to be a critical organ, from a radiation-sensitivity point of view,” Cagnon explains.

on the Head of a pinSome physicists are famous for

hairsplitting scenarios, but it doesn’t take a lot of imagination to envision the confusion and chaos that could ensue if patients start comparing radiation measurements of different types, believing them to be an accurate reflection of patient dose. Imaging devices, themselves, report different kinds of measurements. Radiography and fluoroscopy machines report exposure, air kerma, and dose, but whether that is dose to the skin or air dose is something that physicists almost always have to reverse engineer.

CT, the object of the Medical Radiation Safety Act, is unique. The tube (or source) travels around the patient in a circular fashion, so the dose in a range of slices is actually more uniform than it is

As long as technologists and others are manually entering dose measurements into a radiology

report, there is the potential for error, particularly when two studies are done at once, and (for simplicity’s sake) there is the inclination to add the measurements together. Michael McNitt-Gray, PhD, DABR, FAAPM, a professor in the department of radiological sciences at the David Geffen School of Medicine at the University of California–Los Angeles, offers guidance.

When does it make sense to add volumetric CT dose indices? “When the same anatomic region is scanned repeatedly and assumptions of CT dose index apply, such as table movement and large anatomic regions,” he says. “For example, when you do a noncontrast chest exam followed by a postcontrast chest exam, then it makes sense to add those volumetric CT dose indices.”

When does it not make sense to add volumetric CT dose indices? “When we do different anatomic regions and when there is no table movement,” McNitt-Gray says, do not add the measurements. “For example, when we do a chest exam followed by an abdomen/pelvis exam, it does not make sense to add those volumetric CT dose indices, because dose is energy absorbed per unit mass and these are different anatomic regions that are

being irradiated. As for the case of no table movement, it should be remembered that volumetric CT dose index overestimates peak dose,” he adds.

When does it make sense to add dose–length products? The logic that applies here is similar to the arithmetic for volumetric CT dose index: McNitt-Gray says, “When the same anatomic region is scanned repeatedly, then you can add dose–length products. Some people add dose–length products even when they scan different anatomic regions within the body; I think I am OK with that.”

When does it not make sense to add dose–length products? “If you image something very different, like a head versus an abdomen (and we do this all the time, in trauma), then it doesn’t make sense to add the dose–length products, for reasons that I hope will be obvious: If people add dose–length products, then the next thing they are going to do is estimate dose,” he explains. “It doesn’t make sense to add those and multiply by a number.”

He also cautions providers against adding the dose–length products of two exams for which different-sized phantoms are used—such as a brain scan, which uses a 16-cm phantom, and a cervical-spine exam, which uses a 32-cm phantom.

To Add or Not to Add?


for a projectional exam of the same body part (for example, a chest radiograph). In addition, the dose from a study that scans a volume of the patient is higher than the dose from a single, thin slice of anatomy because it incorporates scatter from one slice into the next. CT dose index is the absorbed dose to a 16-cm or 32-cm phantom. Volumetric CT dose index—one of the measurements that CT systems report—is computed by dividing the weighted CT dose index (the weighted average of the center and peripheral measurements within the phantom) by the pitch (or table movement).

CT systems also report dose–length product, an attempt to incorporate how much of the body is irradiated (something that volumetric CT dose index does not do). For instance, if you perform a scan that covers both the chest and the abdomen using the same technique, the volumetric CT dose index is the same as if you did only one region, but the dose-length producr would be higher (because of the greater length of the scan) when you scan both regions. What dose–length product does is multiply the volumetric CT dose index by the scan length. Using the example of the chest and abdomen scans, a dose–length product of 120 mGy-cm (for three 4-cm slices) becomes 360 mGy-cm (for nine 4-cm slices).

Neither volumetric CT dose index nor dose–length product, however, is an accurate representation of patient dose. By using published data obtained through Monte Carlo modeling of an idealized (geometric) patient, the dose–length product is multiplied by a coefficient (specific to the patient’s age and the body part) to arrive at an estimate of effective dose, which is an estimate of

the stochastic risk of carcinogenesis due to the radiation associated with the study. However, this estimate does not account for variations in patient size.

Another dose-estimating tool also uses a mathematical model of the body to estimate dose. ”I can plug in parameters, but if the patient varies in size and shape from the assumed mathematical model, the estimates are going to be more and more inaccurate,” Cagnon says.

A final complicating factor is that all of the information reported by a CT system is based on phantoms, not patients. Cagnon says, “Patients are not standard; they are not cylindrical, and they are not homogeneous.” Volumetric CT dose index tends to overestimate doses for larger patients and underestimate them for smaller (including pediatric) patients.

A patient with twice the dose–length product or volumetric CT dose index of another patient does not necessarily receive more dose because a larger patient has more tissue to absorb the energy. Dose–length product underestimates the dose for exams where there is no table movement. CT dose index overestimates the dose for stationary exams by approximately a factor of two.

CT dosimetry is still very much a work in progress, Cagnon says. Ongoing work includes adjusting CT dose index for patient size, accounting for tube-current modulation (a feature used on nearly all

I can plug in parameters, but if the patient varies in size and shape from the assumed mathematical model, the estimates are going to be more and more inaccurate. Patients are not standard; they are not cylindrical,

and they are not homogeneous.—Christopher Cagnon, phD, DABR

UCLA Medical Center



modern CT systems that adapts output to patient size), and performing Monte Carlo modeling that produces more realistic results.

Right now, California’s providers would settle simply for the ability to have the DICOM Radiation Dose Structured Reports (RDSRs) or patient protocol go directly into the radiologist’s report from the CT system, Cagnon says. Not only would it prevent radiologists from having to dictate that number into the report, but it would put the number in front of radiologists—to create awareness of dose. “I want them to have that number; I just have to train them not to call it patient dose,” Cagnon says.

size MattersOne key data point missing from the

reported CT-system numbers that is a barrier to reporting patient dose is patient size, according to McNitt-Gray. “CT dose index is an index,” he explains. “It is dose in a phantom; it has lots of good uses. We’ve been using this for almost 40 years, to very good effect. It’s a great measure of scanner output, it’s a good index when comparing protocols and technical parameters, and it also is a good indicator of how scanner output is being adjusted with patient size.”

In clinical practice, he notes, CT-system output is increased for large patients, and decreased for small/pediatric patients, so the volumetric CT dose index will be larger for the bigger patient than for the smaller patient. Based on the volumetric CT dose index, one could presume that the larger patient received twice the dose that the smaller patient received.

“Actually, that’s not true,” explains McNitt-Gray. “The scanner output was higher, but the absorbed dose was not increased by a factor of two.” A task

group2 (which included McNitt-Gray) of the American Association of Physicists in Medicine (AAPM) developed a method to account for patient size—using effective diameter, lateral width, or anteroposterior thickness—when estimating dose.

Further ComplicationsVolumetric CT dose index still

can be somewhat troublesome in several situations. Since volumetric CT dose index is a weighted average of measurements made at the periphery and center of a cylindrical phantom (allowing for the scatter that accrues with table movement), it actually overestimates skin dose to patients who are undergoing scans without table movement, such as the brain-perfusion scans that played a pivotal role in launching SB 1237.

McNitt-Gray reiterates that volumetric CT dose index and dose–length product are not patient dose—and when taken by themselves, can be misleading: “You need other information, such as the patient’s size, body region, and clinical indication, to determine if a scan was done correctly,” McNitt-Gray says. “That’s not always available or captured in dose reports.”

According to McNitt-Gray, it also is important to know the size of the phantom that the vendor used to calculate dose: Currently, all vendors use a 16-cm phantom to calculate volumetric CT dose index for head studies, and all use a 32-cm phantom to calculate it for adult body studies. Small-adult and pediatric studies get a bit tricky: Two vendors use the 32-cm phantom and two others use either a 16-cm or 32-cm phantom, based on the scan field or the patient size.

Volumetric CT dose indices, depending on whether the 16-cm or 32-cm phantom is used, will vary by a factor of 2 or 2.5, depending on the scan. “If

you guess the wrong phantom, those numbers are going to be very high or very low, and that is going to affect the dose–length product as well,” McNitt-Gray explains.

Nonetheless, beginning July 1, something about dose must be placed in the medical record. McNitt-Gray says, “We know how to do this, from a physics point of view, for an odd case. To make it really generalizable and powerful for all of the patients we see—and to comply with state laws—we really need informatics solutions.”

All California facilities performing CT exams will be required to send each CT study and protocol page that lists the technical factors and radiation dose to the PACS, if the CT system has that capability. The new law says that the protocol page or the DICOM RDSR will meet this requirement.

“As long as we take that from the scanner and push that patient protocol page or the DICOM RDSR to our PACS, boom: We are in compliance—done,” McNitt-Gray says. It does get trickier, though. The law also mandates that the radiology report of a CT study include the radiation dose, either by recording the dose in the report itself or by attaching the protocol page to the report.

Many older CT systems are still in use in California, and not all of them are capable of producing a CT DICOM RDSR, raising a thorny question: Who will take the time to input the dose measurements manually into the radiologist’s report? The law also stipulates how the dose is defined: either the volumetric CT dose index, the dose–length product (both of which have their limitations), or a dose unit recommended by the AAPM.

“The AAPM has not spoken on this,” McNitt-Gray reports, “so we are stuck with volumetric CT dose index or dose–length product for July 1, and we’ve got to get that in, which is a little bit of a problem. Not all scanners are capable of generating the RDSR; it’s out there, and the manufacturers all have it, but we don’t have it on all of our scanners.”

Community-hospital ResponseIf some of the leading physicists in

academic medicine are struggling to

We know how to do this, from a physics point of view, for an odd case. To make it really generalizable and powerful for all of the patients we see—and to comply with state laws—we really need informatics solutions.

—Michael Mcnitt-gray, phD, DABR, FAApMUCLA David geffen Medical school

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find a satisfactory way to meet the letter of the law, it is somewhat disconcerting to imagine the challenge for a rural community site without physics support, even with an extra six months to comply.

As a 2007 Malcolm Baldrige National Quality Award winner, Sharp HealthCare (San Diego, California) is hardly a backwater. It does, however, offer a great example of a community hospital taking a proactive approach to meeting the demands of the law, resulting in some significant dose efficiencies.

Blankenship reports that the health-care system took the opportunity to review, evaluate, and revise all of its more than 700 CT protocols. She explains, “We verified the doses, we verified that they were within a reference value that was acceptable to our radiologists, and we asked, ‘Can we do more? Can we pull more dose out of these and have a reasonable and excellent image for the radiologist to read?’”

Through this exercise, Blankenship had an epiphany: Sharp Memorial Hospital had way too many protocols in place, none of which were the same. Working from exam to exam, reducing dose little by little “until the radiologists screamed,” she says, Blankenship was able to reduce dose for head protocols by an average of 35%; for neck protocols, by 60%; for chest protocols, by 43%; and for abdomen/pelvis protocols, by 45%.

Blankenship also recognized the need to go back to the technologists at the CT systems, reinforce their training, and make certain that they understood the meaning of a reference value. Relying on guidance from the AAPM3,4 on what constitutes a red flag when viewing a dose page, she spent time clarifying when technologists should call for help, at the

outset of an exam, if they encountered a variable greater than what they were used to seeing,

The next challenge addressed was how to get the dose measurements into the RIS (for the radiologists to include in their reports). Purchasing analytics software is the current goal for Sharp Memorial Hospital, but the interim (time-consuming) step is for technologists to document manually the dose variables used in each study.

While the dose pages are automatically pushed to the PACS, where radiologists have access to the dose data when reviewing images, there currently is no way to send those data from the CT system to the RIS automatically. Currently, technologists access the dose measurements documented on the dose page and manually enter the volumetric CT dose index and the dose–length product into the RIS, which then automatically populates the physician’s dictated report with that information. “It’s very time consuming, especially when you’re doing trauma, and you have 60 patients you’re pumping through a CT scanner,” Blankenship emphasizes.

Essentially, what the Medical Radiation Safety Act did was add amend/add four sections—111, 112, 113, and 115—to the California Health and Safety Code, intended to govern the safe use of CT for diagnostic purposes (as well as the use of therapeutic x-ray systems operating at energies of less than a million electron volts). It does not specify how much radiation a procedure should deliver, but it does set limits beyond which a facility must report the event to the state, the patient’s physician (both within five days), and the patient (within 15 days).

Russell says that the state is not dictating the practice of medicine. “The California law and regulations don’t limit how much radiation a patient can receive,” she states. “That’s still a call of medical necessity, so that’s the physician’s call. We’re not saying that if you have a head CT that goes over x dose or dose indicator, you have to report it. We’re looking at excessive dose—extra dose—dose that wasn’t intended for the diagnostic purpose.” The law does stipulate reportable events (see figure).

extenuating CircumstancesRussell is quick to point out that the

state recognizes that there are legitimate reasons for a repeated exam. “If the patient moves, either voluntarily or involuntarily—due to a seizure, for instance—then that is not considered a reportable event,” she says. “If the patient, caregiver, or anyone who’s required to be in the room with that patient during the study interrupts the study or (due to abnormal patient anatomy) if the protocol was followed using the proper landmarks, but you didn’t get the right parts in there, that’s still not going to be considered a repeat. We’ll consider that patient interference because everything was followed appropriately.”

If a physician, including a radiologist, orders a repeated exam, then that is not a reportable event, Russell emphasizes. “If your contrast doesn’t arrive at the right time, you miss the bolus, and the radiologist says, ‘Do it again,’ that’s not reportable,” she explains.

The law also raises the quality bar—as well as regulatory hurdles—for all CT providers by requiring facility accreditation, taking it a step beyond the Medicare Improvements for Patients and Providers Act of 2008. Beginning July 1, 2013, all facilities that perform CT exams—not just those billing Medicare and Medicaid—must be accredited by an accrediting body used by CMS (the ACR®, the Intersocietal Accreditation Commission, or the Joint Commission) or as designated by the California Department of Health Care Services (DHCS). To date, the DHCS has not received any requests from interested parties.

Five days is a short time in which to

We verified the doses, we verified that they were within a reference value that was acceptable to our radiologists, and we asked, ‘Can we do more? Can we pull more dose out of these and have a reasonable and excellent image for the

radiologist to read?’—Bette Blankenship, Ms, DABR

sharp Memorial Hospital


report an overradiation event, but the DHCS does not expect War and Peace, Russell says—just an initial report that includes a brief summary of what happened, to whom it happened, and when it happened. The report must include contact information for the person filing the report, the date of the event, the equipment specifics, the software version being used, and the technical factors involved in the exam.

The DHCS will make compliance inspections, as well as following up on all reported events, Russell promises, and it will verify that appropriate policies and procedures are in place. The investigator will want to know who determines which protocols are used in CT and therapy, how they are modified, when they are modified, and who approves modifications.

The investigator will also want to know whether the physicians have training for the studies that they are reading and whether the technologists have specialized training for the technology that they are operating, “especially if you have a number of CT units from various vendors, and the technologists are moving among them,” Russell says.

The investigator will ask to see the last physicist’s report on the CT system. “We want to see if the physicists identified any issues or concerns,” she continues. “We’ll want to see corrective action by the facility, and we want to see how the facility addresses those issues and concerns.”

The investigator will ask to see the CT console to be sure that a reference chart is available, with anticipated values and trigger values, so that technologists know when to raise the red flag about a potential event. “We want to see that the scanner displays the required values and how the technologists verify that the patient is the correct patient,” she continues. “We want to know when the technologists should seek guidance or additional authorization, from whom, and by what method. That should be very clearly outlined and, always, the technologists should be aware of it, especially if they’re working at night or on weekends.”

Other items that the DHCS will want to see following an event include dose reports in PACS, dose values in the

radiologists’ reports, the methodology and calculations that the physicist uses to arrive at patient dose, copies of any internal reports on the event, and your corrective action (or plan to prevent a repeat of the event).

An ounce of preventionIt’s clear, from Russell’s presentation,

that the Medical Radiation Safety Act will usher in a new era of awareness of dose on the part of CT providers in California, from the CT suite to the executive suite. “One of the lessons we’ve learned so far, from voluntary reporting and the frequently asked questions we’ve had, is that an ounce of prevention goes a very, very long way in keeping you from having to report to us,” she says.

“Do your training, to be sure that all staff members understand the equipment and protocols—so when they are putting someone in feet first, they don’t forget to change the kilovoltage,” she says. “Make sure everybody understands what you’ve got, and make it simple. Simplify protocols as much as possible, establish the trigger levels, and post them right there, so people will know when there might be an event. You don’t want to come across an event that happened last

month when somebody’s doing monthly quality assurance—and then have to deal with it, when they don’t even remember what happened.” Inevitably, mistakes will happen, so everyone needs to know what to do in that event.

While the legislation does not specify optimal radiation levels, Russell says that the DHCS is looking for them. “We are hoping that everybody is working to use the least amount of radiation necessary to perform adequate imaging, and this is one of the things we’re looking for—hoping for,” she says.

Russell believes that success will hinge on hospital-administration support. “That’s especially important when you’re looking at services that report to different administrators—for surgery, for cardiology, and for radiology,” Russell notes. “Sometimes, it goes all the way up to the administrator before there’s a common denominator.” To become compliant across the board, Russell recommends, hospitals should appoint a patient-safety committee and a radiation-safety officer to examine internal processes, and they should loop in risk management and the physicist.

“Some facilities have actually established dose-reduction committees,

Except for an event that results from patient movement or interference, a facility shall report to the department an event in which the administration of radiation results in

any of the following:

• repeating of a CT examination, unless otherwise ordered by a physician or aradiologist, if the following dose values are exceeded: 0.05 Sv effective-dose equivalent,

0.5 Sv to an organ or tissue, or 0.5 Sv shallow-dose equivalent to the skin;

• CT x-ray irradiation of a body part other than that intended by the orderingphysician or a radiologist, if one of the following dose values is exceeded: 0.05 Sv effective-dose equivalent,

0.5 Sv to an organ or tissue, or 0.5 Sv shallow-dose equivalent to the skin;

• CT or therapeutic exposure that results in unanticipated permanentfunctional damage to an organ or a physiological system, hair loss, orerythema, as determined by a qualified physician; and

• a CT or therapeutic dose to an embryo or fetus that is greater than 50 mSvdose equivalent and that is a result of radiation to a known pregnant individual,unless the dose to the embryo or fetus was specifically approved, in advance,by a qualified physician.

Figure. Reportable events under California’s Medical Radiation Safety Act.1

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Accomodating Imaging Volume Under Health-care ReformIntroduction: Assuming that the Patient Protection and Affordable Care Act (PPACA) extends coverage to an additional 31 million formerly uninsured patients, we project a postreform increase in imaging volume of 13.6% in 2015.1

The additional spending is quantified, under Medicare and Medicaid rates, using projected postreform imaging volume in six states (California, Florida, Massachusetts, New York, Tennessee, and Texas). Based on the existing providers established in those states and the number of CT and MRI systems installed in inpatient and outpatient settings there, some conclusions can be drawn about the capacity of equipment currently in place to absorb additional volume.

Methods: To project the ability of the currently installed equipment (in the six states under review) to accommodate the projected increases in imaging volume, we adapted the assumed equipment availability used by CMS: 50 hours per

week. The practice-expense RBRVS formula assumes that equipment is in use 75% of those 50 hours (37.5 hours per week), but this analysis assumes 100% use (50 hours per week). Current capacity was measured against the additional volume to be generated by health reform.1

Applying an outpatient utilization/capacity calculation to a six-state installed base of MRI and CT units would not take into consideration the generally higher throughput characteristic of inpatient imaging. Therefore, using inpatient/outpatient-mix data from hospitals in the Regents customer base, an adjustment was made to the hospital MRI and CT installed capacity that reflects an 80% use assumption for MRI and a 60% use assumption for CT.

Imaging Market File

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Equipment count: MRI capacity (Table 1) has been adjusted to eliminate MRI systems that have field strength of less than 1T and are therefore set to be phased out of use due to the inability to accredit them under the PPACA. This factor will have minimal impact in the hospital setting, but will be more significant in the outpatient setting, where 12% of all outpatient MRI systems in the six states under review have field strengths of less than 1T. The states with the most MRI systems with a field strength of less than 1T are California, Florida, and Texas.

Spending comparison: The increased number of insured patients is projected to result in an increase in revenue for imaging providers. The financial impact (using the generally lower Medicaid rates) would be additional spending of more than $1 billion for MRI and CT exams in California alone. If all imaging growth projected in these six states materializes, the additional volume paid for under the lower Medicaid rates would increase spending more than $3.3 billion.

California leads the six states in anticipated increased spending for imaging under the PPACA, followed by Texas and Florida.

Unknown elements under health reform include the level of reimbursement. Will reimbursement conform to Medicare or Medicaid rates? The last column of Table 2 averages the sums under the generally higher Medicare Physician Fee Schedule rates with the sums calculated under the generally lower Medicaid reimbursement rates.

Capacity: While the absolute numbers in the columns for current need and current capacity in Table 3 would indicate an inability to provide access to MRI and CT in, for example, Tennessee and Florida, we understand that this is not the case. The more relevant number to observe is the net change

needed in capacity. New York, California, and Texas might need to add technology, while Florida’s installed CT base would indicate the ability to meet future need.

Equipment totals for the states focus on the current number of MRI and CT units in each state, encompassing hospitals and outpatient locations and including nonradiologist physicians’ practices. The count of MRI units with field strengths of less than 1T was subtracted from the state totals.

Capacity caveat: Using the Medicare measurement for equipment availability and use creates anomalies at a macromeasurement level. First, outpatient data include emergency-department utilization. Hospital emergency departments are commonly available and used 24/7. This results in the current and postreform capacities being overstated. Some locations also might operate more than 50 hours per week.

Second, capacity is a result of the number of units, the hours that a machine is available for use, and total exam time needed. A

capacity that is more than 100% is a result of applying the Medicare standard for machine availability of 50 hours per week at 100%. Third, the Regents standards for capacity calculations dictate an appropriate measure of 80%. This measure allows for schedule flexibility and emergency add-on procedures, when required. Once 80% utilization is consistently reached, capacity must be increased in order to maintain timely patient access.

Reference1. Forecasting imaging use under health-care reform. Radiology Business Journal. 2012;5(2):19-20.

Table 1. CT and MRI Systems in Six States

State PoPulation HoSPital HoSPital HoSPital MRi outPatient outPatient outPatient MRi Ct SySteMS MRi SySteMS SySteMS of < 1t Ct SySteMS MRi SySteMS SySteMS of < 1t

California 36,899,700 341 274 11 383 536 78

Florida 18,413,600 477 236 4 749 620 69

Massachusetts 6,613,100 116 99 4 60 80 3

New York 19,221,100 252 144 2 392 477 30

Tennessee 6,243,900 248 142 7 134 105 11

Texas 24,840,100 453 285 6 494 541 88

Imaging Market File

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Regents Health Resources was formed in 1996 to assist hospitals and physicians in the development and management of their medical-imaging and oncology services. The consultancy has served more than 500 clients nationwide with a diverse range of services, from strategic planning and operational assessments to joint-venture planning, valuations, and imaging-center sales and acquisitions. Installed-equipment counts were provided by Radiology Data Corp. www.RegentsHealth.com

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Table 2. Projected Postreform Revenue Increases

VoluMe ReVenue inCReaSe ReVenue inCReaSe aVeRage of MediCaRe and inCReaSe undeR MediCaRe undeR MediCaid MediCaid ReVenue inCReaSeS

California CT 782,942 $517,140,840 $347,609,883 $432,375,361Mri 645,183 $851,588,912 $756,377,707 $803,983,310Total, Mr and CT 1,428,125 $1,368,729,752 $1,103,987,590 $1,236,358,671other 7,543,913 $1,450,685,379 $1,030,860,686 $1,240,773,032Total, all imaging 8,972,038 $2,819,415,131 $2,134,848,276 $2,477,131,703florida CT 567,430 $171,160,809 $95,294,569 $133,227,689Mri 438,321 $260,068,211 $144,666,975 $202,367,593Total, Mri and CT 1,005,751 $431,229,020 $239,961,545 $335,595,282other 5,060,528 $462,620,615 $173,340,558 $317,980,586Total, all imaging 6,066,279 $893,849,635 $413,302,102 $653,575,868MassaChuseTTs CT 43,305 $14,847,995 $9,946,516 $12,397,256Mri 20,983 $14,375,385 $9,725,107 $12,050,246Total, Mri and CT 64,288 $29,223,381 $19,671,623 $24,447,502other 313,769 $29,006,153 $15,815,371 $22,410,762Total, all imaging 378,057 $58,229,534 $35,486,994 $46,858,264new York CT 398,820 $137,754,736 $74,086,746 $105,920,741Mri 249,650 $172,010,187 $95,331,325 $133,670,756Total, Mri and CT 648,470 $309,764,923 $169,418,071 $239,591,497other 3,732,946 $409,577,866 $185,422,119 $297,499,993Total, all imaging 4,381,416 $719,342,789 $354,840,191 $537,091,490Tennessee CT 131,740 $25,263,703 $20,210,874 $22,737,288Mri 68,374 $24,581,137 $19,664,902 $22,123,019Total, Mri and CT 200,114 $49,844,840 $39,875,776 $44,860,308other 979,837 $41,318,290 $33,054,905 $37,186,598Total, all imaging 1,179,951 $91,163,130 $72,930,681 $82,046,905Texas CT 716,778 $200,266,824 $136,120,621 $168,193,723Mri 490,263 $271,916,160 $176,302,636 $224,109,398Total, Mri and CT 1,207,041 $472,182,985 $312,423,257 $392,303,121other 6,148,984 $467,467,127 $375,923,980 $421,695,554Total, all imaging 7,356,025 $939,650,112 $688,347,237 $813,998,674ToTal, Mri and CT 4,553,789 $2,660,974,899 $1,885,337,861 $2,273,156,380ToTal, all iMaging 23,952,350 $4,802,307,540 $3,344,915,290 $4,073,611,415

Table 3. Current and Postreform CT and MRI Needs and Capacities

CuRRent CuRRent PRojeCted PRojeCted need CaPaCity need CaPaCity CHange

California CT 635 108% 735 125% 17%Mri 1,004 133% 1,190 178% 45%florida CT 491 47% 563 54% 7%Mri 681 84% 808 110% 25%MassaChuseTTs CT 161 124% 166 128% 4%Mri 153 96% 159 104% 8%new York CT 456 84% 507 93% 9%Mri 545 92% 617 110% 18%Tennessee CT 148 52% 165 58% 6%Mri 147 67% 167 83% 15%Texas CT 435 57% 527 69% 12%Mri 580 75% 721 107% 31%

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www.imagingbiz.com | June/July 2012 | Radiology Business JouRnal 29

RepoRting Ct Dose | Challenges and issues

and they have done some phenomenal work in lowering the doses, simplifying the protocols, and making the referring physicians aware of what they’re asking for (when they’re asking for it),” she reports. Russell urges providers to do an internal audit of processes and protocols, with an eye toward simplifying protocols and making them uniform.

“You can have a consultant come in and audit to give you an assessment,” she says. “The vendors have some fantastic products, and they can give you a lot of guidance on how you can improve. The people who have taken advantage of that, from what we’ve seen, are a lot more successful—not only in reducing their doses, but (when they do have an event) in explaining what happened, what went wrong, and how they fixed it. You don’t really want to rely on us and your compliance inspection as your external audit process, but some people do.”

putting the Law into practiceIn order to guide technologists in

complying with the Medical Radiation Safety Act, Blankenship developed a flowchart to guide technologists’ responses to such questionable events as repeated exams and higher-than-normal dose values. The technologists’ concern is being able to identify a reportable event. “They’re beginning to understand that everything needs to be reported internally for evaluation and training purposes, but to get to a reportable event, I think most of us agree, it’s going to take quite a bit.”

Reporting on outlier studies is a key to Blankenship’s compliance plan at Sharp Memorial Hospital. She reports (to the radiation-safety committee and the quality council) all studies that exceed a reference value specific to a body region. Happily, she is down to zero reports, but that has not always been the case.

In order to track past compliance, Blankenship pulled every CT study since 2010 and discovered that 13 to 15 patients per month had been imaged inefficiently and outside the established protocol design. “I wanted to know why,” she recalls. “Now, in 2012, we’re down to zero on every single scanner.”

Judging by Blankenship’s experience, California’s Medical Radiation Safety

Act has had a transformative effect on service delivery at Sharp Memorial Hospital. Protocols have been reviewed and streamlined. Reference values have been posted. Technologists have been trained to report exams outside the reference values and to enter the dose measurements into the RIS.

Still, there is the problem of getting the dose measurements into the radiologists’ reports. Blankenship says, “Someone shared with me that when they have somebody do something manually, you can count on a 17% error rate.” Addressing informaticists and vendors, she adds, “It is a step we are hoping you are going to help us remove.”

Cheryl Proval is editor of Radiology Business Journal.

References1. Bill number SB 1237: chaptered bill text. Official California Legislative Information. http://www.leginfo.ca.gov/pub/09-10/bi l l / sen/sb_1201-1250/sb_1237_bill_20100929_chaptered.html. Accessed June 15, 2012.2. AAPM Task Group 204. Size-specific dose estimates (SSDE) in pediatric and adult body CT examinations. http://www.aapm.org/pubs/reports/RPT_204.pdf. Published 2011. Accessed June 19, 2012.3. AAPM Task Group 23. The measurement, reporting, and management of radiation dose in CT. http://www.aapm.org/pubs/reports/RPT_96.pdf. Published January 2008. Accessed June 18, 2012.4. AAPM Task Group 111. Comprehensive methodology for the evaluation of radiation dose in x-ray computed tomography. http://www.aapm.org/pubs/reports/RPT_111.pdf. Published February 2010. Accessed June 18, 2012.

At Hoag Memorial Hospital Presbyterian,a reimagining of the delivery of care— and by proxy, radiology—is underway

Defragmenting HealtH Care | The Hoag Experience

In recent years, health-care reform (in all its guises) has spurred providers to investigate new methods and models for delivering services to inpatients

and outpatients alike. Some do not affect radiology, but others have major ramifications for the way that imaging is delivered, managed, and paid for, as well as for the integration of radiology with other medical disciplines. An unprecedented, ongoing metamorphosis at Hoag Memorial Hospital Presbyterian (HMHP) in Newport Beach, California, falls into the second category.

HMHP is a nonprofit regional health-care–delivery network that now encompasses two acute-care hospitals (Hoag Hospital Newport Beach and Hoag Hospital Irvine, known collectively as Hoag Hospitals); five urgent-care centers; seven health centers; and a network of more than 1,300 physicians. In a move spearheaded by Richard Afable, MD, MPH, president and CEO, HMHP’s orthopedics program—one of California’s largest—was closed in November 2010 and replaced with Hoag Orthopedic Institute (HOI) in Irvine, a specialty-hospital joint venture with HMHP’s physicians.

The joint venture created the largest orthopedic specialty hospital and specialty center west of the Mississippi River. It includes Hoag Hospital Newport Beach; two medical groups (Newport Orthopedic Institute and Orthopedic Surgery Center of Orange County, both in Newport Beach); two independently owned ambulatory-surgery centers (Orthopedic Specialty Institute and Main Street Specialty Surgery Center, both in

30 Radiology BusinEss JouRnal | June/July 2012 | www.imagingbiz.com

By Julie Ritzer Ross

Radiology’s Role in a Defragmented System:The Hoag Experience

v In the thick of the campaign to defragment health care, Richard Afable, MD, CEO of Hoag Memorial Hospital Presbyterian, has embraced the value theory of Michael Porter, PhD, which defines health care’s value as clinical outcome multiplied by patient experience and divided by cost.

Preload: Previewv Key strategies include reorganizing service delivery using institutes of excellence and a joint venture (with its orthopedic surgeons) that created a focused factory for joint replacement.

v Alignment of subspecialist radiologists with the institutes has boosted referrals in some cases, but has resulted in declines in others, prompting radiologists to ask where they fit in the value chain.

www.imagingbiz.com | June/July 2012 | Radiology BusinEss JouRnal 31

Orange); 35 orthopedists; and the 70-bed HOI facility (with nine operating rooms), which was designed as a specialty orthopedic hospital.

While ownership is divided 51% to 49%, in favor of the physicians, to enable HMHP to maintain its not-for-profit status, governance is split equally. Participating physicians hold 100% of the operating responsibility for the organization, but all entities—the hospital, ambulatory-surgery centers, and imaging—fall under the joint-venture umbrella.

Afable made the move based on his belief in the shared value theory espoused by internationally renowned strategy expert Michael Porter, PhD, Bishop William Lawrence professor at Harvard Business School. Porter’s theory holds that if health-care professionals and institutions invest in their own outcomes, they will be more personally invested in treatment and more likely to deliver improved outcomes, an enhanced patient experience, and fewer repeated procedures and readmissions. Afable explains, “According to the formula, value is clinical outcome multiplied by patient experience and divided by cost. For us, adding value means improving clinical outcomes and the patient experience while simultaneously reducing the cost of care.”

Early success gave rise to the recent establishment of four other institutes of excellence at HMHP: Hoag Family Cancer Center, Hoag Heart & Vascular Institute, Hoag Women’s Health Institute, and Hoag Neurosciences Institute. While some have referred to this evolution as a peeling off of service lines, Afable begs to differ. He notes, “From a corporate standpoint, it appears to be a move away from HMHP; however, through shared equity comes closer alignment, which opens us up to greater opportunities to add value.”

the UpsideStronger allegiances and alliances

among physicians from different disciplines have indeed been born of the model, with significant benefits being

reaped by radiologists. Miles Chang, MD, is chief of radiology services at Hoag Hospital Irvine, vice chair of the department of radiology for Hoag Hospitals, and a radiologist with Newport Harbor Radiology Associates Medical Group in Newport Beach.

He says, “The structure has definitely elevated the level of our interpretations and the perception of the value we offer. We can do studies better, more quickly, and at a lower cost because our musculoskeletal subspecialists work closely with HOI; neuroradiologists, with the Neurosciences Institute; and breast-imaging subspecialists, with the Women’s Health Institute. We have also refined the format of our reports somewhat to reflect the individual subspecialties and facilitate matters for the physicians.”

Michael Brant-Zawadzki, MD, FACR, executive medical director of Hoag Neurosciences Institute and a radiologist with Newport Harbor Radiology Associates Medical Group, corroborates Chang’s impression. He adds that a comprehensive PACS makes a contribution here. Although the structure of the HMHP model permits subspecialty radiologists to be deployed to the various

institutes when needed, the PACS allows subspecialty radiologists to read studies wherever they happen to be.

The closer alignment of subspecialty radiologists with specialist physicians in the institutes of excellence has, in turn, been good for radiology referral patterns. Michael Roossin, MD, is president of Newport Harbor Radiology Associates Medical Group, medical director of Newport Imaging Center, and director of ultrasound at Hoag Hospitals. He deems the volume of patients referred to centers that the practice staffs to be higher now that the institutes of excellence are in place, attributing the trend (in large measure) to the influence on physicians’ referral decisions of a guarantee of subspecialist care for patients.

“The fact that a neurology patient will be certain to have his or her study read by a neurology subspecialist (and the like) has a bearing,” Roossin observes. “The one variation is orthopedics, because HOI has its own MRI component, and although we are called upon to help with interpreting studies, patients can be referred there. Still, in all, being so subspecialized is the key to fitting into the model.”

For us, adding value means improving clinical outcomes and the patient experience while simultaneously reducing the cost of care.

—richard afable, mD, mPH

The fact that a neurology patient will be certain to have his or her study read by a neurology subspecialist (and the like) has a bearing.

—michael roossin, mD



Another byproduct of jumping on the institutes-of-excellence bandwagon is enhanced collaboration among radiologists and other physicians. Such collaboration is especially evident within HOI, according to Alan Beyer, MD, medical director of HOI. Beyer describes a sequence of events that unfolded a few months ago, when a large number of studies of different patients revealed the presence of pulmonary emboli. He and his colleagues immediately met with radiologists to discuss the use of spiral CT to identify such emboli and the interpretation of studies that show multiple emboli. “This type of collaboration—and the resultant value and quality of care—would never have been possible in a large-hospital setting,” Beyer says.

In just one year, HOI made significant improvements in everything from infection rates (from 0.9% to less than 0.1%) to lengths of stay (2.4 days for total knee/hip replacements, compared with a national average of 3.9 days) to turnaround times (from 40 minutes to 22 minutes). These results were achieved while reducing the cost of care by 20% to 25%.

Six months ago, HOI physicians and members of the Hoag Hospitals radiology department also engaged in a similar collaborative effort aimed at improving value by revising certain ordering protocols for imaging. For instance, prior to this endeavor, it was common for older patients who were experiencing knee pain (but had not experienced any trauma) to be have four knee views acquired—when

a bilateral weight-bearing radiograph would have sufficed, Beyer says. Together, the constituents drew up guidelines and a revised protocol, he says, “reducing the number of films, in this case, from four to two—and specifying more relevant films, in the bargain.” The results were decreased costs and simultaneous improvements in the clinical experience.

erosion of Purchasing PowerIn a somewhat less positive vein, the

model has wrought significant changes in imaging-equipment purchasing. Prior to its inception, equipment acquisition was imaging driven, Brant-Zawadzki says, “with radiologists pounding their fists at the COO about how much money a particular machine would bring in” and the requirements of the radiology department almost exclusively taken into consideration as buying decisions were weighed.

In contrast, purchasing is now clinically driven and under the control of all five institutes of excellence. The final determination of whether a given service will obtain a given piece of equipment, do without it, or cede it to another center is predicated on how the acquisition will affect the bottom line of the institute in question. Its effect on radiology business and strategic development does not come into play.

Not long ago, Hoag Heart & Vascular Institute won out over the radiology department when it came to the purchase of a CT-equipped angiography suite. Similarly, Hoag Neurosciences Institute—instead of Chang and his colleagues—recently got approval to acquire an additional SPECT camera to perform ioflupane testing for the early detection of Parkinson disease. “In both situations, greater clinical need was the driver,” Brant-Zawadzki recalls. “The Heart & Vascular Institute has been performing a high volume of percutaneous heart-valve insertions.” Its need for the angiography suite, therefore, was deemed greater than the need of the radiology department.

The fact that it has its own imaging equipment has permanently shifted to HOI’s shoulders any determination of when the addition of new technology is warranted there. “The orthopedists, not

This type of collaboration—and the resultant value and quality of care—would never have been possible in a large hospital setting.

—alan Beyer, mD

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the musculoskeletal radiologists, make the determination,” Brandt-Zawadzki states. “With a model like ours, lots of different layers and players are involved.”

Chang adds, “We see many more cooks stirring the purchasing pot; it’s inevitable.” In addition, in certain instances, sums that might once have been approved for investment in imaging equipment are earmarked for other capital investments instead. If radiologists working under an institutes-of-excellence model want to play a more significant role in the technology-purchasing process, they will need to make a stronger business case for each acquisition. This means bringing evidence to the table that the equipment in question will yield a cost saving and a good return on investment, Brant-Zawadzki says.

One aspect of the model that remains in the midst of evolution—and for which the impact on radiology remains

to be seen—is payment. Reflecting improvements in value and clinical outcomes, decreases in the cost of care, and a now-enhanced patient experience, HOI participates in a bundled-payment pilot project sponsored by the nonprofit Integrated Healthcare Association.

HOI maintains contracts with Aetna, Blue Cross Blue Shield, and CIGNA for total knee replacement. It is also an Anthem preferred network provider, as well as one of 16 California hospitals selected by the California Public Employees’ Retirement System and Anthem to provide a voucher system under which patients receive a $30,000 voucher to pay for a knee or hip replacement. Patients are awarded a 90-day postsurgical warranty; HMHP covers any complications related to the joint replacement during that period.

A bundled-payment structure for the other four institutes of excellence has not yet been adopted; Newport Harbor

Radiology Associates Medical Group continues to receive direct payments for interpretations, according to Michael Madler, COO. Madler notes that while HOI’s arrangement for hip and knee replacement is still in its infancy, he foresees major changes in the payment structure in the near future, with services provided to patients of the institutes paid for in bundled fashion and subsequently divided among radiologists, surgeons, pathologists, physical therapists, and others. “I think the days of each specialist negotiating separately with each payor will soon be behind us,” Madler says.

Political/Organizational issuesThe move toward the kind of patient-

centered, value-focused, integrated delivery system being established at HMHP bodes well not only for HMHP and systems like it, but also for radiology within and beyond its walls. Nonetheless, as the HMHP experience illustrates, there have been, and will continue to be, bumps in the road that will affect radiology, to a certain extent.

Such roadblocks, according to Brant-Zawadzki, encompass a tendency among physicians to view the model as creating an us-versus-them scenario and the devaluation of individual services, including radiology, that are not specifically identified within an institute of excellence.

The key to overcoming or minimizing these challenges, he insists, is communicating to stakeholders the value proposition afforded by moving away from a traditionally structured, institution- and physician-centered, service-based organization. Explaining what will change and what will not is crucial, as is clearly defining the institute-of-excellence concept (a subject on which Brant-Zawadzki et al1 reported in 2009).

A key communication point is helping constituents to understand that institutes of excellence and affiliated programs are not power-based entities within a given organization, but rather, in Brant-Zawadzki’s words, “philosophical and organizational exoskeletons developed toward optimizing the main mission.” In this model, each individual or service might, at some juncture of

Unless that revenue and expense cycle is, in keeping with the model, reallocated to the programs and centers of excellence as a whole, it would be impossible to achieve a comprehensive analysis of their patient value.

—michael Brant-Zawadzki, mD, faCr

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RBJ_june12_ahra.indd 1 2012-06-05 09:04:36



a patient’s experience, function as a component of an institute of excellence or affiliated program. This structure can potentially take some of the pressure off unprofitable service lines that face the threat of being discontinued, Brant-Zawadzki notes.

Nonetheless, there are political and organizational implications when the issue of revenue allocation is considered. For example, Brant-Zawadzki states, radiology leaders might object to the allocation of revenue from many MRI scans to a neurosciences institute of excellence. “Unless that revenue and expense cycle is, in keeping with the model, reallocated to the programs and centers of excellence as a whole, it would be impossible to achieve a comprehensive analysis of their patient value,” he explains.

There also is the question of where radiology generalists fit into the model. At Newport Harbor Radiology Associates Medical Group, leaders found themselves considering how to assign radiologists in the practice who do not subspecialize

and, consequently, could not be assigned to serve any of the institutes.

“Clearly, we did not want to eliminate them, so we identified other places for them to concentrate on general radiology within our organization,” Chang states. “Any provider choosing to go in the institutes-of-excellence direction will probably need to do the same,” Chang explains, because subspecialization and subspecialty alignment are where the value of radiology reside, in such a model. General body imaging (including body CT exams, plain films, and fluoroscopic procedures) was shifted to the generalists. Some general radiologists needed refresher courses on some of the procedures or studies, but overall, Chang reports, the redistribution of studies went well.

In addition, although the advent of the model has not altered the cohesiveness of the radiology department, it has introduced an element of competition between radiologists and certain other physicians in the institutes of excellence. Orthopedists and neurosurgeons, Brant-

Zawadzki points out, are growing more skilled at harnessing imaging technology.

Such aptitude, coupled with the increasing sophistication of the equipment itself, is (to some extent) enabling these physicians to step partway into radiologists’ shoes. In addition, Brant-Zawadzki says, vascular intervention has been largely taken over by cardiologists.

adding Value to ValueSuch competition and other disruptive

changes notwithstanding, radiologists will continue to play an important part in defragmented health-care delivery. “It simply isn’t practical for clinicians to be handling the bulk of imaging studies,” Brant-Zawadzki says. Afable perceives the ongoing role of radiologists as centering on the addition of value to value, within the HMHP model and others like it.

“Clinical outcomes, the patient experience, and cost are all important,” he states. “Does imaging improve clinical outcomes? You bet: Without good, effective imaging, we cannot make accurate diagnoses, whether we are talking about appendicitis or a subdural hematoma. If clinical outcomes and the patient experience are the same at two facilities, though, cost is going to be the deciding factor in where care is obtained.” This is especially true as patients become responsible for a larger share of payment and as health-care reform brings accountable-care organizations to the table.

“Appropriate use of imaging adds tremendous value,” Afable says, and appropriate use can start and end with radiologists. He adds that HMHP is currently exploring new means of expanding the institutes-of-excellence concept to other areas of the organization. “We are at the tip of the iceberg,” he concludes, “but wherever we go with it, radiology should have a place in the value chain.”

Julie Ritzer Ross is a contributing writer for Radiology Business Journal. reference1. Brant-Zawadzki M, Wortham J, Cox J. Search for meaning: centers of excellence, service lines and institutes. Physician Executive. 2009;35(3):32-37.

Clearly, we did not want to eliminate [radiology generalists], so we identified other places for them to concentrate on general radiology within our organization. Any provider choosing to go in the institutes-of-excellence

direction will probably need to do the same.—miles Chang, mD

One hallmark unites the winning entries in the top five medical-imaging IT projects of 2012, cosponsored by Radiology

Business Journal and the Society for Imaging Informatics in Medicine (SIIM): Each project represents a view beyond the traditional acquisition, archiving, and communication of radiological images. All of the winning entries take a global view of medical imaging:

• mining the data in the DICOM headers and dose sheets to produce a relevant number for patients’ exposure to radiation;

• solving the technical and operational problems of including non-DICOM images in PACS;

• creating a nonlinear, flexible workflow layer that can tell the radiologist whether a brain tumor

Igniting the Spark of Innovationhas grown before he or she looks at the image, as well as creating a worklist for a geographically disparate organization;

• solving the interoperability issues inherent in the movement of pathology images to create a digital consultation portal for pathology; and

• scouring the electronic medical record (EMR) for the data required to create a safe protocol for a study.

The entries were judged on their innovation/ingenuity, on whether they met critical/urgent/unmet needs, on whether they improved quality, on the product/tool/idea validation or evaluation, and on the universality of the application. All six judges are members of the SIIM board: Donald K. Dennison is an imaging-vendor executive; J. Raymond Geis, MD, is a radiologist with Advanced Medical

The Top FiveMedical-imaging IT Projects of 2012

Imaging Consultants, PC (Fort Collins, Colorado); David S Hirschorn, MD, is director of radiology informatics at Staten Island University Hospital in New York; Elizabeth A. Krupinski, PhD, FSIIM, is a research professor in the departments of radiology and psychology at the University of Arizona; Wyatt M. Tellis, PhD, is an informaticist in the radiology and biomedical imaging department at the University of California–San Francisco; and James T. Whitfill, MD, is CMIO of Southwest Diagnostic Imaging, Ltd (Scottsdale, Arizona).

Winners received a $1,000 scholarship to subsidize the cost of attending the 2012 annual SIIM meeting (an award made possible by an unrestricted grant from Bayer HealthCare, maker of the Certegra™ informatics platform).

By Cheryl Proval

1 Reference on file2 Presented at Society of Thoracic Radiology (2008) Poster Session; Christopher R. Deible MD, PhD. Information and images provided through the courtesy of the University of Pittsburgh. Used by permission.

3 510(k) FDA clearance number: K082905.

© 2012 MEDRAD, INC. All rights reserved.

Bayer, the Bayer Cross, Contrast Dose Management, MEDRAD and Certegra are trademarks of the Bayer Group of Companies.

www.medrad.com/each-dose-matters

EACHENTRYMATTERS

The Certegra® Workstation is the industry’s first1 informatics-driven Contrast Dose Management™ Solution that puts time back in your day:

Certegra® saves keystrokes.

• Eliminate redundant manual documentation

• End the need to look up or dictate records

• Reduce rework and delays

• Streamline actionable data to get to insight faster

• Decrease unnecessary rescans with fewer sub-diagnostic quality studies2,3

With Certegra, each minute matters. And that means better patient care, better workflow and operational efficiencies, and better compliance throughout the chain of care.

Bayer RBJ June-July 15-5x10-875 v06_Layout 1 6/18/2012 1:19 PM Page 1

1 Reference on file2 Presented at Society of Thoracic Radiology (2008) Poster Session; Christopher R. Deible MD, PhD. Information and images provided through the courtesy of the University of Pittsburgh. Used by permission.

3 510(k) FDA clearance number: K082905.

© 2012 MEDRAD, INC. All rights reserved.

Bayer, the Bayer Cross, Contrast Dose Management, MEDRAD and Certegra are trademarks of the Bayer Group of Companies.

www.medrad.com/each-dose-matters

EACHENTRYMATTERS

The Certegra® Workstation is the industry’s first1 informatics-driven Contrast Dose Management™ Solution that puts time back in your day:

Certegra® saves keystrokes.

• Eliminate redundant manual documentation

• End the need to look up or dictate records

• Reduce rework and delays

• Streamline actionable data to get to insight faster

• Decrease unnecessary rescans with fewer sub-diagnostic quality studies2,3

With Certegra, each minute matters. And that means better patient care, better workflow and operational efficiencies, and better compliance throughout the chain of care.

Bayer RBJ June-July 15-5x10-875 v06_Layout 1 6/18/2012 1:19 PM Page 1

Radiation Dose Intelligent Analytics for CT Examinations (RADIANCE)

In June 2012, Cook had one month remaining in her residency at the Hospital of the University of Pennsylvania in Philadelphia before she would begin a fellowship there in cardiovascular imaging. As a combined engineering and computer-science major in undergraduate school, Cook’s interest in IT actually preceded her interest in radiology. Cook credits mentors William Boone, MD, and Woojin Kim, MD, for their roles in the birth of the open-source CT dose-monitoring solution called RADIANCE.

“We were at a conference when we started discussing the dose-monitoring problem,” Cook recalls. “When I got back to Philadelphia, I tested a few open-source optical–character-recognition (OCR) tools and stumbled upon something that worked. From there, I continued building and extending the application, and within a few months, we realized that we had a tool that could be useful not only to us, but to the rest of the community.”

From the dose sheet, kilovoltage, milliamperage, reference milliamperage, volumetric CT dose index, dose–length product, and phantom type are gathered by RADIANCE. It also imports the total study milliamperage and dose–length product, if they are reported. RADIANCE pulls information from the DICOM study header about the study type, scanner, imaging facility, and patient.

These data are stored in a searchable database, on top of which the

personnel involved; the emergency department can review dose estimates for a particular patient before deciding on a study.

Monthly RADIANCE scorecards are distributed to radiologists, technologists, section chiefs, and clinical administrators. The radiologists and technologists receive an overview of their average dose estimates for studies, as compared with their doses for the preceding month (and the rest of the department’s doses for the current month). Section chiefs can review data for individuals, as well as for specific study types. Administrators can examine long-term dose trends for particular studies to analyze the effect of protocol-optimization measures and the consistency of applying protocols across scanners.

Using data from the RADIANCE dashboard and scorecards, the thoracic-imaging section of the department successfully implemented protocol modifications for four common studies: enhanced and unenhanced chest CT exams, pulmonary-embolism chest CT exams, and high-resolution parenchymal chest CT exams. By optimizing tube voltage for patient size (for example, using 100 kV for average patients and 120 kV for larger patients), decreasing the reference tube current, always using tube current modulation, and scanning the patient more than once only if ordered by the radiologist or referring physician, dose estimates for the four study types have been decreased by 30%, 38%, 30%, and 65%, respectively.

RADIANCE dashboard, scorecards, and tool kit are built. “We can also query the RIS to pull information such as patient height/weight and personnel involved with the study,” Cook says. Over the summer, Cook plans to develop the HL7 messaging necessary to send the data to an EMR, RIS, or dictation system—news likely to cheer California providers required to include volumetric CT dose index and dose–length product in the imaging report.

Problem/ObjectiveThere is growing interest in

monitoring imaging-related radiation delivered to patients. With CT dose parameters conventionally stored as pixel data on image-based dose sheets, large-scale archival/analysis of these data has proved challenging. Data recorded on these dose sheets represent dose delivered to an acrylic phantom, not the individual patient.

SolutionNewer CT scanners include dose-

related parameters in the DICOM study header, as part of the Radiation Dose Structured Report (RDSR). Scanners that cannot produce RDSRs, however, will continue to generate image-based dose sheets. RADIANCE was developed to address this vast repository of CT exams with legacy dose sheets.

RADIANCE uses OCR to parse image-based dose sheets from all four major CT vendors and stores dose parameters in a relational database. It can import scanner-generated RDSRs, allowing facilities to maintain a centralized repository of all dose data, even with scanners of different ages. RADIANCE can also generate RDSRs from legacy dose sheets, allowing facilities that produce dose sheets to participate in the ACR® Dose Index Registry.

ResultsRADIANCE has been used to

process over 250,000 CT exams from three hospitals. This has produced an extensive database of dose parameters that can be analyzed. Using the RADIANCE dashboard, section chiefs and department administrators can review dose estimates for particular study types and compare doses across scanners (to identify opportunities for protocol optimization). They can review dose estimates according to

The Top Five Medical-imaging IT Projects of 2012

RadIology BusIness JouRnal | June/July 2012 | www.imagingbiz.com

Tessa Cook, MD, PhD Hospital of the University of Pennsylvania

DICOM-enabled Workflow-engine System (DEWEY)

Some years ago, Erickson and a team at the Mayo Clinic (Rochester, Minnesota) partnered with a global IT company on high-performance computing to put into practice some of the algorithms for computer-aided diagnosis they developed. Invariably, they faced challenges implementing them; for each parameter, they had to create a special workflow for the technologist to send the required data for processing—and another to get the results back to the radiologists.

A representative from the IT company told the team about a workflow engine that had been used in other industries to help orchestrate different events. Erickson views this as a seminal moment in the development of DEWEY. “What we built there, we don’t use anymore, but it was a great learning experience,” he says.

Radiologists are in no danger of losing their jobs to DEWEY, Erickson says, but the application does assist them in some tedious tasks, such as looking for brain aneurysms or tumors on MRI studies. “Computers are good at the things that humans tend not to like,” Erickson explains. “One of the most common applications of computer-aided detection is screening mammography; it is a task that many radiologists don’t particularly enjoy. It’s very repetitive, and you’re just looking for one thing: cancer. Because the task is very focused on one goal, computers can do that fairly well.”

Initially, the team intended to commercialize the system as a next-generation image-management solution that would support the complex workflows of large organizations with multiple image-acquisition sites. Instead, the team developed a system

elements reflecting software versions and compares them with the most recent software-version description, allowing automated detection of modifications to imaging devices.

ResultsDetection of brain-tumor change is

a complex workflow because it requires recognition that a brain-tumor protocol is being acquired in the current exam and requires recognition that a prior exam of that type exists in the archive. This is challenging for humans and machines to determine.

Prior to the implementation of DEWEY, the current and prior results were available in time for interpretation in 29% of brain-tumor cases. After implementation, 95% of cases were successfully identified and delivered (there were occasional failures of the algorithm itself, as well as occasional failure to identify the proper exams).

A simpler workflow was identification of MR angiography (MRA) exams of the brain. For these, Erickson developed an algorithm for highlighting regions suspicious for aneurysm. Preimplementation success was about 70%, but after implementation of this workflow, the success rate was 98%. Failures were primarily due to software changes in the MRA parameters, which resulted in failure to detect the MRA sequence.

Erickson also implemented software-change detection. This system was developed to detect changes (usually upgrades) to imaging devices that were not communicated to the department. Most detected changes had been properly communicated, however, and no changes resulted in significant outages during the test period. The motivation for this system was that a system outage previously had been created by an unannounced system upgrade that had subtle (but important) effects on the department.

DEWEY uses a graphical user interface to define workflows. This provides a good way to develop, document, and maintain workflows in a complex department. These tools are relatively simple to use and do not require programming expertise.

that would work in tandem with PACS and RIS, rather than replacing them.

The workflow engine was DICOM enabled to initiate a complex computer-aided–detection workflow to find change in a brain tumor; to create a worklist for a multisite enterprise that will determine where a study should be read based on individual radiologists’ schedules; and to perform any other specific task based on the data in the PACS/RIS.

“It’s like the change from procedural programming languages to object-oriented languages,” Erickson explains. “With procedural languages, you build a series of steps in order to get the result, whereas with object-oriented languages, the object has properties that make sure it is processed properly.”

Problem/ObjectiveComplex organizations necessarily

have complex workflows. Current radiology systems have not kept up with that complexity, relying on linear workflow consisting of few steps. Erickson developed DEWEY to support highly complex workflows that are easily maintained by nonprogrammers.

SolutionErickson extended a well-established

workflow engine to deal with DICOM data. The system was implemented in phased fashion at the practice. Some workflows were automated and fairly linear, while others involved decision points and DICOM queries.

The most complex required a specific MRI acquisition and the most recent matching prior exam, sending that pair of exams to the algorithm and waiting for the algorithm to be completed (or to fail, if it ran longer than the specified time). Erickson also developed a workflow that captures DICOM

www.imagingbiz.com | June/July 2012 | RadIology BusIness JouRnal

Bradley J. Erickson, MD, PhD Mayo Clinic

The Mayo Clinic DEWY team included (from left) Xiojiang Yang, PhD, Todd French, Bill Ryan, Daniel Blezek, PhD, Steve Langer, PhD, and Bradley J. Erickson, MD, PhD.

Visible Light Imaging With Enterprise PACS and EMR

Kennedy’s winning solution for accommodating visible-light images in the enterprise PACS and EMR of Kaiser Permanente Northern California (Oakland) was prompted by a direct request from leaders. Both the operating room and the dermatology service needed PACS functionality, but neither worked with existing radiology workflow. Getting the images into the PACS was not the problem: The team was able to purchase a solution from a trusted vendor/collaborator that applied the DICOM wrapper to the visible-light images. The problems arose when Kennedy and his team tried to fit the alien workflow into a radiology-focused PACS.

“I have been doing radiology-based workflows for over 20 years now,” Kennedy explains, “so a lot of assumptions are hardwired, with me. The two most difficult things were unlearning many assumptions and then trying to adapt a radiology-focused PACS to the new solution.”

An initial hurdle was moving beyond the procedure-based context that defines radiology, primarily for billing purposes. “In radiology, it’s very clear to me: I have a CPT® code, I have a given procedure, and I have a description for that procedure that’s out of the data dictionary,” he notes. “It’s relatively mechanistic, in terms of how the RIS and the PACS deal with it; it is much more free flowing in the visible-light arena.”

He adds, “Most PACS work with the procedure codes and the procedure

Problem/ObjectiveThis project’s aim was to integrate

visible-light imaging with enterprise PACS and EMR, and to include support for dermatology, gastroenterology, and surgical endoscopy.

SolutionThe team used DICOM-wrapped

JPEG images and MPEG video content, as well as HL7 messaging, to integrate new image-content streams into PACS and the EMR.

ResultsDermatology and gastroenterology

are now fully integrated, for both outpatient and inpatient workflows, in the institution. Work is now progressing for surgical-endoscopy support for 220 operating rooms in the Northern California region. The team discovered very specific differences between traditional radiology workflows and what was needed for appropriate visible-light clinical-use cases in this deployment.

Significant effort was needed to adapt or modify traditional radiology workflow tools for use with these new cases, and a number of compromises were made. In the future, Kennedy’s team hopes, more workflow-agnostic systems will come to market to support nonradiology/noncardiology workflows, but few are currently available.

Adapting traditional radiology workflow tools for use with visible-light cases will generally result in some level of compromise, and additional effort will be required to meet clinical requirements. Current volumes for visible-light content for the enterprise are around 1,600 studies per day, divided between dermatology and gastroenterology. Full implementation of the operating-room solution is projected to raise the total to around 3,000 studies per day.

descriptions out of the dictionary, with the idea being that they want the two alike because they are used for billing. You are not paid in dermatology, however, for the photography that you do.”

Ultimately, the team chose to tie the procedure identifier and the procedure number directly to the visit itself in the EMR, so the patient visit becomes the encounter and the accession number. “That took some rewiring, in terms of how the RIS and the PACS deal with each other,” he says.

A few other disconnects included the need to deal with color content in a system that is monochrome based. “In general, window level (for example) doesn’t work in color, in our radiology environment,” he explains. “People want to be able to manipulate the images, but they don’t have the tools to do that.” The team also had to develop a polychrome overlay because, particularly in gastroenterology cases, “We couldn’t see the overlays in the images because they needed to have a contrast color and shadow to make them visible,” he explains.

Kennedy and his team were taken aback by the response to the visible-light imaging solution: What began with two use cases has quickly multiplied into approximately 20, and teledermatology is both underway and supported by PACS in the Kaiser Permanente Northern California region. In fact, Kennedy predicts that, in time, there will be more visible-light images than radiology images in the PACS.

Another issue that was not anticipated was the need to train physicians’ office personnel to take good-quality images. “When you put a camera in someone’s hands, you don’t think of it as a modality; you think of it as just a camera,” Kennedy says. “You basically have to grow a culture around image quality.” Kennedy’s team initially spent a lot of time emphasizing the fact that a physician can’t read a fuzzy image, which requires the patient to return.

“This was, frankly, a case of if you build it, they will come,” Kennedy says. “We’re very seriously looking at an entirely new PACS solution for visible light. One of my team members calls it the stem-cell PACS: an undifferentiated tool, capable of being much more flexible than the existing repurposed radiology PACS.”



Richard (Skip) Kennedy, MS Kaiser Permanente Northern California

The Digital Pathology Consultation Portal

You would have to travel back in time more than a dozen years to witness the genesis of this winning entry from the imaging-informatics team—including William Cable; Andrew Lesniak; Eugene Tseytlin; Jeffrey McHugh; Liron Pantanowitz, MD; and Anil Parwani, MD, PhD—at the University of Pittsburgh Medical Center (UPMC) in Pennsylvania.

As Romero Lauro explains, UPMC was already working on the basics of digital pathology consultation in 1999, when he was CIO of the Mediterranean Institute for Transplantation and Advanced Specialized Therapies (www.ismett.edu), Palermo, Italy, a leading transplant hospital. UPMC helped to build the facility and continues to manage it under an agreement involving two hospitals, the regional government of Sicily, and UPMC.

There are clear parallels between the early days of teleradiology and the birth of digital pathology. “We started with the basics: a camera on a microscope, taking pictures,” Romero Lauro recalls. “The pathologist would have to send cases via Internet, attaching the images and sending questions via email. We thought we could do better than that, and we started building more and more automation. It has been a continuous evolution.” In time, UPMC transitioned to a more automated process whereby the remote pathologist was able to upload (to various subspecialists in the UPMC system) not just static images of areas of interest, but entire cases.

overnight-shipping fees, and results can be received much more quickly than they would be using traditional overnight mail.

Pathology-consultation tools based on digital slide images need to allow the client to share imaging data with the consulting pathologist. The solution developed at UPMC allows both the asynchronous upload of whole-slide images and real-time streaming of imaging data directly from the source storage location.

ResultsThe average size of whole-slide

imaging studies in digital pathology is thousands of megabytes (in contrast to other studies in other specialties, where the average is tens or hundreds of megabytes). The asynchronous-transfer method developed at UPMC leverages technology that frees the user and the remote workstation during the transmission of large datasets, that automatically monitors the transmission for interruptions, and that resumes transmission from any point of failure.

UPMC’s solution has the option of installing a software service at the client’s remote-storage location linking the appropriate imaging dataset and streaming the information in real time, while the pathologist is providing the consultation. A sophisticated algorithm only transmits the information that fits in the pathologist’s screen, therefore limiting the data to be transmitted and making quick consultation turnaround possible.

Other challenges in digital pathology are the lack of established imaging standards and the fact that proprietary imaging formats from the largest vendors are in continuous evolution. The solution used by UPMC leverages an open-source, vendor-neutral viewer that is compatible with the most common pathology-imaging formats available in the market.

In September 2011, the KingMed telepathology Web portal went live for KingMed Diagnostics, providing consultation services to KingMed’s customers in China. UPMC pathologists have the ability to view whole-slide images hosted on an imaging server at KingMed’s facility. The Web portal viewer affords the pathologists the ability to manipulate, annotate, and take snapshots of areas of interest on the whole-slide image; these actions can also be included in the final report.

“As long as we were doing consultations within our own walls—our own domain—that was relatively easy to accomplish,” he says. “Even when we were dealing with Italy, we knew what the challenges were, so we knew what to expect. What really made us think about how to take this to the next level was the opportunity that came to work with a commercial laboratory in China.”

He knew that the joint-venture partner, KingMed Diagnostics (Guangzhou, China), was not necessarily going to use the specific vendor solutions in use at UPMC, raising interoperability issues prevalent in digital pathology, where many vendors have their own proprietary imaging formats.

To create an environment that would be as vendor agnostic as possible—and easy to implement—the solution uses key open-source software and other custom-developed software, including software that addresses the potential interruptions that can occur when transferring huge whole-slide–image datasets over the Internet. Clients can choose from two options for image sharing: a simpler asynchronous transfer or a client–server method that allows viewing of whole-slide images (but requires more advanced network connectivity between institutions).

“With this solution, we create a market for pathology that is open to the world,” Romero Lauro says.

Problem/ObjectiveUPMC developed a set of Web-

based tools to support remote digital pathology consultations and viewing of whole-slide images. The team addressed the challenge and practical implementation of two different user types: the occasional user (professional or patient) uploading digital whole-slide images and requesting a second opinion online, and the external laboratory or hospital looking for an established real-time consulting relationship covering a high volume of cases.

SolutionThe Digital Pathology Consultation

Portal provides subspecialty coverage across the 20 hospitals of UPMC and to external organizations, giving immediate access to expert diagnostic anatomic pathologists in different subspecialty areas. The UPMC Digital Pathology Consultation Portal saves

www.imagingbiz.com | June/July 2012 | RadIology BusIness JouRnal

Gonzalo Romero Lauro, MBA University of Pittsburgh Medical Center



The Radiology Protocal Tool and Recorder (RAPTOR) System

Medverd, a radiologist on staff at Washington’s VA Puget Sound Health Care System, Seattle Division, also holds a faculty appointment at the University of Washington. He has long held the belief that making protocols for advanced imaging exams is undervalued in private, public, and university settings.

“The process is not optimized,” he says. “You get a piece of paper with one or two lines on it providing the clinical provider’s problem and questions to be answered; then, when one wants more information, it’s often time consuming and cumbersome. If you talk to any radiologist who has protocol responsibility for cross-sectional imaging, he or she will tell you there’s a constant battle between efficiency and effectiveness for that task.”

Using funding from the VA Innovations Initiative and leveraging VA IT resources, Medverd designed a prototype for filling those gaps with information from the EMR, with an extensible design that could be rolled out nationally. Because the VA has a legacy health IT architecture with a vast repository of health information, Medverd approached the project with the intention of designing the application in layers.

He planned to use Web services, for example, to virtualize the electronic health record, so that a Web application (as opposed to software that needs to be installed on every user’s computer) could be used. “With Web services,

all we need to do is build a sort of data-adapter layer into the content-management system for the presentation of the data,” he explains.

A happy discovery was the availability of the VA’s Medical Domain Web Services (MDWS), which Medverd and his team used to virtualize the health records. “Frankly, I was not aware of it when I first submitted the idea, and I thought we’d have to build it ourselves,” he says. “The discovery of MDWS was great because somebody else had already done the work, and that’s the advantage of working in layers. That MDWS layer provides the interactivity with the legacy archives that we would have had to build, if it weren’t there.”

For a Veterans Integrated Service Network (VISN) to implement RAPTOR, the VISN’s protocol library would be uploaded to the RAPTOR server. Through the uploading process, the VISN would also have the opportunity to cross-link the protocol library with commonly accepted naming conventions in the RSNA’s RadLex.

Medverd’s goal of improving efficiency and patient safety throughout the VA system appears within reach. “Given the amount of enthusiasm folks have had, I’m very optimistic that we’re going to move forward,” he says.

Problem/ObjectiveThe paper-based workflow

predominantly used to create protocols for advanced medical imaging at Veterans Health Administration (VHA) facilities is subject to numerous process errors. The RAPTOR system leverages the VHA’s EMR and open-source content-management frameworks to provide an efficient Web environment, with decision support for contrast risk assessment and protocol assignment.

SolutionThe RAPTOR system extracts

relevant information for each patient from the EMR and displays it next to the imaging requisition. The Web interface provides access from a variety of systems and includes features to sort the worklist, flag relevant allergy history and renal-function tests, suggest relevant department-approved imaging protocols, suggest standardized pre- and postexam hydration, and suggest premedication for those with a history of contrast reactions.

This offers a significant advantage over the prior system by ensuring legibility, standardization, prioritization, multiuser access, and improved patient safety. Additional features of RAPTOR will include secure messaging, restricted ordering access for specialized studies, recognition of order duplication, and logging of physicians’ and staff members’ input into the protocol decision-making process. While this solution will initially be deployed as a pilot at selected VHA facilities, the goal will be deployment across the entire VHA enterprise.

ResultsA review of the current paper-

based protocol workflow at one VHA facility evaluated 341 MRI orders over the course of a month, of which 61% were for neuroradiology, 12% were for musculoskeletal imaging, and 6% were for body imaging. The average paper protocol required an elapsed time of 11 days from the time that the study was ordered to the day that the patient was successfully contacted to schedule the exam.

It was found that approximately 15% of exams for which protocols had been completed were never performed; for 1%, orders were duplicated but both had protocols prepared, and for 2.5%, protocols were unsigned. Rare (but observed) clerical errors, such as mismatched patient information, further corrupted this system.

RAPTOR prototype testing suggests significant process improvement due to real-time data-query capabilities. Unproductive and redundant protocol-making efforts are minimized, the speed of the protocol process is increased due to prioritization and distribution of work within a multiuser-accessible electronic work list, fulfillment of enterprise quality and safety goals is improved due to automated identification and flagging of patients at risk for harm from the performance of advanced medical imaging, and ambiguity in medical-decision responsibility is eliminated through the capture of documentation logs and electronic signatures.

Jonathan Medverd, MD University of Washington Medical Center, Department of Radiology

Virginia Mason’s radiology department applied the principles of the Toyota Production System to revolutionize clinical and operational processes

Virginia Mason Production systeM | Lean Radiology

www.imagingbiz.com | June/July 2012 | RadioLogy Business JouRnaL 45

By Cat Vasko

Waste Not, Want Not:Inside the Virginia Mason Production System

A decade ago, the executive team of Virginia Mason Hospital and Medical Center (VMHMC) in Seattle,

Washington, flew to Japan for training in the Toyota Production System (TPS), a continuous–process-improvement method pioneered by the automobile manufacturer. Lucy Glenn, MD, chair of VMHMC’s radiology department, says, “We began to understand how applicable this method was to health care. So many of the things we do in health care are processes. Everything that surrounds the physician–patient interaction is a process that can be improved.”

The result of this training was the development of the Virginia Mason Production System (VMPS), which takes the principles of the TPS (also known as lean production) and applies them to health care. The radiology department was quick to adopt the new system, performing seven week-long workshops in 2002 alone to learn to use the lean tool set. “Subsequently, we learned to do rapid-kaizen (-improvement) events,

which are two-day process-improvement events,” Glenn says. “Week-long rapid–process-improvement workshops are for more complex issues.”

Critical to the adoption of the VMPS was the goal of putting patients first, which was introduced in the hospital’s 2001 strategic plan. Glenn explains that the objective of many of the radiology department’s process-improvement events is improving the patient experience.

“In any area of radiology you can think of, there are opportunities,” she notes. “One of the things we strive for is elimination of waste, and one of the biggest wastes is time. Offering same-day access for patients is critical to making

v A busy radiology department discovered the power of the lean tool kit to transform clinical and operational performance.

v Over 10 years, patients’ waiting times were dramatically reduced, while bigger projects focused on dose efficiency and evidence-based medicine.

Preload: Previewv Embracing and reinforcing lean culture necessitated some surprising steps, including an unconventional commitment of resources from health-system leaders.


46 RadioLogy Business JouRnaL | June/July 2012 | www.imagingbiz.com

imaging a value-added service. You want to be timely in providing the imaging and timely in reporting the results.”

identifying targetsProcess-improvement methods are

applied to targets large and small; a key facet of lean production is an emphasis on the authority of frontline staff to understand how their own processes can be optimized. Richard Lee, administrative director of radiology operations at VMHMC, says, “We go to the people who are actually doing the work and are in immediate contact with the patients. We have a process where we ask them to generate ideas as to what could be improved, and that’s where it starts—from identifying how our processes could be made better for the patient.”

At the other end of the pipeline, Lee says, administrators look at improving value streams to reach clinical, financial, and operational goals. “That macro perspective can result in process-improvement events and kaizens as we work a value stream from the top down,” he notes. “If it’s a more complicated issue, it may result in a series of kaizens. Process improvement can start anywhere in the organization.”

In the VMPS, quality and cost are viewed as being inextricably linked, Glenn says, meaning that an opportunity for improvement in either area can launch a process-improvement project. “The more you improve quality, the more you reduce cost—because you are eliminating waste,” she explains. “You could reduce cost without improving

quality, but that’s not what we’re after; we’re after reductions in the number of defects, in the amount of lead time, and in the waste within a process. Those will lead to cost reductions, but the ultimate goal is to improve quality.”

In fact, Lee says, in lean production, cost is seen as a symptom of quality problems. “It’s symptomatic of waste and defects,” he observes. “We’re not thinking, ‘Let’s get rid of this cost.’ Instead, if a cost is out of line with what it should be, we’re considering what the implications are for the process. The tools are designed to address quality, not cost.”

radiology-department ProjectsIn 10 years, the radiology department

at VMHMC has tackled an array of issues using lean tools. Glenn says, “We’ve

In 2011, the radiology department of Virginia Mason Hospital and Medical Center (Seattle, Washington)

performed two week-long rapid–process-improvement workshops and three kaizens.

t Participants in a scheduling workshop (Integrated Procedural Center) planned and designed a resource-scheduling process that is transparent, integrated, standardized, and based on customer demand. They allowed for production planning of room, staff, and provider resources on the day of the procedure.

t A clinical-admissions workshop (procedure patients) focused on reducing the lead time for procedure-patient admissions by eliminating waste, for patients and staff, that resulted in patients being left waiting. The workshop created and refined procedure groups and created standard processes for preparing patients for procedures.

t In a kaizen for emergency-department CT flow, participants created criteria/guidelines to ensure defect-free contrast administration to all patients. They also created signaling between the radiology and emergency departments to ensure smooth patient flow.

t Participants in a kaizen for standing radiography designed a new device for obtaining foot and ankle images of standing patients.

t During a kaizen for ultrasound flow management, participants improved the flow of patients, providers, information, and equipment in the ultrasound department by applying the concepts of flow management, skill–task alignment, and visual control.

2012 Lean events

In 2012, the radiology department has already performed one week-long rapid–process-improvement workshop

and three kaizens.

t A second scheduling workshop (Integrated Procedural Center) focused on planning and designing a resource-scheduling process that is transparent, integrated, standardized, and based on customer demand. It will allow for production planning of room, staff, and provider resources on the day of the procedure by standardizing the flow of information for procedure scheduling. It will allow for production planning, optimizing the flow and efficiency of the provider, understanding and meeting future IT needs, and designing a scheduling system that is integrated and is accessible to all

services (and that includes visual controls for resource use).

t A kaizen for radiology forms and document management emphasized elimination of waste in overproduction of forms completed by patients, storage of forms, transportation of forms from the main campus to storage, and transportation and costs of storing forms with a storage vendor. t Participants in a kaizen for interventional-radiology provider flow used the principle of level loading (and principles developed earlier in 2012) to optimize the interventional-radiology scheduling template, ensuring the best procedural experience for patients and providers. t A second kaizen for emergency-department CT flow focused on reducing the time elapsed between appearance of the CT order (in the PACS) and the delivery of results to the emergency-department physician (by phone). Participants examined current workflows to streamline processes and improve efficiency by eliminating waits. They used Virginia Mason Production System tools to create standard processes for the sequencing of services (such as CT exams, laboratory studies, and electrocardiography) and to improve the signaling process between services.

VMPS Radiology Events

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applied them to every area of radiology: all of the different modalities—CT, MRI, ultrasound, the breast-imaging center, and every section. We made a huge push to be able to offer same-day access to all of our modalities. We worked on our backlog to understand what really created that and how to take care of it, on an ongoing basis.”

The department also looked at imaging quality on a larger scale, undertaking multiple projects aimed at gaining a better understanding of the evidence for certain highly utilized studies. One such project dealt with the use of MRI to diagnose back pain, which was found to be almost always inappropriate in a recent study.1

“We realized that the way we had been handling back pain was this: The patient would see the primary-care provider,

who would order an MRI exam, and then they would send the patient to a physical therapist. Maybe a month down the road, the physical therapy might be started,” Glenn says. “We realized that the patient needed to be started on physical therapy right away, and then—if there’s still an issue after six weeks—to get an MRI study.”

This is an example of value-stream mapping and its results: By rearranging the flow of clinical events, the department was able to reduce MRI utilization, with the end result of eliminating waste, improving patient care, and reducing costs. “It’s making sure that we are appropriate in our imaging, and it’s creating access for those patients who really need those exams,” Glenn says.

VMHMC’s radiology department also tackled radiation-dose reduction for CT exams as part of its evidence-based–medicine initiative. Radiologists routinely critique CT exams in terms of appropriateness; in addition, members of the department collaborated on a project to revamp every protocol, in every CT system, to ensure that dose was reduced as far as possible.

“Whenever we have a process-improvement event, we make sure we use everyone involved in that process,” Glenn notes. “That includes a scheduler, a technologist, and a radiologist, if need be. We also try to involve the patient’s voice in most of what we do. If we can’t have an actual patient, we’ll be sure to have the patient’s voice represented by surveys performed ahead of time.” In 2011 and 2012, the radiology department has performed three week-long rapid–process-improvement workshops and six kaizens (see box).

Patient safetyAmong the key benefits of the VMPS,

10 years into its application, is the augmentation of patient safety that it has

Figure. The Integrated Procedural Center’s floor plan.

Whenever we have a process- improvement event, we make sure we use everyone involved in that process. That includes a scheduler, a technologist, and a radiologist, if need be.

—Lucy glenn, Md

www.imagingbiz.com | June/July 2012 | RadioLogy Business JouRnaL 49

made possible throughout the organization. Glenn says, “One of the things we’ve worked on for many years is this culture of safety—getting to a point where every staff member feels safe bringing up every patient-safety issue, no matter what it is. We don’t care what the patient-safety alert is or where it came from; we just want to know about it so we can address it.”

A patient-safety alert results in an examination of the issue from two perspectives: root-cause analysis and culture. “Root-cause analysis deals with whether the problem is a process issue or simply an individual error or behavior issue,” Glenn says. “The cultural analysis looks at behavior that was a human mistake or an at-risk behavior—you’re going 65 miles per hour when you know the speed limit is 55.”

Patient-safety alerts in radiology have often focused on certain contrast media and their association with kidney problems in at-risk patients. “Once you realize what the components are in a patient-safety alert, you can deal with correcting them,” Glenn notes. “Usually, they are handoff or communication issues—problems with information flow that lead to human error. There are things that can be done to improve the processes surrounding a patient-safety event.”

Most critical to improving safety is creating a culture of vigilance, Glenn and Lee note, in which employees feel protected enough to report any problems. “The whole idea that you cannot talk to just anyone, because of a power gradient, is something we work on continually,” Glenn says.

Results are measured using an annual Culture of Safety survey distributed to employees. “Last year, 78% of our employees said they felt safe reporting a patient-safety issue; at many organizations, it’s around 40%,” Lee notes. “That’s not good enough for us, though. Our goal is 100%.”

Facility designVMHMC recently opened the doors

of its new Integrated Procedural Center (see figure), which brings together the catheterization, interventional-radiology, and gastrointestinal laboratories. “This center directly reflects the VMPS

principles,” Lee says. “We listened to the voices of the patients, physicians, nurses, and technologists to design a unique work area, in which we really worked to remove waste.”

The facility was designed using a lean tool kit for space design that focuses on production, preparation, and process (3P). “3P allows you to look at a process before you start a service line and bring the frontline staff together to map it out,” Glenn says. “You look at information flow, supply flow, provider flow, and

patient flow; you determine the best way to optimize these and have a facility that will make the work easier, not harder.”

In applying 3P principles to the design of the center, the team at VMHMC looked at the similarities among the three procedural areas that could be used to create an effective shared space. Although the rooms for each procedural area are quite different, the admission and recovery areas are shared. A central patient area is considered onstage, while backstage, provider and technologist flow



is occurring, invisible to the patient. “The patients’ experience is very

calming and relaxing,” Glenn says. “They don’t see what’s going on backstage (all of the communication between the radiologists and the technologists). There’s a central space for patients, who then go into the rooms on the outside of that space; the outermost ring is the backstage workflow area.” A similar process was used to design VMHMC’s breast-imaging center. Glenn says, “We went from a large space to a smaller space, but managed to do much more within that smaller space because it was designed for better efficiency.”

The 3P design-optimization process has more than increased patient satisfaction to offer the radiology

department, however; by reducing overall square footage, it lowers operational and staff costs. “A lot of space is wasted in waiting rooms,” Glenn notes. “We try to design our processes so that there are few waiting states, and you don’t need those big rooms.”

Lee adds, “We design the rooms so that we require fewer staff members to watch patients. Rather than having staff covering three separate areas, we’re down to one person who can control the flow.”

The result is a facility that supports the organization’s patient-first strategy by freeing staff to deal with clinical, safety, and service concerns, instead of issues arising from patient flow. “We designed it to improve quality and safety and to reduce the burden of the work that the

staff has to do to provide a quality service for patients,” Lee says. “It’s a design in which we strove to perfect the health-care experience for our patients.”

creating the cultureGlenn and Lee stress that the lean

culture is continually supported and enforced in the organization. “The culture change didn’t happen overnight,” Glenn notes. “We’ve been doing this for 10 years, and it probably took five to seven years before we got to a tipping point where everyone in the organization understood and embraced the method.”

Creating the culture requires very strong top-down support, they say; the organization’s leaders must be committed to clearing the time and

At the 2012 Health Connect Partners Radiology & Imaging Conference in Miami, Florida, Dan Littlefield, RPh, MBA, director of

process improvement and lean consulting at Healthcare Performance Partners, presented “Improving Imaging Services Using Lean,” on May 11. Littlefield outlines a set of lean tools that are particularly useful for radiology practices and departments.

Standard work methods: Littlefield defines standard work as “the current, one best way to do an activity,” he says, as documented on a one-page job guidance sheet. For a department to function optimally, he says, 80% of the work done in a given day should abide by standard work protocols, freeing staff to handle the other 20%, or outlier work, more efficiently and effectively.

Single-piece flow: To differentiate between single-piece flow and its converse, batching, Littlefield offers the example of escalators versus elevators: Escalators convey people one at a time, in an even flow, while elevators convey them in batches. “Error potential increases as batch size increases,” he says, in reference to patients. Radiology departments should endeavor to make the flow of patients even, rather than dealing with them in batches.

Visual management: In lean production, the highly visual sharing of information “exposes abnormalities, eliminates waste, and promotes error prevention,” Littlefield says, in addition to making quick recovery possible and supporting standardized work. Visual management also uses measurements to inspire the staff to meet goals; examples of these indicators, for radiology, might be daily turnaround times, hours worked per unit of service, and error rates.

Error proofing: Littlefield observes, “Too often, in health care, we inspect at the end of the process to make sure that whatever we did has been error free.” Instead, he recommends, radiology practices and departments should seek the root causes of errors—to prevent them before they can happen. “You cannot inspect quality into a product,” he notes, paraphrasing Harold Dodge (1863–1976). “You can only build quality into a product.”

Leadership: Effective leadership is “the most important tool we can use in lean,” Littlefield says. Leaders must invest personal time and attention to following through on actions related to change, and they must also be change advocates, constantly challenging the status quo of the practice or department. “If you consistently meet your goal,” he says, “then you need to change the goal.”

Error potential increases as batch size increases.

—dan Littlefield, rPh, MBaHealthcare Performance Partners

A Lean Tool Set for the Radiology Department

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resources that staff members need for true process improvement and change. At VMHMC, a centralized kaizen-promotion office helps develop process-improvement projects with the radiology department, and the department reports to the entire organization on the results of these projects at the 30-, 60-, and 90-day marks. “You have to show the rest of the organization the targets you achieved—so that there is rigor, in terms of implementation and making sure those changes stick,” Glenn explains.

Every Friday at noon, hundreds of VMHMC employees join the organization’s leaders in an on-campus auditorium for what is known as reporting out, in lean terminology. In the 60- to 90-minute meeting, staff members are invited to

report on process-improvement projects that have taken place that week (and, in doing so, to hold one another accountable and encourage one another to continue).

“There is a strong commitment from executive leaders to implementing staff ideas,” Lee says. “Staff members have seen those efforts come through and have seen those ideas become a reality. In our organization, the commitment to helping the staff put its ideas into play has been a constant.”

Lee continues, “Over 10 years, everyone becomes a participant. People are excited to share what they have accomplished. They are proud of the time and hard work they put in; as a frontline employee, I view the events as very self-reinforcing.”

As health-care facilities seek efficiency opportunities to offset reimbursement declines, lean process-improvement techniques (see sidebar) are capturing the interest of health-care executives across the country. Be advised, however, that results are not achieved overnight.

Time and persistence are the keys to making lean methods work for radiology and for health care in general, Glenn concludes. “This is our strategic plan. It’s our vision,” she says. “Quality is our top goal, and the strategic plan is everywhere. We start every meeting with it. It’s on our screen savers. It just takes constancy of messaging and time.”

Cat Vasko is associate editor of Radiology Business Journal.

reference1. Cohen SP, Gupta A, Strassels SA, et al. Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial. Arch Intern Med. 2012;172(2):134-142.

There is a strong commitment from executive leaders to implementing staff ideas. In our organization, the commitment to helping the staff put its ideas into play has been a constant.

—richard LeeVirginia Mason Hospital and Medical center

Las Vegas, Nevada, was particularly hard hit by the economic crisis of 2008, and Desert Radiologists—a 47-radiologist practice that has seen plenty of market fluctuations since its inception, in 1966—knew that the slump would bring challenges, as well as opportunities. As William P. Moore II, MBA, CRA, CEO of the practice, recalls, “The economic downturn brought home foreclosures and business closings, and that really reshaped the economic climate, but our practice has grown since 2008, in spite of the down economy. That’s due, first and foremost, to the quality of our services—and second, to the strategic decisions we’ve made regarding the opportunities that have come our way.”

The practice experienced another change in 2008. After a year of managing its billing in-house, it began to transition to outsourced billing through Zotec Partners. Moore explains that while the decision was multifactorial, having real-time access to the reams of data generated by the practice’s 1.1 million exams in 2008 was a key issue. “Zotec’s reporting tools give us near–real-time data, and that was important to us,” he says. “The alternative billing company we were looking at would not have provided us with data until it was

over 30 days old. With Zotec, the data we’re looking at is never more than a day old.”

The availability of this near–real-time business intelligence has affected nearly every area of the practice in the ensuing four years, according to Whitney Edmister, MD, PhD, a cardiac and thoracic radiologist. “Over time, the data has made a huge impact on our practice, but through thousands of little, incremental changes,” he says. “You keep fixing all these small

issues that the data brings to your attention and, over time, you notice your gross collections are rising, while your days in accounts receivable are falling.”

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Identifying ChallengesEdmister cites multiple examples of challenges that the

reporting tools have helped Desert Radiologists identify. One key example is the downcoding of reports, he says. “If there is a discrepancy in a report, the radiologist is notified electronically,” he explains. “The radiologist can then review the report, and, if deemed appropriate, dictate an addendum with the missing information so that the report can be coded and billed accurately.”

Over time, radiologists whose reports are consistently downcoded become aware of the mistakes that they are making, improving overall billing efficiency. “It encourages them to learn from their mistakes and update their templates, so they are no longer leaving anything out of that particular report,” Edmister says.

The practice also uses data from Zotec’s reporting tools to track radiologists’ productivity by RVUs, enabling it to identify and deal with any outliers. for outliers on the lower end of the productivity distribution, Edmister says, “It encourages them to improve their productivity. since we started doing this, everyone has moved closer to the mean [for the group].” for outliers on the higher end, Moore says, “We ensure that there are not quality concerns or complaints regarding the thoroughness of the report.”

“When you can quickly identify areas where you might be grossly underpaid by a certain payor, you can go back to the payor with that data and renegotiate that aspect of the contract.”—Whitney Edmister, MD, PhD

Business intelligence can also be used to evaluate payor contracts and determine whether the rates being paid for certain procedures or supplies are fair, according to the market. for instance, Edmister says, “We can easily see what different payors are paying us for isotopes, and we can use the software to find the payors that are outliers. When you can quickly identify areas where you might be grossly

underpaid by a certain payor, you can go back to the payor with that data and renegotiate that aspect of the contract.”

Monitoring Performance

Patricia harms, MBA, CPA, CfO of Desert Radiologists, leverages the data to monitor the practice’s financial performance daily, weekly, monthly, quarterly, and annually. “We have a dashboard we look at daily that shows us where we are with our month-to-date charges and payments; we also monitor what we are receiving in our lockbox and do a daily reconciliation with our bank accounts to see what our cash flow is,” she says. “We can know, on any given day, what we’re currently collecting—and over time, I know what that figure was for 2011, so I can compare to assess whether we’re on track or have improved.”

special reports generated by harms and her team on a monthly, quarterly, and annual basis assess the profitability of the practice’s outpatient imaging locations. These reports are especially valuable in light of recent regulatory changes affecting imaging; she notes, “What’s been happening, over the past couple of years, is that there is more volume, but the revenue per RVU is going down (with the bundling of some of the procedures into single codes and revisions to the RVU system). Our outpatient centers are having to complete more volume because the revenue per RVU is on the decline.”

The practice also uses business intelligence to track referral patterns, primarily for the purpose of more targeted marketing to referring physicians. “We pull data to identify our biggest gainers and losers, from a referral standpoint,” Moore says. “If we’re seeing an MRI, CT, or PET referral source with the numbers going up or down significantly, we try to find out why that volume is changing. We look at that data in reference to what opportunities exist as well. for instance, if there’s a referrer who’s part of a big network of physicians, but we’re not getting the lion’s share of referrals from him or her, we’ll use business intelligence to determine why.”


Evaluating OpportunitiesAs Moore’s comment underscores, one of the key

benefits of the business intelligence generated by Zotec is identification of opportunities for growth. “We use the data to get our arms around future expansion,” Moore says. “We analyze what we have, how we’re doing, how we can improve, and where we can grow.”

In one example, Edmister recalls, the practice was evaluating whether it could add a service line for implanted central venous access (port-a-caths) at its eastern location, which offers interventional-radiology services. “We looked back at a small number of port-a-cath implantations that we had done, and using the reporting tools, we could see exactly what we were reimbursed and figure out that this procedure was well reimbursed (based on the time required for radiologists). Now, we offer it as a service, and it’s done very well for us. The data help us evaluate new business opportunities to determine whether a modality is something we want to introduce—or offer more of,” he says.

In another instance of business intelligence providing the data necessary to make a decision, the practice recently decided to implement a PET/CT system at its

northwestern location. “for many years, we only had PET/CT on the east side of the Las Vegas Valley, so patients who lived in the far northwest would have to drive a significant distance for an exam. It became a hardship for them, and using the data allowed us to identify how many patients were coming from that area of the market, as well as how many more we were not scanning,” Moore says.

Data-driven Results

Today, Moore says, Desert Radiologists performs nearly 1.3 million exams annually, and its growth shows no signs of stopping. “We’ve increased our overall business,” he notes. “Zotec and our in-house staff work hand in hand to ensure that accounts are not prematurely turned over to collections. We haven’t seen our bad debt grow even compared with 2006 levels, and that speaks volumes (in a down economy). Kudos both to Zotec and to our in-house staff.”

Outsourcing its billing has saved the practice around $2 million per year compared to its previous efforts,

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Moore estimates. In addition, the thorough charge capture made possible through the integration of Zotec’s electronic billing system with the practice’s RIs/PACs ensures that the business capitalizes on every available dollar, Edmister says. “Your RIs and practice data really drive your billing,” he notes. “You need that tight link—that integrated exchange of information.”

With it, he says, come leaps and bounds in financial efficiency. “We know we have 100% charge capture across all of our locations,” Edmister says. “The billing process starts immediately for every exam, in every location, and that keeps the days in accounts receivable very low.”

harms adds that the ready availability of business intelligence has made more agile decision making possible across the practice. “If we’re going to add a piece of equipment, for instance, we can project the volume we would need to break even on that investment and assess the market in that part of town; that data is pulled from Zotec’s reporting tools,” she says. “We do that type of analysis before making any expansion or equipment decisions. The data plays a key role.”

Looking Ahead

Desert Radiologists currently has seven teleradiologists in its roster of clinicians, and it has identified remote reading as a key growth opportunity for the future. here, again, the business intelligence provided by Zotec enables the practice to make more informed decisions, Moore says. “We’re reaching out into other states and picking up hospital (and other) reading contracts,” he notes. “We can compare national aggregated data, available through Zotec, to help us make decisions in reference to where we want to grow.”

Expanding services to rural hospitals is another goal of the practice, Edmister says. “We’re always looking for rural hospitals that are seeking better-quality coverage,” he explains. “We can offer them fast turnaround times and high-quality reports.”

Quality is critical, Moore stresses, and Desert Radiologists leverages business intelligence to understand exactly what it can bid on a potential contract, while still providing the level of service and quality for which the practice is known. It’s a strategy that has paid off; he says, “Whether they be hospital systems, referring physicians, or clinics, they get frustrated when their quality standards aren’t met.” Edmister adds, “When you talk about taking on a large hospital contract, it’s a big project. To have the resources and availability to say yes (and to be reading for them 24 hours a day and providing interventional services just a couple of months later) gives us a tremendous advantage in the marketplace.”

“Business intelligence affirms whether we’re on the right track, and we learn from that when we create our long-term strategy. We have to be nimble and able to adjust as the need arises.”—Patricia Harms, MBA, CPA, CFO

As a result, the practice can follow its tradition of high-quality imaging while keeping an eye on future opportunities, harms concludes. “We want to continue to be the premier radiology group, and in order to do that, we have to stay on the cutting edge,” she says. “Business intelligence affirms whether we’re on the right track, and we learn from that when we create our long-term strategy. We’re in this to maintain our business and remain a thriving entity 20 years from now, and that means we have to be nimble and able to adjust as the need arises.”

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11460 N. Meridian St.Carmel, IN 46032


By focusing on the job at hand, elevating those around them, and seeing beyond the radiology department, two radiologists and one former department administrator have achieved key hospital-leadership positions

Hospital leaders | Three From Radiology

www.imagingbiz.com | June/July 2012 | Radiology Business JouRnal 57

By Matt Skoufalos

Ascending the Hospital’s Leadership Ladder

Times of change generally present increased opportunity for those willing to find the right door and open it. With hospitals merging,

buying practices, and acquiring imaging centers, there is just such an opportunity, in health care, to rectify what many believe is a paucity of radiology representation in the upper echelons of hospital administration.

room at the top

As unusual as it is to find imaging experts in general-leadership positions, Robert Grossman, MD, has attained a position in his field that makes him even more of a rare species. Grossman, who is both dean and CEO of NYU Langone Medical Center (New York, New York), logged 20 years as a neuroradiology chief and another six as department chair. His career as a researcher is equally distinguished: He won a a National Institutes of Health (NIH) Javits Neuroscience Investigator Award in 1999 for research on multiple sclerosis, and from 1997 to 2000, he chaired the NIH Diagnostic Radiology Study Section.

Grossman also invested time in the service of organized radiology, as a past president of the American Society of Neuroradiology, as editor of the American Journal of Radiology, and as a fellow of the International Society for Magnetic Resonance in Medicine (ISMRM). He

received a gold medal from the ISMRM in 2010 for his pioneering research in MRI in medicine and biology.

By some measures, though, one of his greatest achievements was turning all that experience into a true C-suite position. After all, radiologists are physicians first. “I didn’t have a linear pathway at all for this job,” Grossman says. “I was never focused on being the dean/CEO; I was focused on doing what I did at the time that I was doing those jobs.”

The accolades didn’t stop piling up once he got the job, either. In the years since he’s held the dean/CEO position, two NYU Langone Medical Center facilities—Tisch Hospital and the Rusk Institute of Rehabilitation Medicine—have twice earned Magnet Awards from the American Nurses Credentialing Center.

In recruiting the dean/CEO, the board of trustees at NYU Langone Medical Center sought a candidate with a background in research and medicine who would help integrate the school and hospital aspects of the institution. The reason that the board chose Grossman, he says, is that he had sampled a variety of different leadership opportunities along the way.

“If I were trying to talk to young physicians who want to be deans or CEOs, the most important thing I’d



say is not to be afraid of something that you may not be comfortable with,” Grossman says. “Extend your comfort zone, and go with your passion,” he says. “Ultimately, you want to maximize your job satisfaction and happiness, and in order to do that, you have to be willing to stretch, sometimes. By sampling a lot of different opportunities, I gained experience that provided me with a skill set that our board found appealing.”

raising all BoatsGrossman says that his passions—

and his appetite for taking on added responsibilities—were fueled by his recruitment of talented staff, along the way. When he was a section chief, he says, he mentored excellent people and

looked for ways to help them conduct research that would embellish their careers. When he moved up to become a department chair, he simply scaled up his approach, seeking individuals who could help transform an institution into something greater and more successful than it had been.

“There’s nothing formulaic, as far as I’m concerned,” he says. “The best thing is to be a good learner. I think that what you have to do is manage people and have a vision for what you want to make of your institution.”

At NYU Langone Medical Center, Grossman’s vision has to hold for 19,000 people who always ask what’s in it for them, he says. That’s where the effectiveness of a leader is made: in communicating effectively a vision for the future of the organization and in coordinating the deliverables necessary to execute it. Grossman says, “Ideally, you want to have a vision and then manage the components to fulfill the aspirations.”

Unifying those qualities of assessment and implementation, he says, is what makes an effective leader: making an appropriate evaluation (of talent, resources, or strengths): seizing opportunities that other people don’t see; and then delivering on those expectations. “It’s easy to see them,” he says. “It’s harder to make sure that everything works. I think you’re chosen as a leader if you can deliver on vision and your promises. There are many people who are highly articulate, but it’s about rolling up your sleeves and making a decision into reality.”

Beyond having the ability to execute plans, Grossman says, a good leader must also demonstrate emotional intelligence. Good leaders have a lot of

authenticity, he says—and many times, “Very creative, innovative, smart people don’t understand why they can’t be good leaders,” he explains, if they lack emotional intelligence.

A radiologist hoping to climb the executive ladder must have something from each of many skill sets, Grossman says. Imaging professionals are in short supply at the top for any number of reasons—not least of which is that many, he feels, enjoy economic rewards that are sufficient to keep them where they are.

“They don’t have any seats at any tables,” he says. “They don’t embrace, or haven’t recently embraced, leadership training. They’re underrepresented in Congress; there are none in CMS.” Of more than 150 US medical-school deans, he estimates, four are radiologists, and radiologists account for even fewer hospital CEOs. “I think that the specialty hasn’t really promoted or embraced leadership,” Grossman says. “It’s been very inwardly focused.”

private practice to an integrated delivery Network

That assessment is one of the things that deeply frustrates Keith S. White, MD, medical director of imaging for Intermountain Healthcare (Salt Lake City, Utah). The notion that radiologists can’t become administrative leaders until they achieve a certain status as senior medical leaders has really handicapped the profession, he says.

White, who has more than 20 years of experience in diagnostic and pediatric radiology, says that since becoming a radiologist, he has tried to expand the role of the discipline within a broader system that doesn’t place as much emphasis on RVU production; instead, it allows radiologists to contribute to care process model development, treatment planning, operational efficiencies, “and other areas of our expertise that are underused,” he says.

He continues, “I think the business market compensation models and IT solutions under which we’ve practiced have so strongly pushed personal productivity that they have taken us away from direct contact with patients and referring physicians—and in some cases, out of leadership roles. What happens if there’s no apparent or immediate opportunity for a radiologist to demonstrate viability as a leader?”

In such instances, White advocates “becoming involved in whatever administrative opportunities become available to you,” he says. Some of these smaller opportunities to gain

If I were trying to talk to young physicians who want to be deans or CEOs, the most important thing I’d say is no to be afraid of something that you may not be comfortable with. Extend your comfort zone, and go with your passion.

—robert Grossman, Md

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administrative experience frequently present themselves both within health systems and in associated private groups. “Although these opportunities may not be in high-profile areas, active participation and positive performance will open doors,” he says. “My personal experience was one of just gradually growing, step by step, along the way. There were opportunities in IT, quality improvement, business-office management, and departmental operations.”

White’s own experiences, he says, consisted of working for several years in an academic environment; then, joining a private-practice radiology group; and ultimately, becoming the corporate president of that group. After that, he says, it was another natural step to his current position at Intermountain Healthcare.

the teleradiology problemWorking against the kind of hands-

on experience that develops good administrative leaders (as well as good physicians), White says, is the expansion of teleradiology. In many circumstances, the demands of the profession remove imaging professionals from direct personal contact and from the relationships that are needed for radiologists to have a powerful impact on care decisions. White says, “I think that a real challenge we face, in radiology today, is not to be dragged along by the natural business incentives that are present in a volume-based, fee-for-service model, and to build a new, superior model more compatible with the value-based incentives of the future.”

He adds, “Appropriate utilization of imaging services has a huge impact on cost. Controlling and managing cost and

preserving the well-being of a patient are going to be the name of the game in the future, and radiologists are key players in that process. It’s very important for us to be able to create these care-process models, and we can’t do that if we’re not contributing members of the multidisciplinary care teams that will develop these models.”

What is needed (more than anything), White says, is a new generation: leaders who can look beyond the field of radiology

to being part of a global multidisciplinary care team that turns away from arguments over turf to focus on defining and implementing best care within an integrated delivery system. To achieve that, he says, imaging professionals need to abandon a department-specific bias. “If we were to embrace this other model of driving patient-care initiatives, then the value of our expertise and of our tools would speak for itself,” he says.

At the intersection of these competing interests, White adds, is an opportunity to use the quantitative analytical assessments of good medical practice to drive a more patient-centered model of care delivery. In fact, he says, there is a surprising lack of attention to the basic science of quality improvement in the day-to-day lives of radiologists, even as imaging professionals are compelled to deliver outcomes-based services.

“That’s another major opportunity for young radiologists interested in pursuing a leadership track: dedicating themselves to learning about the science of quality improvement,” he says. “That’s what’s going to be necessary for us to have an impact, in the future, and there will be ample opportunity for radiologists who have these skills to lead.”

technologist to Coo

Richard Helsper, MBA, FACHE, agrees with White that change is at the core of everything that radiology leaders are called upon to achieve—and that such change doesn’t necessarily demand an adherence to traditional measures. Helsper is COO of Genesis HealthCare System (Zanesville, Ohio). He was vice president of operations for Clarian Health (now Indiana University Health) and was COO of its Midwest Proton Radiotherapy Institute (now the IU Health Proton Therapy Center)—but he says that his foot in the door in health care was in patient transport. Later, he became a radiologic technologist.

“My last boss, CEO of two hospitals and COO of an 18-hospital system; a previous boss, CEO of a major hospital system in North Carolina; and I—all of us were radiologic technologists who no longer keep our licenses because the CE credits we now earn no longer apply to radiology,” Helsper says. “Now, it’s not as though any of us are going to go get behind a camera again, but I actually thought about going back to get the CEs. At that point, my life was so busy that I let it lapse.”

Sometimes, the field is at cross-purposes with itself, Helsper says. Imaging rewards its subject-matter experts with departmental promotions, but to get out of the department, “You need more than that,” he says.

“To me, it’s the culture that the only thing that’s important is radiology expertise,” Helsper adds. “That doesn’t

That’s another major opportunity for young radiologists’ interested in pursuing a leadership track: dedicating themselves to learning about the science of quality improvement.

—Keith s. White, Md

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Leadership | An Inside View

62 RAdIology BusIness JouRnAl | June/July 2012 | www.imagingbiz.com

help the radiology leader grow beyond radiology.” Even when imaging professionals ascend to other leadership roles, Helsper says, they often become known within their organizations only as radiology leaders, not as leaders in the broad sense.

“Being a technical expert is a great thing, but it doesn’t lead you into the next realm,” Helsper says. “When the radiology director is seen as an expert only in radiology, and not in any of the other initiatives and priorities, it’s more difficult for him or her to break out” of being thought of as a technologist.

Subject-matter expertise doesn’t differentiate an imaging professional from other leadership candidates over the long term, Helsper says—but leadership capabilities do, and one of the easiest ways to demonstrate them is to earn an advanced degree, such as an MBA. “To move up in the world, into a vice president’s or COO’s position (or one of those kinds of roles), you absolutely must have a master’s degree,” he says. “There’s too much competition out there. If that’s where you want to be, then the only way to get there is to be prepared at the master’s-degree level.”

One in FiveWhat keeps many professionals

from obtaining MBAs, he says, is either intimidation at the prospect of taking on such a task or an unwillingness to sacrifice some of the creature comforts that will be lost on enrolling in advanced education. For Helsper, who didn’t earn his MBA

until he was in his 40s, it required 22 months of priority realignment, as he puts it.

“I was working at the time, and I think I gave up six or seven weeks of my vacation to make sure I was successful in the program,” Helsper says. It was a deliberate decision, he adds, and it was definitely worthwhile. “There are a lot of people who want their home lives, want to work fewer hours, and also want to be promoted,” he says. “There’s nothing wrong with that; however, it often does not lead to growth. One should understand that the measure of work is accomplishment. When I got out of school as a technologist, I was driving around in a $1,000, seven–year-old car,” he says.

Helsper always encourages people who work for him to consider pursuing an MBA, MHA, or other master’s degree, and he offers his assistance in putting a program together, he says. He believes that the imaging field should be attempting to develop no fewer than one in five of its members into executive/administrative leaders. That’s tough to do in an environment where the goalposts are always moving, he says, but it is, ultimately, a necessary strategy if the profession is to exert greater influence on the future of health care.

“Look at the number of things in the past 15 years that have flipped radiology,” he says. Health care is going through similar changes, causing fundamental differences in how care is delivered, compared with how it once was performed. Without leaders who have radiology backgrounds, he asks, “How do we incorporate those changes into our practices and execute them effectively?”

Matt Skoufalos is a contributing writer for Radiology Business Journal.

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Being a technical expert is a great thing, but it doesn’t lead you into the next realm. When the radiology director is seen as an expert only in radiology, and not in any of the other initiatives and priorities, it’s more difficult for him or her.

—richard helsper, mBa, FaCheGenesis healthCare system

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I have written frequently about the implications of economic

turbulence in radiology; we are facing some now, and others will unfold in

the months and years ahead. These far-reaching implications concern nothing less than the survival of some private radiology practices and the death of fee-for-service payment. Our current economic model is obviously unsustainable: Society can’t afford it, and payors are tired of feeding this dysfunctional beast.

Key to understanding how anticipated changes in payment will profoundly affect the profession three to five years from now is the notion that ours is a

marketplace in which supply and demand are unbalanced—in favor of payors. This gives buyers confidence that continuing to squeeze costs out of imaging will not result in denied access. The wait for a study might become longer, but excess imaging capacity indicates that such delays will be minimal.

The problem arises from the payor/regulator/legislator perception that at least 30% of imaging studies are unnecessary. Add to this the conundrum of the sustainable growth rate’s so-called doc fix (which adds hundreds of billions of dollars to federal balance-sheet liabilities), and the radiology bubble begins to stretch to its limit. The fee-for-service model is under the closest scrutiny that it has ever faced, and its future appears uncertain (at best).

It gets worse. Some bundled-payment and capitation models have become attractive precisely when cultural shifts have

made many younger radiologists amenable to the idea of predictable, stable hospital employment (versus risky, unpredictable, and turbulent private practice). The bubble expands even more.

Now, let’s add the macroeconomic piece. The United States is deeply in debt. The bright spot of health care is dimming, as it becomes more obvious that health reform is adding costs as it adds covered lives. The tension among medical specialties, as they jockey for turf and revenue, is creating enemies among those who were once colleagues. First on the enemies list is radiology, as its piecework payment model continues to build wealth and create lifestyles that are the envy of all.

Reality check: This bubble will definitely burst. The only questions are where you will be when it happens, what you will do

about it, and how you will handle a potential reduction of 25% or so in your income. Will you have plan B ready for implementation? Will you understand the new normal and how to navigate its complexities? Will you collapse under the weight and strain of this recalibration because you remained complacent, convinced that this was all much ado about nothing?

Perhaps the best way to view these inevitable changes is just as one would look at one’s home, in an honest, objective appraisal. Yes, at one time, the home’s value might have been double or triple what you paid for it, but did you really think it was worth that much money—or were you simply caught up in the tidal wave of growth that carried you along with everyone else? This is the type of cost/benefit/value equation that payors are evaluating as they plan for a future based


Bursting the Radiology BubbleWhere will you be when the day of reckoning comes to radiology? By Curtis Kauffman-Pickelle

FinalREAD

on a much more restricted use of fee-for-service payments.

What is to be done? First, realize that the new normal is approaching faster than we anticipated. Second, create a strategic plan that expects more severe cuts and a bundled-payment mechanism similar to DRGs. Third, get all people in your organization on the same page—aligned, understanding the stakes, and linked in ways that will tap their skills and creativity to build survival strategies. In other words, lead from the front, and use the business intelligence in your systems to imagine alternative scenarios that will strengthen your operation, in preparation for the day that bad news arrives.

I remain optimistic about the future of radiology. The specialty’s contribution is unparalleled. The brainpower is incredible. The value proposition is amazing. Soon, though, it will be a different ball game, and the rules will change dramatically.

Those who plan well, are prepared, and understand the stakes in this realignment not only will survive, but will come through in fine shape. Organizations that differentiate themselves, build top-level brand value, cultivate customer loyalty, and link their people and resources in a formidable competitive machine will thrive, no matter what payment model emerges.

Those who ignore the fiscal realities of health care must hear this: The pin is mere centimeters from the bubble, and when it bursts, there will be serious consequences. If we all work together, as a profession committed to being in the forefront of the new system, we might be able to help let the air out of the bubble in a more orderly fashion. I know that ACR® leaders understand this need and are doing their part to align all radiologists around this mission.

Curtis Kauffman-Pickelle is publisher of ImagingBiz.com and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry.

Reality check: This bubble will definitely burst. The only questions are where you will be when it happens, what you will do about it, and how you will handle a potential reduction of 25% or so in your income.

TELE

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Radiology Business Journal June/July 2012