Radiology Business Journal Jan/Feb 2009

FOR LEADERS IN MEDICAL IMAGING SERVICES

February/March 2009

The CCTA

Playbook Coding | Reimbursement | Operations

PAGE 18

FEATURED IN THIS ISSUE Imaging Executives Crunch the Numbers | page 28 Mining the RSNA Landscape | page 34 Teleradiology Permeates the Specialty | page 40 w w w. ra d b i z j o u r n a l . c o m

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CONTENTS F E B R UA R Y / M A R C H 2 0 0 9 | VOLUME 2, NUMBER 1

FE ATURES 18

18

THE CCTA PLAYBOOK: A GUIDE TO CODING, REIMBURSEMENT, AND OPERATIONS

By Jonathan Berlin, MD, MBA

A compendium of the business intelligence required to launch a CCTA service.

24

MASTERS OF MANIPULATION

By Cat Vasko

Radiologists and vendors race to grasp and improve the tools of advanced visualization as imaging modalities churn out ever more information.

24

28

DATA MINING: IMAGING EXECUTIVES CRUNCH THE NUMBERS

By George Wiley

RIS data, keyed to billing, can be analyzed to improve competitive capability and pare inefficiency to the nub.

34

RSNA 2008: MINING THE LANDSCAPE, ASSESSING THE EXHIBITS

By Lisa Bielamowicz, MD

In assessing the imaging technologies on display at RSNA, an observer provides tools for making critical decisions regarding your capital budget for 2009.

40

DAY FOR NIGHT, EAST FOR WEST

By Greg Thompson

28

Teleradiology permeates the specialty as practices cross state, regional, and global boundaries to purchase and practice radiology.

DEPARTMENTS 8

ADVIEW Prove It

By Cheryl Proval

40

10

THE BOTTOM LINE Radiology: Ancillary No More

By Howard Fleishon, MD

4 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

There’s a whole lot going on inside Synapse®.

Synapse brings all the domains, modalities, tools – everything together in one place.

No more logging on and off different systems with different interfaces and different tools. Now Radiology, Cardiology, Mammography, Oncology, Ophthalmology, Endoscopy and more are all in one system. And since it’s Synapse, you can work anywhere you want: at the hospital, at home, wherever. Synapse medical imaging informatics gives it all to you – in one brilliant package. With over 1500 sites and more than ten million studies, Synapse has helped thousands of radiologists be more productive, be more efficient and deliver a higher level of care. There’s a whole lot going on inside Synapse, so you can feel a little less stressed. Call 1-866-879-0006 or visit www.fujimed.com.

www.fujimed.com © 2008 FUJIFILM Medical Systems USA, Inc.

CONTENTS F E B R UA R Y / M A R C H 2 0 0 9 | VOLUME 2, NUMBER 1

46

PUBLISHER Curtis Kauffman-Pickelle ckp@imagingbiz.com EDITOR Cheryl Proval cproval@imagingbiz.com ART DIRECTOR Patrick R. Walling pwalling@imagingbiz.com TECHNICAL EDITOR Kris Kyes kris@imagingcenterinstitute.com CONTRIBUTING WRITERS Jonathan Berlin, MD, MBA Lisa Bielamowicz, MD Howard B. Fleishon, MD, MMM Daniel McLaughlin Greg Thompson Cat Vasko George Wiley

12

DEPARTMENTS 12

ADVERTISING DIRECTOR Sharon Fitzgerald sfitzgerald@imagingbiz.com

(continued)

PRIORS

PRODUCTION COORDINATOR Megan Runyon mrunyon@imagingbiz.com

12 HEALTH POLICY | Further TC Cuts Ahead?

14 UTILIZATION | Under the Influence of RBMs

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15 STRATEGIC PLANNING | Thoughtful Management for Hard Times 46

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FINAL READ

PRESIDENT/CEO Curtis Kauffman-Pickelle VP, PUBLISHING Cheryl Proval

Highly Functional Imaging

VP, CLIENT SERVICES Steve Smith

By Curtis Kauffman-Pickelle

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BPA Worldwide membership applied for February, 2009

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Radiology Business Journal is published bimonthly by the Imaging Center Institute, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. February/March 2009, Vol 2, No 1 Š 2009 Imaging Center Institute. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to Imaging Center Institute, 17291 Irvine Blvd., Suite 406, 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.

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A dView Prove It It is time for the specialty to take a proactive role in evidence-based radiology

By Cheryl Proval

I

f you have any doubt that imaging remains a target for further cuts, you will find an article within a section on imaging1 in the November–December 2008 issue of Health Affairs enlightening—if not to your liking. The authors are analysts for the Medicare Payment Advisory Commission (MedPAC), and they are urging CMS to take a scalpel, instead of a hatchet—as in the DRA—to the technical reimbursement for imaging. In the end, the cuts would be likely to exact a similarly painful pound of cure.

You decide whether the fixes proposed by Winter and Ray (summarized on page 12) would render a more accurate payment methodology for practice expenses in this era of dwindling resources. My point is this: Payors, regulators, and, now, health policy experts perceive imaging as a problem, not a solution. What is radiology going to do about that?

The price of medical technology is the theme of the Health Affairs issue in which the above article appeared. The first five articles are devoted to medical imaging and are required reading for anyone who cares about the specialty, how it is perceived, and what is required to demonstrate its usefulness.

A group from Stanford University, Stanford, Calif, led by Baker, wrote the first article in the section. Using an equipment census and Medicare claims data, the team documents a direct relationship between the growth in the availability of high-tech imaging technology between 1995 and 2004 and the growth of the total number of procedures performed on Medicare beneficiaries. The team acknowledges the difficulty of determining whether the increased expenditures provided an equivalent benefit to society, but it does offer an approach to developing population-level evidence to begin to answer that question, using the diagnosis of abdominal aortic aneurysm as an example.

Winter and Ray’s article appears second in the section; a third article is provided by Smith-Bindman (a University of California–San Francisco radiologist) and two researchers associated with the Group Health Cooperative, Seattle, a nonprofit, mixedmodel integrated care system covering approximately 10% of Washington state residents through its own facilities.

Studying the imaging patterns of 377,048 patients between 1997 and 2006, the authors calculate the number of imaging tests per year by anatomic area, modality, and year within age groups (including elderly enrollees), with a focus on repeat imaging and cost. The Group Health Cooperative data describe patterns in its managed care environment that are very similar to those growth patterns reported by MedPAC in the Medicare population, leading the authors to surmise that disincentives in the managed care model may not suffice to change the impulses toward increased use of imaging in the fee-for-service population.

The fourth article in the section comes from a team of researchers led by Pearson at the Institute of Clinical and Economic Review at Massachusetts General Hospital’s Institute for Technology Assessment (ITA), Boston, which is directed by Gazelle (a radiologist who is also one of the article’s authors).

Stating that new medical tests and treatments frequently become widely used prior to definitive evidence of their effectiveness, the authors assert that medical imaging is prime for clinical effectiveness studies.

After describing the challenges of performing those analyses—and they are considerable—the authors describe a technique called decision-analytic modeling that can accommodate information gaps. The authors demonstrate the method in a case study to assess the comparative effectiveness of CT colonography.

In the last of the five articles, a USA Today reporter offers an account of the CMS attempt to roll back reimbursement for cardiac CT angiography (CTA) and the successful efforts of cardiology and radiology to overturn that decision.

EXHILARATING AND TROUBLING

Throughout this section, some familiar and new ideas emerge, both exhilarating and troubling. The work done by Smith-Bindman et al in this population is not their first, and we are likely to see the authors continue to mine this rich vein of information over time as they study the impact of coverage decisions and new technologies. They have laid the groundwork for collecting the evidence that is expected to become even more important to health care decision-making.

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In the next article, Pearson et al address the problem of new technologies and procedures adding an extra layer of cost to the system by failing to replace older, less effective ones. The work done at ITA; at Johns Hopkins University, Baltimore; and at the Permanente Foundation, Oakland, Calif, to assess the comparative effectiveness of CT colonography represents a refreshing advance beyond the dithering about the challenges of obtaining outcomes data for radiology.

Yes, it is difficult, but this team plots a path around the hurdles. The method described in this article requires the input of a great number of people to preserve the integrity of the results, but in the absence of the gold standard of large, prospective studies, it provides much-needed, well-vetted information on which to base decisions.

Here’s the troubling part. In introducing the imaging section, the editor of Health Affairs draws parallels between the boom brought about by subprime mortgage lending and unbridled securitization and the rapid increases in medical imaging. Also disturbing is the reporter’s cynical summation of the struggle to retain reimbursement for cardiac CTA, which is characterized as a money grab by cardiology and radiology.

Clearly, radiology has a perception problem. The specialty can reverse this perception by taking a proactive role in proving the value of imaging, but it can’t be done in the absence of the comparative effectiveness studies on new technologies and techniques that are required to address the issue of spiraling health care costs. A new era in medicine has dawned: Prove it or lose it.

Cheryl Proval is the editor of Radiology Business Journal and vice president, publishing, The Imaging Tustin, Calif; Center Institute, cproval@imagingbiz.com.

Reference 1. The imaging boom. Health Aff (Millwood). 2008;27:1466-1521.

THE BOTTOM LINE

Radiology: Ancillary No More Radiologists must counteract practice developments that can result in trivializing their specialty’s contributions to medicine BY HOWARD B. FLEISHON, MD, MMM

U

nder the 1989 Stark legislation, radiology services, both diagnostic and therapeutic, were classified by Medicare as ancillary.

Medical imaging and radiation therapy were categorized as comparable to laboratory services, physical therapy, occupational therapy, speech/language pathology, durable medical equipment and supplies, nutritional therapy, prosthetics, home health services, and similar fields.

The word ancillary is derived from the Latin ancilla, which means maid. As an adjective, ancillary is defined as subordinate, auxiliary, or secondary. The context of the term’s use, within the Stark legislation, was the intent to address self-referral abuses within those services that were considered extensions of physician-office visits. These services included tests like chest radiographs, or even ultrasound exams in obstetrician/gynecologists’ offices.

Such services, arguably, serve as extensions of the stethoscope in the new age of technology.

As we all know, modern radiology is by no means ancillary. Studies, particularly those acquired on high-tech equipment, are usually scheduled and performed at separate visits, and commonly at different locations than those of the originating office visits. These are not incidental exams, and they should no longer be classified as ancillary. The ACR currently is presenting this argument to CMS in an attempt to address the in-office exemption loophole on which most self-referral models rely for their justification.

Radiologists (and many referring physicians) realize that medical imaging is vital to evidence-based medical care. The booming rate of utilization for imaging tests is a testimony to the importance of radiology as a diagnostic imperative. For example, up to 75% of all emergency-department patients receive some sort of medical imaging.

The perception that radiology is something less than real medicine, however, somehow persists in many circles—including among some physicians, the public, and, unfortunately, politicians and regulators. On

November 17, 2008, in the South Florida SunSentinel, Ted Epperly, MD, president of the American Academy of Family Physicians, was quoted as saying, “America won’t be cared for properly by having a million radiologists and dermatologists. We’re producing the wrong doctor work force for America.” During the 2008 ACR branding campaign, it was determined that only about 50% of the public was aware that radiologists are doctors.

We also are contributing to this misperception. Our business models have emphasized increased productivity in order to make up for decreasing reimbursement. Some consequences of these new priorities include decreasing communication and contact with those we serve. The diffusion of PACS and teleradiology into our practices and hospitals has significantly reduced our direct interactions with referring physicians. Night-coverage services have led others to conclude that radiology can be commoditized. Put the CT data into a black box and an interpretation will appear.

Take a look at modern ECG machines. A computer-aided detection program types out the preliminary report before any physician touches the study. Automation is challenging the value proposition of some physicians’ professional services, including ours.

ADDED VALUE The problem with this path is that it discounts the added value that we, as physicians, bring to the health care enterprise.

Radiologists are the experts in image interpretation, but we do much more. We care for the patient, assume the responsibility for communication and follow-up, attend to contrast reactions, determine appropriateness, maintain protocols, monitor radiation safety, administer conscious sedation, and serve as medical directors for our hospitals and offices. Those reading this article could add many more responsibilities.

We also add value, in the business of medicine. We have established practice models that can handle large volumes of encounters. Radiology groups have developed orga-

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nizational structures that have served to manage large numbers of physicians.

Radiologists must re-establish their roles as physicians integral to the health care enterprise. We are, first and foremost, physicians. We all went to medical school before we went into radiology. Our focus is on taking care of patients.

There are numerous opportunities, every day, for us to promote ourselves and the specialty. Talk to patients, introduce yourself to the patient as his or her radiologist, call referring physicians with important results, make yourself available for consultations, contribute to community functions, become a member of hospital staff committees, be active in medical societies, and coordinate facility visits for your local, state, and federal politicians.

Radiology has been blessed over the past few decades. Radiologists have been remunerated well while enjoying professional satisfaction. We must not fall victim, however, to our own success through apathy. We all have a responsibility to raise the profile of our specialty. Residency directors can indoctrinate the next generation of radiologists by prioritizing patient interaction and communication in their training programs.

The importance of medical imaging, and the promise of its future, secure its claim in any paradigm to be considered in the health care reform debate. Our relevance as radiologists, however, depends on the value that we add to our machines and methods. Our challenge is to communicate that, as physicians, our imaging services are vital to medicine, patient care, and the health care enterprise.

Radiology has a great story. Let’s go out and tell it.

Howard B. Fleishon, MD, MMM, is a diagnostic radiologist; past president of Valley Radiologists, Phoenix; and cofounder of Southwest Diagnostic Imaging Ltd, Phoenix.

He is a member of North Mountain Radiology Group, Phoenix, a hospital-based practice, and he serves on the ACR Council Steering Committee.

PR I O R S {PR I O R S}

Further TC Cuts Ahead?

D

ue to inequities in payment methodology, are providers of imaging services overpaid?

That question is raised, along with others, in a provocative article by Winter and Ray,1 two analysts for the Medicare Payment Advisory Commission (MedPAC), that was published in a recent issue of Health Affairs. In examining the growth in imaging and Medicare’s method of paying for imaging, the authors identify several weaknesses in the payment methodology that may lead to inaccurate rates, and they suggest some options to improve the system. While much of the information in the report had been previously published, the MedPAC analysts take this opportunity to reply in the affirmative to the above question.

The authors first review the now-familiar data charting the outlier growth of imaging (61%), compared with all physician services (31%), between 2000 and 2005, as paid under the Medicare Physician Fee Schedule (MPFS). In fact, Medicare spending on imaging paid under the MPFS practically doubled between 2000 and 2005, from $6.4 billion to $12.3 billion.

After describing the mechanics of physician reimbursement under the MPFS, the authors identify what they characterize as inaccuracies in the distribution of payments among all physicians, even after accounting for the DRA cuts, the discount for contiguous body parts, and impending declines in payment that will accrue through 2010 due to a recent revision to the methodology CMS uses to calculate practice-expense RVUs.

H E A LT H P O L I C Y

Until 2007, payment for practice expenses not involving physician work— including imaging services—was based on physician charges from 1998. CMS began phasing in new methodology in 2007; when it is fully implemented in 2010, this will result in an estimated 9% decline in practice-expense RVUs for all imaging services. This decline notwithstanding, practice-expense RVUs for imaging services may still be overvalued due to the following shortcomings, the authors contend.

THREE SYSTEM WEAKNESSES One weakness in the system, the authors believe, is the overstatement of equipment costs. Due to the expensive nature of high-end imaging technology,

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equipment costs account for a large percentage of practice expenses. The authors offer the example of an MRI of the brain, for which equipment costs account for 90% of the total direct cost of the procedure. For a chest radiograph, equipment costs account for just slightly more than half of the direct cost of such a procedure.

The per-unit cost of a procedure is based on the number of minutes that the equipment is used multiplied by its cost per minute. The authors posit that recent advances in imaging technology that have resulted in shorter scanning times, such as 64-slice CT and 3T MRI, mean that the times per scan generated in 2002 and 2003 by the AMA’s RVU Update Committee (RUC) may result in an overvaluing of the practice expense for some procedures.

They also point out that CMS uses a formula that spreads the cost of the technology over the number of minutes that the scanner is expected to be operating during its useful lifetime to derive the equipment cost per minute. Another fundamental assumption used by CMS is that the equipment is in operation 50% of the time that the site is open for business.

The authors report that a MedPACsponsored survey in six markets found that MRI scanners are used during 91% of operating hours and CT scanners are used during 73% of operating hours (MedPAC recently voted to recommend that the secretary of HHS increase the equipment-use standard to 90% for MRI, CT, and PET scanners). The authors believe that CMS would be encouraging

the efficient use of high-tech equipment with a 90% use rate.

A second inequity of the system that favors higher costs for imaging services is the fact that CMS began using new practice-expense data in 2007 for the eight specialties that responded to CMS’ invitation to submit new data. The authors believe that this has resulted in all of those eight specialties, including radiology and cardiology, receiving a higher value for practice expenses than those specialties that did not submit new data.

Cardiology’s hourly practice costs, for instance, more than doubled, from $82 per hour to $184 per hour. The authors believe that, had radiology not submitted new practice-expense data, imaging practice-expense RVUs would have declined by 20% instead of 9% by 2010.

The authors believe that CMS needs current practice expense data from all specialties in order to achieve an equitable solution.

The third point made by the authors relates to the three separate geographic practice-cost indices (GPCIs) used to account for differences in price inputs for physician costs. The authors point out that

the GPCI does not recognize that individual services have different shares of inputs for which prices vary geographically (such as nonphysician staff and office space) and for which prices are uniform (such as equipment and supplies).

Therefore, for services with aboveaverage costs for equipment, such as imaging, the index adjusts too large a portion of the practice-expense payment; for services with low equipment costs, the index adjusts too little of the cost.

The average share of practice expenses related to equipment for all physician services is 14.6%, but equipment and supplies account for 60% of the practice expenses associated with MRI of the brain. In assuming that 14.6% (rather than 60%) of the practice expense of an MRI is related to equipment, the GPCI allows too much of this payment to vary geographically.

The authors believe that this may result in overpayment for imaging in high-cost areas and underpayment for imaging in low-cost areas. On the other hand, equipment accounts for just 7.5% of an office visit, so the index allows too small a share of the practice-expense payment for an

office visit to vary geographically. The authors suggest that this may result in fewer office visits and excessive imaging in areas with high input costs. MedPAC has discussed an alternative practice-expense GPCI that would exclude equipment and supplies, at least for those services with high equipment costs, such as high-tech imaging.

OPTIONS FOR ACHIEVING EQUITY The authors conclude that inaccuracies in how Medicare pays for the practiceexpense portion of physician services may be driving the overutilization of imaging.

They ask CMS to request a review of CT and MRI codes by the RUC, to ensure accuracy; to acquire more current practice-cost data for all specialties; and to consider using an alternative GPCI that would recognize that different services have larger portions of costs that do not vary geographically.

—C. Proval Reference 1. Winter A, Ray N. Paying accurately for imaging services in Medicare. Health Aff (Millwood). 2008;6:1479-1490.

Under the Influence of RBMs

I

t’s no secret that utilization control has emerged as the method of choice for private payors focused on reining in imaging costs. What is surprising is the speed with which radiology benefit management (RBM) companies have brought the commercial-payor market under the influence of precertification. At the end of 2005, RBMs covered approximately 25% of all lives in the commercialpayor market, but by the end of 2008, market penetration surpassed 60%, Shay Pratt, practice manager, The Advisory Board, Washington, DC, believes.

Pratt addressed Advisory Board members in his Outlook for Imaging Payment on December 3, 2008, at the University of Chicago’s Gleacher Center. “For 2009, we can probably expect a bit of a slowdown for further precertification adoption, but we are approaching 70% of the commercial market covered by precertification,”

he notes. “These programs are here to stay; they are entrenched.”

Precertification loomed large in Pratt’s outlook, due in part to the growing influence of RBMs and their impact on volume.

The top five companies—National Imaging Associates, CareCore, American Imaging Management, MedSolutions, and HealthHelp—together cover an estimated 130 million lives.

Based on the premise that RBMs are denying an average of 15% of referrals in the outpatient imaging market, Pratt estimates that precertification blocked more than 2.5 million CTs and 1.5 million MRIs from getting to outpatient scanners.

Just how great an effect precertification is having is best understood when those losses are translated into dollars.

Precertification eliminated more than $1 billion in CT and MRI revenue in 2008 alone. The Advisory Board based these

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estimates on rates of 150% of Medicare payment levels.

THE MODELS In formulating his overall outlook for imaging, Pratt took into account three factors: volume, price, and provider supply.

Even here, however, RBMs and precertification figured largely. “With volume, one of the most important questions is this: Will private payors still cling to precertifications, or are there any alternatives that are emerging that might give providers some relief?” he asks.

“Precertification is having a very real effect on hospital bottom line,” Pratt notes.

In modeling annual procedure volumes to calculate how much volume and revenue hospitals are losing to precertification, Pratt estimates that a radiology department doing 30,000 CTs annually is losing 1,942 exams, or $1.08 million in revenue.

THE OUTLOOK While Pratt believes that precertification is here to stay, he also sees signs that the door is opening to decision support. Blue Cross of Massachusetts has three types of programs for radiology ordering, including an alternative radiology-management program that excuses physicians from the regular precertification process if they run their orders through a decision-support tool, Pratt reports. He also cites a program in Minnesota that permits referring physi-

cians to order outpatient imaging procedures using decision support in lieu of precertification.

“The overall message that decision support may be a viable option in the future is encouraging, even if it does potentially require some investment on your part,” he says. “Playing a more active role in the appropriateness of imaging is going to be increasingly important in relationships with payors, and also in demonstrating overall quality: right scan, right patient, and right time.”

Despite the obstacles, Pratt’s outlook is fairly sanguine for imaging providers.

Imaging volumes continue to grow, and radiologic procedures continue to contribute the lion’s share of profit among hospital-based outpatient services. “For hospitals, especially, it is still key to remember how important imaging is to overall financial health,” Pratt notes. “I think we are still in that golden period of physicians learning what imaging can do for them, particularly on the advanced imaging side.”

—C. Proval

U T I L I Z AT I O N

pendent office to acquire precertifications for referrers, and referrers pay a fee, at fair market value, per order.

The fourth model is outsourced precertification acquisition. A third-party entity with no financial relationship to the imaging provider or referring physician obtains the precertification on a fee-per-order basis.

Pratt warns providers to proceed with caution in participating in the precertification process, as RBMs have been inconsistent in their acceptance of these models, and some may cause hospitals to run afoul of anti-kickback regulations. “The waters are being muddied here in terms of what is allowable, what is not,” Pratt notes, adding that a recent OIG opinion appeared to approve of the outsourced precertification model. “We have yet to see a case go to court on this, so right now, it is a bit of a free-forall,” Pratt adds.

{PR I O R S}

Hospitals with an annual MRI volume of 13,500 would lose an estimated 1,014 MRI procedures to precertification, or $806,117.

Because RBMs require referring physicians to obtain the precertification, hospitals often find themselves in the difficult position of either withholding imaging procedures or absorbing the cost if the paperwork is not in order. “Hospitals are being held accountable financially for referring physicians getting this right, but at the same time, we are barred, technically, from participating in this process,” Pratt explains. “There is a lot of experimentation across the country, with hospitals as well as imaging centers trying to take a more active role in the process.” Pratt outlines four models that The Advisory Board has observed providers using to obtain precertification for imaging examinations.

The first is the precertification-initiation process. The provider’s staff contacts the RBM or payor to initiate the precertification process on behalf of the referring physician. The referring physician must conclude the process with each request.

The second model is a precertificationacquisition service. The provider’s staff contacts the RBM or payor for the referring physician and acquires the precertification number for the referring physician.

The third is an external precertification office. The provider establishes an inde-

Thoughtful Management for Hard Times

BY DANIEL McLAUGHLIN

ST R AT E G I C P L A N N I N G

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istorically, financial downturns have not affected the health care industry, but it is not so this time. Patients are deferring care or avoiding treatment completely; uncompensated care and bad debt are rising; and the impact is being felt by all provider organizations, both large and small.

Out of necessity, practices are responding. Some of these reactions are thoughtful, but unfortunately, many appear to focus on short-term, bottom-line fixes. This is very significant, as many gains in long-term quality improvements and cost management achieved during recent years may be lost Daniel McLaughlin through poor decisions being made today.

Industries outside health care have a more robust history of coping with market swings. Therefore, it is useful to learn from their experiences and understand how they have preserved the core values of their organizations as they have navigated tough times.

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 15

Be open with employees about the business problems you face and invite them to be part of the solution, while encouraging them to meet critical needs in other parts of their lives. Do this correctly and you’ll reduce stress, decrease wasted time, boost trust, build resilience, and improve productivity.

Acknowledging the pressure that employees feel during downturns and paying attention to employees’ lives beyond work shows concern for the whole person and will be rewarded with loyalty and extraordinary effort.

THE WISDOM OF CROWDS The December 2008 issue of Harvard Business Review provides a useful focus on this topic: Staying Calm at the Center of a Storm. Health care leaders can learn useful approaches from these wellrespected industry leaders and consultants. Three articles from this issue will be particularly helpful to the struggling health care leader.

STRATEGIC BUDGETING

{PR I O R S}

ST R AT E G I C P L A N N I N G

Kaplan and Norton1 (inventors of the balanced scorecard) suggest that challenging financial times provide the motivation to focus on productivity improvements. They also caution readers that cost reductions can sometimes sacrifice strategic initiatives that will build capabilities for long-term strategic management.

To avoid this dilemma, they recommend that organizations maintain and manage a separate budget for strategic expenditures.

To avoid the easy financial reflex of deferring these expenses, successful organizations specifically indentify each strategic initiative with a budgeted amount and assign it to an existing manager.

LOWER THE HEAT Friedman2 cautions against turning up the pressure and making employees work harder. He advocates a smarter approach:

Erickson3 suggests that, during tough times, executive instinct drives greater control; executives review costs, tighten approval criteria, redirect key decisions to higher levels, ensure that everyone is as busy as possible, narrow the scope of the business, and so on. Small teams of executives attend secret retreats to review options, even as meetings that would bring all the troops together are canceled.

As a result, authority becomes centralized.

What leaders frequently forget, in the heat of crisis, is that the wisdom of crowds applies within their own companies.

Instead of hogging the ball during a downturn, they ought to tap the ideas and the energy of the entire organization.

ADAPTIVE LEADERSHIP An extension of all of these recommendations is another very useful approach to change that is used by many industries: adaptive leadership. Heifetz4 developed this model at Harvard, and it focuses on successful change management.

Change can take two forms. Technical change uses existing knowledge and skills; an example would be expanding a clinic’s space, but using existing staff and procedures to operate the new space. In contrast, adaptive change requires individuals and groups to generate new knowledge, skills, and behaviors. An example of adaptive change would be the installation of new software that changes work processes and roles within a clinic.

Conflict and ineffective change occur when a technical fix is applied to an adaptive problem. This phenomenon is particularly widespread in health care due to its technical and scientific base. Adaptive problems usually cannot be successfully solved by someone who provides answers based

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on authority structures. To the contrary, adaptive work creates and demands both independence and interdependence of individuals and teams.

Heifetz provides a number of strategies for successfully confronting adaptive challenges. Find partners in the change, and be sure to inform and involve even those who are opposed to change. As people’ roles are revised, acknowledge the difficulty of change and accept their loss.

It is also very helpful to create a holding environment. This could include an outside facilitator to manage team meetings.

An off-site retreat is helpful for examining and planning adaptive changes while acknowledging shared language and history. The pace of change must be carefully controlled, and if resistance to adaptive change is increasing, a focus on technical issues can help keep a major project on track. After the technical issues are resolved, the team can return to the adaptive problem. Keeping the desired future state in front of the team is also necessary.

The most important aspect of successfully executing an adaptive change is giving the work back to the people. This is very difficult for managers who pride themselves on being problem solvers who act decisively.

Having the team itself devise new processes and roles for an adaptive challenge, however, will provide robust and long-lasting change for the successful organization.

Tough times can be stressful, and poor decisions can be made to solve immediate problems. The wise manager, nonetheless, will use this time to reset, refocus, and structure the organization for many future years of success.

Daniel McLaughlin is the director of the Center for Health and Medical Affairs at the University of St. Thomas, Minneapolis. He is the author of Healthcare Operations Management and was formerly the CEO of Hennepin County Medical Center, Minneapolis.

References 1. Kaplan RS, Norton DP. Protect strategic expenditures. Harv Bus Rev. 2008;86:28.

2. Friedman SD. Dial down the stress level. Harv Bus Rev. 2008;86:28.

3. Erickson TJ. Give me the ball! is the wrong call. Harv Bus Rev. 2008;86:30.

4. Heifetz RA. Leadership Without Easy Answers. Cambridge, Mass: Harvard University Press; 2003.

CCTA SERVICE | A Guide

The CCTA Playbook: A Guide to Coding, Reimbursement, and Operations

n the United States, unspecified chest pain is the second most common reason for an emergency-department visit. Each year, 5 million to 8 million patients present to the emergency department with chest pain; in 2004, more than 6 million patients presented to US emergency departments with acute chest pain.

Of these patients, 4% to 5% have a coronary event that is not properly diagnosed, resulting in an erroneous discharge from the emergency department.

Approximately 40% of elective stress tests will yield false-positive results, but only about 13% of coronary CT angiography (CCTA) exams (see Figures 1 through 4) will have potentially false-positive results. The lower false-positive rate should mean better patient care and cost savings, which should be important to payors.

heavily utilized study, payors want outcomes data before approving reimbursement for new technologies. In the case of imaging, that information can be extremely difficult to obtain. Drugs and medical devices may have measurable effects on patient outcomes, but diagnostic technologies have a less direct connection with

Market Forces In an acute situation, CCTA could result in cost savings and better patient care by decreasing unnecessary hospital admissions for chest pain. In addition, its use could decrease the incidence of patients being discharged from the hospital if they have true disease.

In a 2007 study,1 54 low-risk patients with chest pain who showed no acute ischemia on ECG then underwent CCTA. None of the 46 (85%) patients who were discharged following negative CCTA results experienced any coronary complications within the 30-day follow-up period. These findings support the conclusion that CCTA may safely allow rapid discharge of patients with negative studies.

Given the well-documented sensitivity and specificity of CCTA, why is there hesitation to reimburse for this exam on a uniform national level? For a potentially

Figure 1. Patient referred to cardiac CT angiography to rule out obstructive coronary-artery disease was scanned on a Philips 256-slice Brilliance iCT scanner with a low-dose, prospectively gated protocol, demonstrating a nonobstructive mixed (calcified and noncalcified) lesion in the left main artery.

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patient outcomes because outcomes are more likely to be altered by treatment decisions and patient compliance, among other nonimaging factors.

It is clear, however, that utilization of radiology services is increasing. Diagnostic imaging services paid for under Medicare’s physician fee schedule grew more rapidly than any other type of physician service between 1999 and 2003. During the same period, the average growth in physician services was 22%, but for imaging, it was 45%. Imaging costs are growing at twice the rate of prescription-drug costs, and may continue to grow at an accelerated rate.

These figures make imaging a target for cost cutting, even in areas where imaging has great potential to reduce the total cost of care. In 2007, for example, CMS proposed a restrictive national coverage determination that would have required coverage with evidence development, effectively restricting CCTA to research settings.

In January 2008, six professional societies informed CMS that, if implemented, this policy would have a profoundly negative effect on Medicare beneficiaries by limiting needed access to CCTA for clinically appropriate indications. In response to this and other public commentary, CMS withdrew its proposal in March 2008, allowing Medicare carriers to retain their own local coverage determinations. Until payors become convinced by further research that CCTA replaces other tests (instead of being added to them), a national coverage decision resulting in the creation of category-I CPTÂŽ codes for CCTA is unlikely to be made.

Coding There are eight current CPT codes in category III that are applicable to CCTA.

Image courtesy of Martin HK Hoffmann, MD, university Hospital, Ulm, Germany.

I

A compendium of the business intelligence required to launch a CCTA service By Jonathan Berlin, MD, MBA

Image courtesy of Toshiba Americas Medical Systems, Tustin, Calif.

CCTA SERVICE | A Guide

Figure 2. Cardiac CT angiography showing left anterior descending artery stent, acquired using a prospective scan protocol with the time frame of one heartbeat on Toshiba’s Aquilion ONE.

They are: • 0144T, for CT of the heart without contrast material, including image postprocessing and quantitative evaluation of coronary calcium; • 0145T, for cardiac structure and morphology, CT of the heart before and after contrast administration and further sections, including cardiac gating and 3D image postprocessing; • 0146T, for CTA of the coronary arteries (including native and anomalous coronaries and bypass grafts) without evaluation of calcium; • 0147T, for CTA of the coronary arteries with evaluation of coronary-artery calcium; • 0148T, for cardiac structure and morphology with CTA of the coronaries and without coronary calcium scoring; • 0149T, for cardiac structure and morphology with CTA of the coronaries with coronary calcium scoring;

CCTA STANDARDS AND TURF

T

urf questions have always surrounded the provision and interpretation of coronary CT angiography (CCTA) studies. Who should read these studies? Cardiologists and radiologists are unlikely to exclude each other from interpreting these studies, but the application of standards may help both specialties ensure an emphasis on appropriate training and experience as indicators of probable interpretation quality.

Professional standards are becoming increasingly important as part of the reimbursement process as well. For example, Medicare carriers may require compliance with the specified levels of competence for the professional and technical components of CCTA, as defined by the two guidelines issued by the ACR1 and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA).2 For political reasons, two competing guidelines exist for cardiac CT; at this time, neither set of guidelines is universally accepted or endorsed.

Cardiology and Radiology Standards The ACCF/AHA guidelines for qualifying to perform and interpret CCTA, issued

in 2005, were based on the contributions of the ACCF, the AHA, the American Society of Echocardiography, the American Society of Nuclear Cardiology, and the Society of Atherosclerosis Imaging, and they were endorsed by the Society of Cardiovascular Computed Tomography (SCCT). They specify three levels of competence; in order to interpret CCTA unsupervised, the physician must reach level 2 (contrast cardiac CT).

This level requires eight weeks of training, the performance of 50 mentored exams, and the interpretation of 150 mentored exams (with the use of textbook and teaching-file reviews permitted). In addition, the candidate must have completed 20 hours of lecture instruction in general CT or cardiac CT. Continuing experience of 50 contrast cardiac CT exams conducted and interpreted per year is also required.

The ACR guidelines have separate criteria for physicians with and without prior qualification in CT interpretation. Physicians who have prior qualification in CT interpretation should meet one of two requirements. The first calls for the completion of at least 30 hours of CME training in cardiac anatomy, physiology, and pathology and in cardiac CT imaging. The second calls for interpretation, reporting, and/or supervised review of at

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least 50 cardiac CT examinations in the preceding 36 months; coronary-artery calcium scoring does not qualify for inclusion in meeting these requirements.

For physicians without prior qualification in CT interpretation, the ACR guidelines require completion, within the specialty practiced by the physician, of a training program approved by the Accreditation Council for Graduate Medical Education, plus 200 category-1 CME credits in the performance/interpretation of CT exams. In addition, the physician must have completed, under supervision, during the preceding 36 months, the supervision, interpretation, and reporting of 500 cases, at least 100 of which must be thoracic CT or thoracic CTA (with coronary-artery calcium scoring being exempt).

The candidate must also complete 30 hours of category-1 CME in cardiac imaging and interpretation, as well as the reporting and/or supervised review of at least 50 cardiac CT exams in the previous 36 months. Again, coronary-artery calcium scoring is not counted toward this total. The ACR has an additional practice guideline for CCTA that advocates interpreting physicians having a knowledge of

At this time, and in all cases, the professional component for CCTA reimbursement is carrier priced (locally determined).

Jonathan Berlin, MD, MBA

• 0150T, for cardiac structure and morphology in congenital heart disease; and • +0151T, an add-on code for function evaluation (left and right ventricular function, ejection fraction, and segmental wall motion).

In general, codes that specify structure and morphology are for use with preelectrophysiology CT studies. These may be ablations, in which the atria and pulmonary veins are being evaluated by CT,

the entire chest, as well as a knowledge of the administration of contrast media.

Outside the Heart Radiologists cannot assume that CCTA technology will be their sole domain. Cardiologists, like radiologists, are already involved. They conduct and attend CME courses on CCTA that are geared for cardiologists.

They are also instrumental in the SCCT; founded in 2005, it already has more than 3,900 members, many of whom are cardiologists (as are 12 of its 16 board members). As its advocacy mission, the SCCT is dedicated to ensuring that competent, skilled physicians—regardless of specialty—can perform (and be reimbursed for) cardiovascular CT procedures.

The turf questions involved in performing and interpreting CCTA are complicated by the fact that extracardiac findings are common in patients who undergo CCTA. For example, of 258 consecutive CCTA patients in a 2007 study,3 56.2% had significant noncardiac abnormalities seen on CCTA. These included lung and pericardial abnormalities, liver disease, adrenal masses, and bone lesions in adjacent ribs or vertebral bodies.

or may be evaluations of the cardiac venous system in anticipation of biventricular pacemaker placement. There are, at present, two separate category-I codes for 3D rendering, but they should not be used for CCTA because 3D imaging is already included in the T codes.

The triple–rule-out CCTA study (Figure 3, page 22) is often ordered to evaluate the patient for coronary-artery stenosis, aortic dissection, and pulmonary embolism. For this study, it is possible to

Can cardiologists learn to describe these findings? Probably; with proper training, there is no reason to believe that cardiologists cannot learn how to interpret the noncardiac portions of a chest CT. As such, the requirement that interpreting physicians also read the chest portion of the exam probably does not shield radiologists from turf incursions.

There is, however, another question that it is important to ask in this context: Will physicians want to interpret these exams if they are reimbursed only at a low level?

—Jonathan Berlin, MD, MBA References 1. Weinreb JC, Larson PA, Woodard PK, et al. ACR clinical statement on noninvasive cardiac imaging. J Am Coll Radiol.

2005;2:471-477.

2. ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance.

Circulation. 2005;112:598-617.

3. Gil BN, Ran K, Tamar G, Shmuell F, Eli A. Prevalence of significant noncardiac findings on coronary multidetector computed tomography angiography in asymptomatic patients. J Comput Assist Tomogr.

2007;31:1-4.

use two codes: 71275 (conventional CTA evaluation of the aorta and pulmonary vessels) and 0146T (CTA of the coronary arteries). Billing for both codes might require advance beneficiary notice for the T code plus a modifier of reduced professional service for one of the codes (a 52 modifier); this may be difficult if the patient is in acute distress. For this reason, it may be preferable to bill for the category-I code (71275) and write off the cardiac portion of the exam.

ICD-9 codes supporting medical necessity for 0146T and 0147T (CTA) are 413.0, 413.1, and 413.9 (angina pectoris, decubitus, Prinzmetal, and unspecified angina); 427.31 and 427.32 (atrial fibrillation/flutter); 786.50, 786.51, and 786.59 (chest pain: unspecified, precordial, and other chest pain); 747.41 and 747.42 (total/partial anomalous pulmonary venous return); 786.05 (shortness of breath); 414.8, 425.4, and 746.85 (chronic ischemic heart disease, cardiomyopathy, and congenital heart anomalies); 428.0 (congestive heart failure, unspecified); and 794.30 (cardiovascular, abnormal function study, unspecified).

ICD-9 codes supporting medical necessity for cardiac structure and morphology codes 0145T, 0148T, and 0149T include 427.31/427.32 (atrial fibrillation/atrial flutter); 428.0 (congestive heart failure, unspecified); and 425.4 (other primary cardiomyopathies).

Reimbursement At this time, and in all cases, the professional component for CCTA reimbursement is carrier priced (locally determined). When CCTA is performed in an outpatient imaging center, the technical component is carrier priced. Each carrier issues its own policy (local coverage determination) regarding category-III codes.

These determinations state whether the code will be reimbursable and what criteria must be met for reimbursement. All 50 states have local coverage determinations in place for CCTA, and many are based on common language taken from a model originally submitted by the ACR and other professional societies.

In one example of a carrier’s local coverage determination on CCTA

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Image courtesy of Vital Images, Minnetonka, Minn.

Image courtesy of Siemens Healthcare, Malvern, Pa.

CCTA SERVICE | A Guide

Figure 3. Reconstruction of the thorax acquired in 0.8 seconds on Siemens’ SOMATOM Definition Flash.

reimbursement, Wisconsin Physician Services (the local Medicare carrier for Wisconsin, Illinois, Michigan, and Minnesota) specifies the four main categories of indications for which CCTA will be reimbursable. The first category is CCTA used as an alternative to invasive angiography following an equivocal stress test or one that is suspected to be inaccurate. CCTA, in this case, could provide a separate method of assessing coronary arteries (different from a stress test) and limit the number of normal invasive coronary angiograms. CCTA may also help clinicians avoid missing coronary-artery disease in patients suspected of having undergone inaccurate stress tests.

The second indication category is evaluation of acute pain in the emergency department. The exam can be used to triage patients quickly in the emergency department and limit resource use in chest-pain patients who do not have coronary-artery disease.

The third category is assessment of coronary or pulmonary venous anatomy.

This includes presurgical planning prior to pacemaker placement or pulmonary vein catheter ablation to eliminate recurrent atrial fibrillation.

The fourth category is assessment of suspected congenital anomalies of coronary circulation. Here, CCTA allows fur-

Figure 4. A 3D view of the coronary tree showing a stent, reconstructed using Vitrea Web.

ther characterization of the presence of (and possible harm from) congenital abnormalities; it may also be useful for surgical planning in such cases.

Wisconsin Physician Services also imposes six exclusion criteria that may be typical of those found elsewhere. First, the test is never covered for screening in asymptomatic patients. Second, the test may be denied on postpayment review if there is sufficient pretest knowledge of extensive calcification of the coronary segment that would diminish interpretive value. Third, the multidetector CT used must have at least 64 slices per rotation and high-resolution slices of 1 mm or less.

Fourth, all studies must be ordered by a physician or a qualified nonphysician practitioner. Fifth, when contrast is given, a physician must be present for direct supervision during testing. Sixth, atrial fibrillation, by itself, is not an indication, but atrial fibrillation with planned ablation is allowed.

It should be noted that CCTA codes include the administration of beta blockers and the monitoring of the patient during the exam by a physician who is experienced in the use of cardiovascular drugs, so these are not separately payable services. Likewise, the administration of sublingual nitroglycerin is unlikely to be separately payable, although it may improve results by dilating the coronary arteries before scanning.

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Medicare coverage for repeat CCTA examinations is also determined by individual carriers, but reimbursement for frequent CCTA repetition is probably unlikely. The frequency of the studies must be reasonable and justified by the course of the patient’s illness, according to some carriers’ utilization guidelines; this means that reimbursement may be denied for repeat tests for the same patient. In California, one Medicare carrier, National Heritage Insurance Co, has stated that it is not normally reasonable to repeat CCTA in less than five years if the patient’s calcium score is less than 10 (or the equivalent) on the initial study; when the score is higher than 10, it is not usually necessary to repeat the study in less than three years.

Empire Medicare, a carrier for New York and New Jersey, stresses the need for CCTA to produce usable information. It states that the selection of the test should be made within the context of other testing modalities, such as stress myocardial perfusion images or cardiac ultrasound results, so that the resulting information facilitates the management decision instead of merely adding a new layer of testing.

Planning for CCTA Because of variations in local carriers’ policies and general uncertainty, it is difficult to predict the reimbursement level

that CCTA will eventually reach. Local carriers and private insurers do reimburse for CCTA, but it is important to ask at what payment rate they do so. Some carriers have published the applicable rates, but these can’t be used to predict the eventual category-I reimbursement level.

Accurate prediction isn’t possible because the data now being collected by the AMA on the utilization frequency of the eight category-III codes will influence which of these codes will survive the migration to category I, as well as whether some of the codes will be eliminated or augmented.

It seems safe to predict, however, that total Medicare payments for CCTA will continue to rise. In 2006, Medicare paid for roughly 70,000 CCTA exams at a cost of $40 million to $50 million. As more facilities perform CCTA, this amount will increase. To limit overall expenditures, local rates could change (perhaps negatively) over time.

If it isn’t possible to predict rates, how can providers approach planning for CCTA provision? Today, the best approach is to examine the nonfinancial factors carefully, in addition to speaking to carriers individually about their policies concerning the CCTA codes. Use of the self-pay system may also be feasible for patients who are not eligible for thirdparty reimbursement.

Jonathan Berlin, MD, MBA, is associate professor of radiology, NorthShore University HealthSystem, Northwestern University Feinberg School of Medicine, Evanston, Ill. This article has been adapted from Business Issues Associated With Cardiac CTA: Coding, Reimbursement, Turf, and Operations, which he presented at the Economics of Diagnostic Imaging 2008: National Symposium on October 23, 2008, in Arlington, Va. Reference 1. Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG. Computed tomography coronary angiography for rapid disposition of low-risk emergency department patients with chest pain syndromes.

Acad Emerg Med. 2007;14:112-116.

CCTA STAFFING AND COVERAGE

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adiology practices and departments that intend to offer coronary CT angiography (CCTA) need to consider how the additional exam volume and time commitments created by CCTA studies will affect their operations and their staffing models. Will they need to hire additional radiologists, nurses, and/or technologists to manage the extra workload? Who will perform the necessary volume renderings and reconstructions, and how long will it take to perform them?

Some radiologists who interpret these exams may insist on performing their own reconstructions before interpreting the studies. If so, how much of their time will this require? Informal surveys indicate that this step could call for as few as 10 extra minutes per case—or as long as an hour. That hour might be difficult to justify, and this possibility of extreme variation in time requirements, in many cases, makes accurate operational planning difficult.

If additional personnel must be hired to interpret CCTA exams and/or to perform reconstructions, this will obviously increase overhead costs significantly, and any such increases should be factored into the practice’s financial analysis of the merits of offering CCTA services. This additional overhead expense could mean that the practice will have to accept lower margins for CCTA on a per-case basis.

In addition to evaluating overall changes in staffing needs that might be made necessary by CCTA, practices must should consider how to provide after-hours coverage for these studies. Since patients who present to the emergency department with chest pain are common candidates for CCTA, it is unlikely, in many settings, that the performance of these exams can be limited to the hours of the day shift.

Who will perform these studies at night?

Who will perform the reconstructions after hours? If your practice is based at an academic hospital, it is important to determine whether residents or fellows will have time to perform reconstructions and interpret exams at night as part of your decision to evaluate staffing needs.

For private radiology practices, it is necessary to decide whether external after-hours services or local night-coverage staff will perform reconstructions for CCTA. Companies specializing in after-hours radiology coverage

have already begun to fill this niche; for example, they may offer processing and preliminary interpretation of CCTA and of triple–rule-out CTA as needed, around the clock. They may also provide images of all the major coronary arteries and a preliminary reading that indicates disease in any of those vessels.

Those practices intending to offer CCTA exams must determine carefully whether this kind of external after-hours service is necessary, as well as whether the practice can afford it—and whether it is wise to purchase such services. Will outsourcing only commoditize radiologists’ services?

Some practices may consider having the CCTA source images sent to the home teleradiology units of their radiologists for after-hours interpretation. Because there is the potential for data overload, however, they should consider four questions. First, how long will it take to send all the axial images to a radiologist’s home unit?

Second, can the radiologists involved perform reconstruction or volume rendering at home? Third, if they can, how long will that take? Fourth, are reconstruction and volume rendering necessary in all cases?

The provision of CCTA studies may necessitate rethinking the need for 24-hour inhouse attending coverage.

—Jonathan Berlin, MD, MBA

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ADVANCED VISUALIZATION | Optimization

Masters of Manipulation Radiologists and vendors race to grasp and improve the tools of advanced visualization as imaging modalities churn out ever more information

By Cat Vasko

R

adiology stands on the cusp of the golden age of advanced visualization, with the two most commonly used high-tech modalities, CT and MRI, increasingly reliant on 3D reconstructions and 4D analysis for examination interpretation. As advanced visualization for CT and MRI comes of age—bolstered by augmented processing power and ever-increasing transmission speeds—how can radiologists optimize the tools at their disposal for the most rapid and accurate diagnoses?

Jeffrey C. Hellinger, MD, director of cardiovascular imaging and director of the 3D Medical Imaging Laboratory at The Children’s Hospital of Philadelphia, advocates an all-inclusive approach. When interpreting cardiac CT angiography (CTA) exams, Hellinger uses a combination of all tools. “The tools have strengths and weaknesses, advantages and disadvantages,” he says. “I interact freely among volume rendering, maximum-intensity projection (MIP), multiplanar reconstruction (MPR), and curved planar reconstruction.”

Gary Wendt, MD, associate professor of neuroradiology at the University of Wisconsin–Madison, finds that the limitations of advanced visualization for MR angiography (MRA) are more infrastructure based. “One of the biggest problems in advanced visualization, in general, is the lack of universal accessibility,” he says.

“The Web-based products are getting better, but they still have their flaws.”

Each subspecialty uses a different toolset, but they all have one common goal: making interpretation as efficient as possible. As MRI resolution improves and 64-slice CT scanners gradually replace older 16-slice units, that goal is both closer and more remote than ever before.

Multislice CT The evolution of CT scanners from 16 to 64 slices or more has meant an order-ofmagnitude explosion in the number of images that compose a single study. While this exponential increase takes its toll on networks and IT infrastructure, it also opens new doors, allowing more detailed visualization of the heart than has ever been possible.

but on the fly, in real time, it’s important to know instinctively whether something will be better with volume rendering, MIP, MPR, or curved planar reconstruction. All the tools have to be used in collaboration.”

C. Dan Johnson, MD, chair of the department of radiology at the Mayo Clinic, Scottsdale, Ariz, specializes in CT colonography. He emphasizes the importance of learning the ins and outs of each tool. “They all have their advantages and disadvantages,” he says, “and they can all be useful in complete analysis of the colon.”

Johnson recommends striking a balance between 2D and 3D visualization, stressing that both have roles to play in comprehensive interpretation. “With 2D

You’re not going to view each dataset with each tool, but on the fly, in real time, it’s important to know instinctively whether something will be better with volume rendering, MIP, MPR, or curved planar reconstruction.

Jeffrey C. Hellinger, MD

“As the technology continues to advance, it’s more important than ever that trainees (from residents to fellows to attending radiologists from academic settings and private practice) learn to use a workstation,” Hellinger says. “You’re not going to view each dataset with each tool,

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images, you have to put the image together in your mind, so sometimes it takes a little problem solving to determine if there’s a polyp,” he notes, “but the 3D data make discrimination of stool or residual barium from polyps more difficult. The very best interpretation includes a primary

2D review of the axial images, as well as the 3D review.”

Hellinger’s most common cardiovascular CTA applications include pediatric and adult congenital heart disease and congenital and acquired pediatric vascular disease. He uses volume rendering and MIP for angiographic analysis and MPR as the principal tool for diagnosis.

Johnson focuses on polyp detection and

tion of stenoses, but so far, they haven’t caught on,” he says. The principal issue is reliability; as he explains, “You need highquality MRA studies, which are becoming more commonplace, but can still be difficult to get.”

Wendt, who specializes in neurological MRA, echoes Bluemke. “Doing things like stenosis quantification in MRI is impossible. Advanced visualization tools

These tools are new, and we don’t have a routine clinical application for them, but 3D point tracking of flow could be used to look at the effect of flow on the vessel wall.

David Bluemke, MD, PhD

finds simulated 3D flythrough and virtual dissection to be the most valuable tools in his arsenal. Both Hellinger and Johnson stress, however, that these tools must be used according to their strengths and weaknesses for the best, most efficient interpretation.

“I always tell people to be flexible and apply every tool when appropriate,” Hellinger says. “If you’re not, then there’s no advantage of 3D imaging beyond the source images. We can do everything imaginable to make treatment planning efficient, but it’s really up to the end user.

Radiologists have to know the principles of 3D imaging. If they approach it in an educated way, then everything’s in place for efficient interpretation and patient care.”

MRI’s Midlife Crisis At 30 years old, MRI technology is reaching middle age, with higher-resolution 3T units dethroning their 1.5T predecessors. David Bluemke, MD, PhD, director of radiology and imaging sciences at the US National Institutes of Health, Bethesda, Md, notes that the modality still has its limitations. “With cardiac MRA, we’re almost always looking for narrowing or stenosis. We use fairly straightforward MIP tools, and the reason for that is it’s very quick—it can be done on the workstation or the PACS, and requires less sophisticated processing than CT. Tools are becoming available for automated detec-

like automated stenosis measurement are more applicable to CTA, where you can accurately define a lumen. With MRA, it’s more about getting a quick, easy, targeted MIP,” he says.

Because much of the image’s background information is suppressed with MRA, Wendt describes the visualization and interpretation process as a quick-anddirty approach. “It’s a technical limitation of the modality,” he says. “It’s nowhere near being as precise as CTA. MRA is all about how fast you can get at it—how fast you can generate the images.”

For Bluemke, the most interesting new advanced visualization tools for MRI effectively leave behind the realm of 3D imaging to visualize flow. “These tools are new, and we don’t have a routine clinical application for them,” he says, “but 3D point tracking of flow could be used to look at the effect of flow on the vessel wall. They’re actually more 4D, because they’re time resolved. You can look at the wall’s shear stress in 3D throughout the cardiac cycle.”

When it comes to incidental findings— including renal cancers, fistulae, or unsuspected aneurysms—Bluemke turns to his PACS for the right tools, such as thin-sliding MIP. “The most useful tools are those that are integrated into the PACS,” he says.

“We’ve had very good software for some time, but on very specialized and expensive equipment. Integration is the key to getting the readings done quickly and accurately.”

Wendt concurs. “We’re a multipleenterprise organization,” he says. “We serve multiple hospitals and we have one PACS. We need a unified, single log-on for advanced image processing, and it needs to be tightly integrated with our PACS. Otherwise, if you try to run advanced image-processing tools in a traditional manner, it becomes challenging.”

PACS Integration The need for tighter PACS integration isn’t limited to radiologists specializing in MRI. Johnson also cites workstationbased advanced visualization as a barrier to more efficient workflow. “Right now, I do interpretation on separate, high-end workstations, where the data are imported to the workstation for evaluation,” he says. “It would be very helpful if these tools were integrated into PACS. It probably wouldn’t speed up my evaluation time, but it would increase productivity if you didn’t have to leave your PACS and go to a workstation to load up a study.”

Bluemke also sees the potential for more timely interpretation. “The ability to do rapid multiplanar imaging at the same time as MIP is probably what’s most important now,” he says. “Radiologists have all those images on their PACS. It’s highly desirable not to have to go to a separate workstation.”

Wendt looks forward to the wide-ranging operational efficiencies that could be achieved via full multiple-enterprise PACS integration. “Then, you won’t need a whole separate deployment or a whole separate method for managing image flow,” he says.

“When you’re trying to figure out how images flow through multiple organizations, you have to deal with managing flow across multiple RIS and hospital information systems. If you have to deploy not only PACS, but also multiple advanced visualization platforms, it gets impossible pretty quickly. How do you manage security, user access, and audit trails?”

Describing his vendor’s process, he says that the company has had a thin client for years. Now, he adds, “It’s integrating its thick client and thin client with the integrated workstation thick client.

It’s all four platforms converging onto one back end.”

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ADVANCED VISUALIZATION | Optimization

Hellinger looks forward to advanced visualization integration not only with PACS, but also for reporting packages and dictation systems. “I think, in the next year or so, we’ll begin to see deeper integration with all health IT,” he says, “and as we advance the technology, education on 3D imaging is more important than ever before.”

3D yet,” he notes. “The images are inherently 3D when they’re generated, but we’re not routinely viewing them in 3D (Figure 1).” As advanced visualization solutions are incorporated into standard PACS and standard PC systems, however, Bluemke expects to see robust thin-client visualization systems proliferate.

Hellinger is more optimistic about the direction in which the technology is heading. “First, you had thick clients; then, thin clients; and now, Web clients,” he says. “The technology will only become more robust. Ten years ago, people were really skeptical about the concept of thin clients. Now, they are the standard for imaging. I think the new standard will be Web clients—no software, just an Internet browser where you log into a server to view and interpret studies (Figure 2).”

How is this possible? Wendt says that we have the Xbox 360® and Sony PlayStation 3®—among other gaming platforms—to thank for coming advances in the field. “The power that’s going into the new graphics cards is going up exponentially, and it’s driven by factors way outside the medical industry,” he notes.

“If you want cutting edge, check out the Xbox. The amount of advanced graphics

Choosing Clients

Image courtesy of Jeffrey C. Hellinger, MD.

Image courtesy of David A. Bluemke, MD, PhD.

The most daunting issue in advanced visualization has nothing to do with the software toolset, according to Wendt.

Accessibility and cost are his concerns.

“With the stand-alone workstations, when you have 15 to 20 of them, every time you do an upgrade, you’re looking at a couple million bucks,” he says. “That’s pretty outrageous. They have more functionality than thin clients, but the pricing gets out of hand really fast. Likewise, I think there are vendors who oversell their thin clients.

They claim to be 100% Web based, but when you hold their feet to the fire, it turns out that you do need to install software. I don’t know of any vendor that’s truly 100% Web based right now.”

Bluemke takes a similarly measured view of the thin-client technology currently available. “We’re not viewing in native

Figure 1. The figure shows a volume-rendered image of a coronary MR angiogram. The left coronary artery and its branches (large arrow) and right coronary artery (small arrow) are shown.

Figure 2. A sagittal oblique 3D MR angiography volume-rendered reconstruction through the thoracic aorta demonstrates high-grade juxtaductal coarctation (long arrow). Note the robust collateral network that has developed to restore aortic flow below the coarctation.

The network includes aortic-arch branch arteries, intercostal arteries, and a dominant postcoarctation collateral artery (short arrow).

26 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

processing that goes on in one game is more than we do in two years.”

What’s Next Advanced visualization evolves alongside emerging clinical applications in radiology. What’s the next frontier in high-tech imaging? For Johnson, computer-assisted detection could mean a big improvement in productivity.

“Computer-assisted detection has yet to be integrated in all of the commercial products yet, and I think it would be very helpful,” he says. “It may well be able to reduce the time on 3D review. If radiologists just did the 2D review and looked for other detections on 3D with computerassisted detection, it could reduce the 3D interpretation time and improve overall exam performance.”

Hellinger also looks for computerassisted detection integration, and that’s not all. “I think there will be more of a bridge between molecular imaging and 3D imaging,” he says. “When you’re imaging at the genomic level with MRI and a radiotracer, being able to diagnose, plan treatment, and guide treatment with greater confidence will be valuable.”

Meanwhile, Bluemke is most interested in the potential for strain imaging of vessel walls. “We could quantify what’s causing the strain and the change in wall strain over time. That may relate to the prognosis for aneurysm expansion and impending dissection. It will probably be done first with echocardiography and vascular ultrasound; I’d say it’s at least two to five years away,” he says.

Further down the line, Hellinger expects the kind of anytime, anywhere interpretative flexibility that’s becoming commonplace in other areas of radiology. “The future is being able to access a workstation remotely anywhere, anytime—in the hospital, out of the hospital, or even from your handheld—with all these advanced tools,” he says. “There’s still a lot of innovation to be done with 3D and 4D visualization, and the success, over the years, has really been through improvements in computers and technology. It will only get better.”

Cat Vasko is a contributing writer for Radiology Business Journal and the editor of ImagingBiz.com.

Kids aren’t the only ones who have questions When it comes to children’s CT scans, parents can have a lot of questions.

That’s why the image gently™ campaign has made parent education tools available to help clinicians answer these questions and provide more information about radiation safety.

Brought to you by the Alliance for Radiation Safety in Pediatric Imaging.

Proudly supported by GE Healthcare.

When parents ask about imaging precautions, direct them to www.imagegently.org for downloadable brochures and an imaging record card to keep track of their child’s exams.

You’ll be empowering parents and yourselves to make better healthcare decisions.

DATA | Analytics

Data Mining: Imaging Executives Crunch the Numbers RIS data, keyed to billing, can be analyzed to improve competitive capability and pare inefficiency to the nub

P

hysicians and executives are similar to scientists; they like data to assist them in making decisions,” Rob Cercek says. Cercek, vice president of ambulatory services at Rochester General Hospital (RGH), Rochester, NY, adds, “If you can put credible data in front of people, discussions between hospitals and physicians become more

and their practices’ physicians—as they make many types of decisions. Should a new clinic be opened? Should certain procedures be marketed, or should they be quietly left to decline? Should productivity be demanded, or will quality suffer if too much pressure is brought to bear?

Cercek says that some of the most helpful reports have been those showing pat-

If you can put credible data in front of people, discussions between hospitals and physicians become more meaningful.

Rob Cercek

meaningful.” He is talking about arming his department representatives with data when they go out to solicit radiology business from referring physicians, but he could just as easily be describing radiologists themselves. Like physicians in any practice, radiologists are indebted to numbers for answers to their operational questions: Are practice RVUs stacking up in a positive way?

Are imaging rooms and equipment being used maximally? Are there too many (or too few) technologists on staff?

Radiology managers and executives like Cercek are working diligently to create useful reports to guide themselves—

terns in physician referrals to the radiology department at RGH. By comparing referrals from doctors on the hospital staff with those from referrers outside the hospital, Cercek says that he can gauge when a referring physician is falling short of sending the number of cases that might be expected.

The department representatives can then be deployed to seek, politely, that missing business. Cercek says, “The people who use these reports feel they are invaluable,” especially for making it possible “to walk into the physician’s office knowing the pattern— knowing what the referral rate should be— and getting them to turn in your direction.”

28 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

By George Wiley

At RGH, which is licensed for 585 beds and conducts about 175,000 radiology exams per year, the RIS is at the heart of the data-gathering effort. The RIS, from the same vendor as the hospital’s PACS, collects patients’ demographic data from the hospital information system (HIS) and correlates them with radiology data from the PACS, such as exam types, exam times, and modalities used. When a radiology report is signed, the RIS also triggers the billing cycle. All these data—exams, referring doctors, technologist times, patient demographics, billing codes, and much more—can be mined from the RIS in the form of either preprogrammed reports or, more pointedly, as customized reports prepared by the RGH staff.

Reports like those being done at RGH can be used to shape (or reshape) a radiology practice. Moreover, the cost of the software needed to issue reports is modest, by hospital standards. The return on investment for data-analysis software is so rapid (a matter of months) that many don’t bother to track it. At RGH, the work of turning out most reports falls to Pam Moseley, radiology informatics director.

A Data Gold Mine When RGH installed its RIS, Moseley says, the radiology department took over its own billing because the RIS could drive that process. Now, when an exam is completed, the patient data and radiology

Pam Moseley

Once the staff was re-educated, a true cycle time was reflected. Overall, our throughput-cycle time has shown an 80% improvement since we went to the RIS.

data, including CPT® code and pricing, are automatically entered into the billing system via RIS. Billers in radiology make sure that all the data match, then send the bill to the hospital’s master billing system for the technical component and to the physician’s billing system for the professional component, Moseley says.

“Prior to this, everything was on paper and medical records was billing,” she adds. “They’re not familiar with radiology exams and functions; thus, there were a lot of charges that weren’t being billed.”

Since initiating semiautomated RIS-driven billing, Moseley says, the radiology department’s receivables have shown a 30% to 40% improvement. This has added up to hundreds of thousands of dollars in recovered income. Moreover, billing time has dropped from more than two days to a day or less, she adds.

Moseley says that the RIS software turns out a number of automated reports, including patterns for the hospital’s top 20 referrers, although this particular task required special programming by the RIS manufacturer. Most of the reports that Moseley submits to Cercek and others are custom reports that she has completed herself, however. Custom reports of this kind provide the real payoff when a hospital or practice wants to make immediate adjustments to workflow, finances, or staffing efficiency. At RGH, Moseley has initiated reports on staff productivity,

room utilization, and even exam appropriateness (based on initial indication).

“We get a lot of MRI orders from the emergency department,” she says, “but does the indication merit MRI? We have to educate our physicians.” Moseley says that the custom reports that she completes aren’t necessarily difficult, although some can get complicated (see sidebar, page 32). She says that her reports have affected staffing, modality efficiency, and scheduling, as well as the recovery of lost billings. She notes that the RIS data can influence purchasing decisions or reveal when imaging equipment is approaching the end of its expected lifetime, which is a key factor in a certificate-of-need state such as New York, where major equipment purchases must be justified to regulators.

“We’ve also adjusted staffing patterns—hours, lunches, and break times,” Moseley adds. “The hospital thought that we were overstaffed in radiology, but in actuality, we’re not.

Report data are based on user input; in our case, the technologists were putting in the incorrect time for how long it took an exam to get done. They thought it was scan time, but it should have been time with the patient. Once the staff was re-educated, a true cycle time was reflected. Overall, our throughputcycle time has shown an 80% improvement since we went to the RIS.”

Moseley is now tracking patienttransport times via RIS in an attempt to justify using radiology staff to transport patients in beds or wheelchairs, instead of a relying on the hospital’s centralized transport service. She says that too much downtime occurs when central transport is called; sometimes, its personnel fail to bring patients on schedule, resulting in a schedule backlog, even though this is the favored approach of hospital administrators.

According to Cercek, RIS data mining has been especially useful for quick marketing response to changes in referral patterns. Efficiency inside the department has also made the hospital more attractive to referrers, he adds. He notes that a third of patients admitted to RGH come through the emergency department.

Those emergency patients who need imaging are now entered into the RIS on a fast track.

“We were looking at a three-hour visit in our emergency department for fast-track patients, and our competitors were at 90 minutes. Of that three-hour visit, 52 minutes were spent in the imaging department,” Cercek says.

“Now, we have a target of less than 30 minutes to perform imaging on fasttrack patients to hit a visit time of 90 minutes or less.” RGH now averages 28 minutes for imaging studies in the emergency department. The order

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 29

DATA | Analytics

issued for imaging triggers a time clock.

Cercek says, “Before, we really didn’t know how to hit that time. Now, we can put a time stamp on how long those patients are in radiology.”

Both Cercek and Moseley note that RIS capabilities also play into the hospital’s larger recordkeeping effort, along with the HIS data and the lab reports, all of which appear in the patient’s electronic medical record. Moseley notes that the city itself is forming a regional health information organization (RHIO) as a central base for shared knowledge.

When the RHIO is finished, the radiology reports will be available there “so that the whole city will be connected,” Moseley says.

Cercek agrees that some skepticism needs to be applied to the reports that flow out of data repositories. “Whenever you receive a report to review, you have to gauge what it’s really telling you,” he says.

“The RIS will never describe the benefits or nuances of a 64-slice CT study versus an interventional procedure. You have to finish the story.”

King’s Daughters Hospital A midsize hospital such as RGH is an obvious fit for RIS data mining because it generates so much information, but even a small hospital can make profitable use of the technology. King’s Daughters Hospital (KDH) in Yazoo City, Miss, has six doctors on staff and 25 acute care beds. Stefanie Dendy, a former mammography supervisor at the University of Mississippi Medical Center in Jackson, is the KDH director of radiology. Coming back to KDH five years ago was a homecoming for Dendy in the most basic sense; she was born at the hospital.

The radiology department at KDH includes diagnostic radiography, nuclear medicine, fluoroscopy, ultrasound, and CT. A mobile MRI unit appears on a regular schedule. The department installed a PACS in 2006 and a companion RIS from the same vendor a year later. There are no radiologists resident at KDH; the single radiologist on staff reads from a site in Louisiana. He was hired when the hospital installed its RIS. Dendy says that KDH completes about 15,000 exams per year,

and that single radiologist reads them all.

“No radiologist will come to our small hospital anymore,” Dendy says.

Nonetheless, she adds, competition is stiff among outside providers. “Now, with PACS, everybody wants your business,” she says. At night, if the contracted radiologist can’t be reached, the hospital will send exams (CT only) to an after-hours teleradiology service for preliminary readings, Dendy adds. She credits the PACS/RIS not only with making this possible, but for making it quite workable.

“He’s been a great find for us,” she says of the contracted radiologist. “We contact him all day long, and he even calls the emergency department with critical results.

He hasn’t been sick, he works holidays, and he has his laptop with him. He can give us preliminary readings from that, and when he gets back to the PACS monitor, he will dictate the final interpretation. That satisfies the doctors on our medical staff.”

Despite the comparative simplicity of the KDH radiology department, Dendy says that she routinely pulls data from the RIS and creates her own custom reports to

IS CUSTOM REPORTING DIFFICULT?

C

ompleting a customized report using RIS data-mining software (or some other system) is simply a matter of learning a little technology. For Stefanie Dendy, director of radiology at King’s Daughters Hospital in Yazoo City, Miss, it can be as easy as changing the start-date and end-date fields for the information that you want to correlate.

Dendy is talking about customizing templates or automatic reports done by the RIS by changing the dates to bracket a particular segment of data. She can do the same thing by changing fields for facilities or modalities, which is mostly enough for her purposes, she says. What she wants next is for her hospital to activate a billing function already present in the RIS. This would let her study the financial bottom line for each modality, she says, but King’s Daughters, for now, is sticking with its old hospital-wide billing system. “We had an interface problem because we use a hospital code instead of a CPT® code,” Dendy says.

At Rochester General Hospital, Rochester, NY, Pamela Moseley, RIS/PACS director, says that she had to learn a reporting-software application, as well as the reporting features of her RIS, in order to create custom reports.

Other than that, she says, it’s been a matter of perseverance.

“Cycle time per shift and per modality—that takes me a long time,” she says. “The clock is in military time, and you have to create two reports and add them together” to cover a shift that the Stefanie Dendy clock divides at midnight.

Sometimes, she adds, she will be asked for reports by modality by room, and she is asked to determine “the number of exams ordered per hour, per month, and per shift, based on patient type—emergency, inpatient, or outpatient.” and Administrative At Strategic Reimbursement Services in Grand Rapids, Mich, CFO Bill Ziemke and his team of finan-

30 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

cial analysts have been able to use their data warehouse and business-intelligence reporting software to provide useful information for making business decisions.

At Infinity Management in Nashville, Tenn, CEO J. Keith Radecic says that creating a custom report is generally a point-andclick affair. “I choose the data, and I have manual control over building that report,” he says. “Today, a client wanted a report built for a specific payor and all claims outstanding for that payor for all of 2007: the charge, the amount paid, and the current balance. I ran that report and created it in about 35 minutes. You have to run on the fly so that everything is used in a timely fashion.”

Radecic says that the benefits of reporting systems are undeniable. “Why not invest in a better reporting tool?” he asks. “For medium-sized to larger groups, the benefits far outweigh the costs. The excuse that we can’t get to the data should not be acceptable.”

—G. Wiley

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DATA | Analytics

guide operational and strategic decisions.

The RIS will track workflow averages and generates stalled-procedure reports.

“The workflow averages help me; they tell me where the breakdowns are,” Dendy says. Is the problem in registration or elsewhere in the exam cycle? Dendy says that the RIS reports answer that question and more. She can look at RIS reports to see where exams are stalling and then respond to physicians who ask why a report is not showing up in the patient’s chart. Is the delay being caused by the radiologist, the transcriptionist, or the clerk?

“The nurses blame radiology, and radiology blames the nurses,” Dendy says.

“That’s another advantage of the RIS: If the report is not in the chart, the clerk can call and print one. On the units, they have access to the reports.” The RIS also allows Dendy to track and respond to modalityuse patterns, on which she reports monthly. After studying these trends, she can make adjustments. She uses the example of a bone-density scanner. “We got that machine at the request of medical staff, but all of a sudden, nobody was ordering the test anymore,” she explains. In such cases, if use of a modality is unusually low for three months, she can remind the medical staff that the hospital has this capability.

“The doctors do go through cycles,” Dendy says. “Sometimes, all it takes is a reminder.”

Dendy has also used RIS data to track the referral sources of patients who don’t show up for appointments. No-shows compromise patient flow by tying up schedules, she notes. Most of the KDH noshows turned out to be coming from clinics with high volumes of indigent patients.

KDH then worked with those clinics. “We said, ‘Talk to your patients,’ and we actually have cut no-shows,” Dendy says.

She also relies on RIS data in a way that may be unusual: She creates the contract radiologist’s monthly invoice. The invoice lists patient names and the code for each procedure that the radiologist interpreted. “I break it down by modality, and by how many studies (and what types) he read most,” Dendy says. What she is doing is creating the radiologist’s bill. She sends it to him, and then he approves it. “It is backwards, but it’s black and white,” she says.

Large-practice Models Data mining, as a management tool, can be even more useful when applied to a large radiology practice. J. Keith Radecic is CEO of Infinity Management, LLC, the management arm of Radiology Alliance, PC, in Nashville, Tenn. Radiology Alliance, with 48 radiologists, is the largest private radiology practice in Tennessee. Its clients include three hospitals and more than half a dozen outpatient imaging centers.

The RIS used by Alliance is interfaced with the HIS and PACS at Alliance’s various clients, and an IT staff of four at Infinity makes sure that those interfaces are performing, Radecic says. For analytical purposes, he relies primarily on a RIS reporting tool that assembles the financial data in conjunction with the imaging and demographic data that flow to the RIS. While customized reports get a lot of attention because they can focus on specific patterns or details, Radecic emphasizes the importance of the template-based reports that the RIS generates automatically. He has more than 150 of them that he can choose from monthly.

A particularly important template report, he says, is the aged trial balance.

This report tracks accounts receivable, showing delinquent payments, where the receivables are with each payor, and what the payment cycles have been. Radecic adds that studying receivables has allowed the practice to lower its turnaround time for receipts from payors from the 50-day range to the mid 40s. “Our goal is the high 30s for 2009,” he says. He also notes that the receivables data, because they can be tracked to the line-item level, have made it easier to prove to insurance carriers that some payments should be given immediate approval, rather than having to go through an appeals process.

Other template reports from the RIS reveal specific modality patterns or CPT

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codes in the aggregate, Radecic says.

Among other things, these can be used to assess work RVUs and other efficiencies.

“There are such powerful tools in today’s market from the various vendors,” he adds.

Like others, Radecic tracks referral patterns. “They go a long way in telling us where our procedures come from,” he says, but the gross figures for a referrer don’t tell the whole story. He drills down to understand why the numbers show what they do. “Do all of a physician’s referrals come from Medicaid? Is he or she giving us all the low reimbursables?

We’ll take any patient, but we need to manage our practice. If all we get is Medicaid or self-pay, we’ll go to that physician and say, ‘We’re happy, but all you’re giving us is self-pay. We want all your business.’ We try to convince that physician that if we’re good for some of his or her business, we’re good for all of it,” Radecic explains.

He adds that Infinity tracks referrals by ZIP code to see whether new centers should be opened or a joint venture with a hospital should be initiated. “These are decision-driving models,” he says. Infinity Management also works with its RIS vendor to turn regularly needed reports from the custom variety into those that the RIS does automatically or nearly automatically.

Radecic uses the example of a report that combines charge counts, charge dollars, work RVUs, and actual cash receipts.

“I used to have to run four reports, coordinate them with one giant spreadsheet based on the physicians’ work at multiple locations, and then calculate their average productivity per day. Now, I have a single reporting tool that gives me all that I need to run that report. I can run, in 25 to 30 minutes, a report that took days before,” Radecic says.

There are, of course, some reports that Radecic can get only by creating the dataanalysis parameters himself. At present, he says, Infinity is trying to cut down on the after-hours readings that its doctors must perform. While Alliance Radiology uses a night-coverage service from 11 PM to 7 AM, the evening hours before 11 are unpopular with radiologists. “We know that on a typical day, we need 31 doctors to manage the business, but of those, should

We used cost-accounting principles to measure productivity for each area.

By tracking productivity, we were able to reduce staffing by 10%.

Bill Ziemke, JD, LLM, MBA, CPA

we schedule two or four in the evening and 29 or 27 in the day?” Radecic asks.

He’s using RIS data to find the most efficient evening staffing pattern that also requires the fewest radiologists. This report, he says, will answer a quality-oflife question that will fit into larger staffing puzzles when doctors want varying workloads and schedules. Another area that Radecic continually investigates is the profitability of certain procedures, including radiofrequency ablation and uterine-artery embolization. “We know that uterine-artery embolization is a good service that generates revenue because we’ve run the numbers,” he says. “If you can’t measure it, you can’t manage it.”

External Management Not every data-mining effort is based directly on billing or RIS-driven data. At Advanced Radiology Services (ARS) in Grand Rapids, Mich, data from seven different health systems are pulled from the RIS, HIS, and PACS at client facilities.

From there, the data flow to servers at the practice’s management service, Strategic Administrative and Reimbursement Services (STARS), LLC, Grand Rapids, Mich, where they are analyzed using business-intelligence reporting software.

ARS is the outgrowth of several radiology practice mergers in the Grand Rapids/Kalamazoo area. Representing 115 radiologists, it is one of the largest radiology practices in the country. STARS handles billing and management for ARS. Bill Ziemke, JD, LLM, MBA, CPA, is CFO at STARS. According to Ziemke, incoming medical reports are entered into coding software, where the reports are coded either manually or using electronic intelligence and entered into a billing system. All interventional radiology procedures are manually coded, whereas some of the diagnostic reports

are coded using electronic intelligence.

Since the billing system itself has limited template-reporting capacity, STARS routes the data from the billing system into a data warehouse. “There is a nightly extract of data fields from the billing system, which are transferred into a data warehouse. The data warehouse can then be used for reporting purposes using business-intelligence reporting software,” Ziemke says.

Financial analysts further segment the data, organizing subsets—for example, daily patient, location, physician, and billing figures—into smaller, more manageable data cubes. Cubes, he says, allow data to be analyzed more quickly than if they had to be pulled off the master file.

“When the data warehouse is updated, the cubes are also updated,” he explains.

Ziemke says that almost all STARS reports are customized. They are designed, created, and updated by financial analysts on staff. Currently, analysts are evaluating the costs of having radiologists on-site after hours.

Among data-analysis successes, Ziemke lists stepped-up productivity in the billing department. “We used costaccounting principles to measure productivity for each area,” he says. “By tracking productivity, we were able to reduce staffing by 10%.” The study took more than number crunching. “We had a cost accountant sit down with the staff doing the work, watch them to measure what they were doing, and discuss outliers to

the standard measures with the staff performing the work,” Ziemke says. “Then, we set the productivity standard, which is constantly being reviewed.”

The analysts are also searching for innovative ways to measure physician productivity. Simply applying RVUs to radiologists’ output is too imprecise, so ARS is looking at numerous items. Other factors that need to be considered are the amount of administrative responsibility a physician has; where the interpretation is being performed (home, hospital, or off-site location); the modality being interpreted; and the degree of acute need for the studies being interpreted. Another factor that ARS is measuring is the quality of the work.

“Our doctors are committed to quality,” Ziemke says, noting that an electronic peerreview system has been implemented to give feedback on quality. “All of these factors need to be considered when looking at and evaluating physician productivity.”

Drowning in Data There are so many benefits of data mining that it’s hard to notice the pitfalls, but they exist. In drilling down, there is always the fear of suffocating on data.

“You research yourself into a hole,” Radecic says.

For example, a practice can study the numbers on a projected service expansion, he says, but until the move is actually made, nobody can answer the most important question: Are the physicians in the new neighborhood going to give the practice referrals? “Excess data make you want to analyze down to the minute level, but you can stymie a business decision because you get so minute you never act.

You overanalyze yourself out of projects,” Radecic says.

George Wiley is a contributing writer for Radiology Business Journal.

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 33

RSNA 2008 | Exhibits Assessment

RSNA 2008: Mining the Landscape, Assessing the Exhibits

In assessing the imaging technologies on display at RSNA, an observer provides tools for making critical decisions regarding your capital budget for 2009

By Lisa Bielamowicz, MD

D

espite reports that capital equipment budgets are frozen at some hospitals, buyers were out in force at the 2008 meeting of the RSNA in Chicago. Nonetheless, professional attendance did not reach last year’s level, and exhibit square footage purchased and vendor attendance also were down, reportedly.

Clearly, the global economic crisis is having an impact, and both vendors and health care providers are feeling pressure on the capital side. Our financial analysts believe that from a capital-purchase standpoint, vendors will feel the greatest effect in the middle of 2009. For providers with technology decisions to make, it is more important than ever to make every dollar count, and we predict that there are still some great market opportunities.

Providers also need to maximize the equipment that they currently own; 64slice (and beyond) CT is a great example.

Scanners capable of doing cardiac imaging are located on every corner in most cities, but we have yet to see a market where one provider has risen to the top as the cardiac imaging provider of excellence. The technology is there, but in almost all areas, the cardiac imaging program for which it was purchased has not developed. The market is wide open, with no new technology purchase necessary.

One positive consequence of these changes is that hospitals, imaging centers,

and now vendors are placing a renewed focus on efficiency. Surveying the offerings on the show floor makes the priorities of every vendor clear: increasing the efficiency of all departments across modalities and decreasing scheduling blocks to increase revenue from one unit dramatically. With digital mammography, for instance, halving the scanning block can more than double revenue.

Top Five Trends We identified five top trends on the show floor. First, focus on superpremium technologies was diminished. We didn’t see a big-splash technology, making this one of the more sedate RSNAs in recent history. The other side of this is that we’ve seen many vendors focusing on developing budget lines: a 1.5T MRI scanner for less than $1 million and a workhorse 16-slice CT scanner costing less than $500,000.

The four major manufacturers have all introduced budget CT and MRI units.

Second, the focus on women’s imaging continued. This is seen not only with digital mammography and the excitement around tomosynthesis, but in a huge array of offerings in the second-line imaging space for treatment planning and diagnosis. Subject to the economy, mammography volumes may decline, but vendors perceive providers as likely to purchase.

Third, interest continues to grow in breast tomosynthesis. We predict that it is

34 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

the one truly disruptive technology that will be introduced in the next few years. Fourth, further advances in ultrasound generated considerable excitement, as vendors continue to add functionality. Increased attention to radiation dose in 2008 has also refocused interest on ultrasound.

Fifth, we are starting to see the additional development of niche offerings, with new market entrants such as specialty, head-only PET/CT scanners and new dedicated breast MRI offerings. There is real interest in developing market-specific platforms for specific patient populations, although, as capital dollars become scarce, these niche scanners are increasingly difficult to justify over a workhorse platform.

CT During the past 12 to 18 months, 64slice CT has become the technology of choice for hospitals interested in purchasing a workhorse CT scanner. While a 64slice CT scanner is not required to perform the vast majority of studies, prices have fallen so precipitously that 64-slice CT can now be purchased for less than $1 million (without the cardiac package). It is a justifiable purchase today if there is a possibility that coronary-artery imaging will ever be performed during the life of that scanner.

Is 64-slice CT good enough for coronary-artery imaging? Evidence demonstrates that 64-slice CT is the standard of

care for coronary CT angiography (CCTA) for most patients (see table), but one serious concern is radiation dose. Dose-reduction protocols exist, but if they are not used, 64-slice CCTA is associated with a hefty radiation dose. Dose-reduction packages are very important for sites planning to offer CCTA in a programmatic way.

Nonetheless, 16-slice CT remains the standard of care for nearly every exam apart from CCTA—more than 90% of diagnostic CT exams performed today. In 2007, it looked as though vendors had completely abandoned 16-slice CT, and some talked about discontinuing their 16-slice CT scanners for the US market.

In 2008, however, one major vendor brought out a bare-bones (but good) 16slice CT with a planned list price of $400,000. It is not necessary to have five superpremium scanners in a hospital.

During the past year, each vendor has solidified its post–64-slice CT offerings, and all are in production today, with list prices holding steady around $2 million.

Vendors are backtracking and filling in the gaps; one introduced a reasonably successful 256-slice scanner in 2007, but also offered a 128-slice scanner (upgradable to 256 slices) at RSNA 2008.

The vendor that introduced dualsource CT rolled out a single-generator 128-slice scanner available in 20-, 40-, 64-, and 128-slice configurations. The 20-slice unit can be upgraded to 128 slices with as little as eight hours of downtime. While that is the best flexibility we’ve ever seen, we haven’t seen these upgrades really pay off; the option is largely an insurance policy, allowing access to premium technology as required. It may help sell the high-end

technology to the CFO, but most sites don’t end up doing the upgrade.

Acute stroke imaging is likely to be the next place where superpremium CT is going to have a large clinical impact. Our instinct is that 64-slice CT is probably not going to be the prime technology. A benefit of a large single 256- or 320-detector array is that it allows capture of the entire brain or heart in one rotation, offering great perfusion images. This will allow rapid assessment of the extent of a stroke and, it is hoped, lead to expedited triage of patients to interventions. Combined with angiography, it creates the true optimal cardiac exam, visualizing the clot with CCTA and then seeing, downstream, the blood-flow data that would have come from nuclear medicine in the past.

In post–64-slice technology, the options available are staggering, with

CT Adoption and Application Profile, 2008 Category

Laggards

Late Majority

Early Majority

Early Adopters

First Movers

Typical Institutions

Rural hospitals in noncompetitive markets

Community hospitals in average markets

Community hospitals in competitive markets

Regional academic centers and community hospitals in highly competitive markets

Top radiology departments serving as test sites for cuttingedge multislice CT technology

Slice Count

Single

64

Next Generation

2

4

8

16

32

General Imaging Trauma 3D Imaging Virtual Colonoscopy Peripheral CTA

KEY

Coronary CTA

Substandard

Standard of Care

Ideal

Source: Technology Insights interviews and analysis, The Advisory Board Co.

Next-generation CT technnologies include 256-slice, 320-slice, high-definition, and dual-source models

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 35

RSNA 2008 | Exhibits Assessment

each vendor offering a drastically different scanner architecture. It is still difficult to assess which design offers the best longterm clinical bet.

CCTA and CT Colonoscopy The slower-than-anticipated development of CCTA has been frustrating.

Clinical evidence has mounted that CCTA is a good way to evaluate symptomatic, low-risk chest-pain patients in an outpatient environment or emergency department. Evidence supports 64-slice CT in this role, and operationally (and perhaps economically), CCTA makes sense. Since chest-pain patients account for 5% to 10% of emergency-department admissions, CCTA will be an operational boost—especially for crowded emergency departments and telemetry units—by allowing proper routing of low-risk patients who are probably not having myocardial infarctions.

Despite the promise, reimbursement and operational hurdles have been roadblocks for fully implementing CCTA programs. Private payors would have followed CMS, had it moved forward with a more positive coverage decision, but CMS has given them reason to sit back as well.

Getting the number of physicians (from radiology, cardiology, or both) necessary to provide the service around the clock is daunting; no US emergency department appears, so far, to be able to offer 24/7 CCTA on its own.

CCTA also was the catalyst for the biggest imaging issue of the year: the response to radiation dose. If the 2007 study1 estimating that 1.5% to 2% of all US cancers could be due to medical radiation is to be believed, this is a significant problem. There is a large risk for the young, and especially for females, from a single CCTA exam, without a dose-reduction strategy.

Media interest guarantees that patients will ask whether they need the study and whether the provider is doing something to make it safer. Providers need to be ready to answer those questions; must have technology in place, where appropriate, to reduce dose; and must ensure that frontline staff is prepared.

CT colonoscopy (CTC) has been slow to take off in recent years, but the publica-

tion of the ACRIN trial led many to believe that coverage was imminent. The ACRIN study provided the first large data sample (5,000 patients) to show that virtual colonoscopy stands up well as a screening procedure next to standard optical colonoscopy. Nonetheless, those hopes were dashed when CMS declined to cover screening CTC in its proposed national coverage decision released in February.

A few caveats: First, this may be the most operator-dependent exam in imaging today, and physicians who are very well trained are needed to replicate the ACRIN results. Second, there is still some patient misalignment here as to the needed prep and experience of a CTC exam, and distributing that knowledge is important. Third, providers should assess what virtual colonoscopy will do to scanner capacity. No volume onslaught is expected, even if CMS coverage comes through, but as volumes start to mount, it will become troublesome that these exams take longer than standard diagnostic CT. Reimbursement is not going to make up for losing the time to perform three or four more diagnostic scans for each CTC study.

For portable CT, resurgence is being seen both in hospitals’ interest and in vendors’ consideration of offering technology.

Our Technology Insights group has seen an upswing in hospitals looking for portable CT, whether for the operating room or, more commonly, for the ICU. There have been few offerings; a head-only portable CT unit has seen reasonable suc-

3T MRI MRI is the modality hit most acutely by the DRA, combining deep cuts in reimbursement and volumes important to imaging centers and physician offices. Due to high costs and longer replacement cycles, MRI is also expected to be hardest hit by any upcoming capital crunch. Therefore, vendors are focusing on efficiency, workflow, and increasing user friendliness.

Continued upgrades in coil technology across vendors are allowing multiple scans with fewer coil switch-outs. One vendor now offers a scanner with switch-out tables, so that the patient can be prepped outside the scanning suite and wheeled in while the other patient is being wheeled out, potentially increasing throughput.

Again, there is pressure on vendors to develop lower-cost workhorse units.

Several vendors showed a bare-bones 1.5T unit priced at less than $1 million (a milestone). Another offered a reasonable upgrade package with which paying Chest/Cardiac

Head/Brain

Other

cess in the ICU environment, and installations are increasing. A unit from the 1990s commands good money on the used market, and there is a CT suite available for the operating room, but at more than $1 million, its cost is comparable to that of an intraoperative MRI unit.

A potentially exciting development is a work in progress: a full-body portable unit that could be the most versatile portable CT scanner available is anticipated within 18 months.

1% Bone/Joint

29%

1%

25%

Breast 3%

36% Abdominal 5% Spine Figure 1. 2007 MRI volumes by anatomic site. Source: GE Healthcare; Siemens Healthcare; and Technology Insights interviews and analysis, The Advisory Board Co.

36 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

PET/CT

The pinch on MRI dollars has not softened demand for 3T scanners.

Vendors are seeing a higher percentage of purchases involving 3T scanners.

Lisa Bielamowicz, MD

slightly more for a 1.5T unit that is basically a tuned-down 3T unit buys future 3T capability with just two days of downtime, at a modest cost.

The pinch on MRI dollars has not softened demand for 3T scanners. Vendors are seeing a higher percentage of purchases involving 3T scanners. It took 10 years, but it is finally prime time for 3T. Nonetheless, this is not a required purchase, as 1.5T remains the standard of care for all but the most advanced neuroimaging. There is a clear benefit for all neurological imaging, but more and more other areas (such as pediatric, abdominal, and prostate imaging) also show a clear clinical advantage for 3T over 1.5T. Breast imaging, which currently accounts for 3% of all MRI procedures (Figure 1, page 40), may be the next area where it is important to have 3T. This may not happens in the next year or two, but early studies3 are showing that 3T MRI has better specificity (the Achilles heel of breast MRI). Even in cardiac imaging, some data are being developed showing some benefits at 3T. More important, the floor has risen: the full portfolio of exams can be done on 3T MRI, and it can be a workhorse scanner in a stand-alone environment, although issues in spine imaging are still being seen. Vendors are expanding their options in 3T, increasing bore size, making a more patient-friendly platform; prices have also reached a plateau at slightly less than $2 million.

Looking hard at high-field open scanners that give 1.5T-quality images with a more open platform is also recommended. Not only do these scanners provide a more comfortable patient experience, they allow better access for procedures and for pediatric patients. A number of hospitals have been able to reduce the number of

pediatric patients requiring sedation.

Open units also have higher table weights, allowing improved access for obese patients. Patients like the experience of an open scanner, and the high-field open scanners give physicians the images they want as well; they are one of the few patient-marketable purchases in MRI. Media attention to nephrogenic systemic fibrosis and MRI contrast over the past year has been significant. Although the number of reported cases seems to have diminished, there is a clear need to reduce the amount of contrast used, especially for angiography, where three or four times the recommended dose was commonly used. Vendors are working to develop noncontrast angiography.

Some niche MRI scanners also deserve recognition. For hospitals, it makes sense to own a scanner with the biggest bang for the buck. Some breast centers can make a case for dedicated breast MRI if they have enough volume, but data for other niche scanners like upright MRI are really equivocal.

PET/CT is the standard of care for oncology imaging, particularly for staging of a large majority of cancers; tumor imaging accounted for 93% of all PET/CT in 2007 (Figure 2). The National Oncologic PET Registry shared data early in 2008 that showed a change in clinical management after PET imaging for 38% of cases.

An Australian registry has replicated those results. Other work showed that PET/CT does a much better job than thoracic CT of detecting lung lesions. The data are there: you need access to PET/CT if you want to have an oncology program.

Despite the development of cardiac and neurological PET, oncology is going to continue to account for 90% or more of all studies performed using PET/CT over the next decade.

PET/CT, however, is an area where reimbursement has been precarious. CMS continued to chip away at coverage for 2009. Reimbursement for oncology studies went down by about $20 per scan.

Cardiac PET coverage has seesawed like no other exam has during the past four years, and it went down about another 20% for 2009. Because it is necessary to cover the $30,000-plus monthly cost of an on-site rubidium generator, myocardial PET remains an expensive business.

Development in PET/CT technology has been somewhat stagnant, with one interesting exception: a new entry that purports to decrease PET scanning time significantly. People have long discussed Myocardial Imaging

Tumor Imaging

5% 93%

Brain Imaging

2%

Figure 2. Oncology continues to dominate total PET/CT volume, 2007.

Source: Technology Insights interviews and analysis.

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 37

RSNA 2008 | Exhibits Assessment

using the excess downtime on PET/CT units to perform diagnostic CT scans, but operationally, it’s not simple. This new platform reportedly completes a wholebody oncology survey in five minutes. If that is true, then it will actually be possible to integrate PET and CT workflows. The scanner is available in 40-, 64-, and 128slice configurations, so a site with a very low CT-slice capability could bring this in as PET/CT, but also as high-end CT with cardiac capabilities.

Hybrid SPECT/CT systems have lagged behind PET/CT in development.

Nonetheless, new SPECT and SPECT/CT systems were on display, with greater focus on noncardiac applications. SPECT/CT may be solidifying its role in the evaluation of some bone and infectious lesions, and other oncology-based applications are developing as well, though this terrain may be largely occupied by PET/CT over the next decade.

SPECT/CT remains a nice-to-have, not must-have, platform. What it needs is a high-volume exam where it makes a substantial clinical impact over standard nuclear imaging, as PET/CT did for oncology imaging. SPECT/CT is still searching for the study that makes it a necessity.

RSNA 2008 did not bring MRI/PET any closer to commercial readiness. Although clinicians are able to fuse MRI and PET performed separately, commercially available clinical PET/MRI (still only discussed as a head-only unit) remains three to five

associated with a decreased recall rate.

While vendors are promising that top-ofthe-line FFDM units will be upgradable for tomosynthesis, this upgrade will probably still require a full-unit switch-out, or forklift upgrade.

CR mammography remains an attractive alternative, allowing hospitals access to digital technology for around half of the cost of a DR system. In April 2008, the FDA approved computer-assisted detection for CR systems, resulting in a sales boost for the one approved system. This vendor hopes to capitalize on the success of its CR platform by developing a DR FFDM solution as well, which could result in further price erosion.

Second-line breast imaging exams like breast MRI and ultrasound have a wellestablished presence, and with recent competition from positron-emission mammography (PEM) and breast-specific gamma imaging (BSGI), the field promises to become even more diverse. PEM uses contrast enhancement with radioactive FDG to assist in the detection of lesions of less than 1 cm in diameter, and is especially effective in the detection of ductal carcinoma in situ and atypical ductal hyperplasia.

BSGI is capable of detecting early-stage tumors and offers differentiation of cancerous versus benign tumors. Two vendors of PEM and BSGI displayed mobile versions of their technologies. The major PEM vendor recently received 510(k) clearance for PET-guided biopsy on the

years away. Architectural issues associated with incorporating a PET ring into an MRI magnet historically have confounded development. One vendor introduced a prototype scanner that is currently used exclusively for investigational purposes.

Women’s Imaging Now considered the gold standard for breast imaging, digital mammography may be eclipsed by breast tomosynthesis in just a few years. Currently, digital mammography is at the forefront of replacement discussions as institutions decide whether to pursue replacement of analog systems with full-field digital mammography (FFDM) scanners or to get lower-cost access to digital exams with CR mammography technology (Figure 3).

At RSNA 2008, vendors showcased their flagship FFDM systems, including new platforms that will serve as the basis for future breast tomosynthesis upgrades.

Indeed, as institutions consider additional digital mammography units, more are considering the market timing of future technological developments, particularly breast tomosynthesis, which provides multiple slice-like views of the breast, allowing better visualization of many breast lesions.

The first commercially available product is expected to receive FDA approval in early to mid-2009. An early clinical study4 indicates that tomosynthesis demonstrates superior sensitivity, compared with conventional 2D mammography, and it is also

As of November 1, 2008

As of November 1, 2007 FFDM: 27%

FFDM: 44%

3,644

62% increase versus 2007

5,913

9,946

Non-FFDM: 73% Figure 3. Accredited mammography units in the United States. Source: FDA

38 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

7,447

Non-FFDM: 56%

PEM platform, adding further versatility to the modality and eliminating a key disadvantage of the unit.

Automated breast ultrasound (ABUS) is not yet gaining momentum. Unlike conventional handheld ultrasound, ABUS standardizes image acquisition and limits variability among operators. Such automated protocols consistently acquire a specific set of 3D volumetric representation, minimizing user error and maintaining quality standards across time and patients. While early results indicate performance equivalent to that of handheld ultrasound, further research will be required to demonstrate (potentially) superior performance. The leading vendor of ABUS has had market exclusivity to date, but one major multimodality vendor introduced a system at RSNA 2008, though its FDA clearance is still pending.

Ultrasound Ultrasound introductions added to rejuvenation of this modality, although it is necessary to spend $600,000 to obtain all of the features that enable the modality to compete more effectively with CT and MRI. Vendors continued to update 3D and 4D models at RSNA 2008; 3D ultrasound and volumetric imaging offer complete assessment of morphology by stacking 2D cross-sections of the volume of interest.

Currently, 3D ultrasound is best suited for obstetric and echocardiography studies, but increasing demand to view anatomical structures clearly, with more measurement parameters, is driving a continual shift away from 2D ultrasound toward 3D and volumetric imaging for other applications. Postprocessing software enhancements are allowing more detailed tissue characterization while simultaneously reducing operator dependence.

DR Digital imaging remains the primary focus for vendors of radiography and radiography/fluoroscopy systems, and portability is also becoming an area of interest. Several vendors are developing new portable plates that are lightweight and durable enough to sustain routine daily use in high-volume settings.

Moreover, vendors are introducing more comprehensive and versatile DR room solutions that combine multiple radiographic modalities.

DR vendors also are focusing on improving workflow and reducing the steps that technologists need to take to acquire images and position patients.

Auto-alignment, auto-image stitching, and tracking software are now becoming routine, as are user-friendly interfaces that are designed to enable hospitals with older systems to improve workflow by replacing one or two rooms with one new system.

Two technologies on display this year, DR tomosynthesis and lung computeraided detection, show promise in their ability potentially to improve the detection of lung cancer and lower the cost of detection. Tomosynthesis acquires 3D images using DR technology, and recent work suggests that tomosynthesis is far superior to DR alone and significantly less costly than multislice CT for the detection of pulmonary nodules. In addition, computer-aided detection with CT has the ability to detect nodules and reduce reader variation (a problem area in CT detection of lesions), even in a low-dose setting. These developments could have a potentially large impact on the way that pulmonary nodules are detected and on radiation dose, as well as reducing the cost of lung-cancer detection.

Outlook for 2009 While molecular imaging is expected to play a significant future role, its near-term clinical adoption is not expected within the decade. That said, future applications include improved lesion detection and the ability to deliver targeted therapeutics.

First, for 2009, expect continued price erosion across modalities. As next-generation products come to market and as broader economic issues continue to constrain capital budgets, acquisition prices will continue to erode. Second, breast tomosynthesis will become a commercial reality. With the ability to improve upon conventional mammography, tomosynthesis could prove to be a disruptive technology, and centers intending to acquire digital mammography platforms should consider their path to tomosynthesis as

they make this purchase Third, look for the continued refinement—and growing adoption—of advanced CCTA applications. As clinical data continue to solidify the role of the exam, more institutions are expected to deploy CCTA in the emergency department, despite the low likelihood of broader Medicare coverage this year. Fourth, 3T MRI will further approach workhorse status through increased versatility, although the attractive prices for 1.5T scanners make it a hard sell this year.

Fifth, moving forward, increasing efficiency and getting more patients through each scanner will be paramount. MRI will represent one of the primary targets of these efforts, bolstered by increased automation in each vendor’s MRI platform. Sixth, look for portable CT offerings—now catering to specific applications such as neuroimaging—to increase the versatility of their platforms with whole-body units.

Lisa Bielamowicz, MD, is the national imaging practice leader, The Advisory Board Co, Washington, DC. For more information about the company’s Imaging Performance Partnership program and technology assessment services for member hospitals, contact her at bielamol@advisory.com.

References 1. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:22772284.

2. Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers.

N Engl J Med. 2008;359:1207-1217.

3. Bogner W, Pinker K, Gruber S, et al.

High-field diffusion-weighted imaging for improved differentiation of benign and malignant breast lesions. Paper presented at: 94th Scientific Assembly and Annual Meeting of the Radiological Society of North America; December 4, 2008; Chicago.

4. Kopans DB, Moore RH, Gavenonis SC. Calcification in breast tomosynthesis.

Paper presented at: 94th Scientific Assembly and Annual Meeting of the Radiological Society of North America; December 2, 2008; Chicago.

www.radbizjournal.com | February/March 2009 | RADIOLOGY BUSINESS JOURNAL 39

TELERADIOLOGY | Crossing Boundaries

Day for Night, East for West Teleradiology permeates the specialty as practices cross state, regional, and global boundaries to purchase and practice radiology

By Greg Thompson

H

ow did a 2000 lecture tour in China spawn a teleradiology revolution? For William G. Bradley, MD, PhD, FACR, the idea for an international business evolved from a reading that he did nine years ago in the Far East. Thanks to PACS and the Web, Bradley, who is now chair of the radiology department at the University of California, San Diego (UCSD) Medical Center, interpreted an MRI of the brain in China and then called the neurosurgeon in the United States.

“It was the middle of the night back in Long Beach, Calif, and the middle of the afternoon in China,” Bradley recalls. “At that point, it occurred to me that with PACS and the Internet, you don’t have to be up at night anymore—which is the worst thing about being a radiologist.” That, he adds, was the genesis of the first after-hours teleradiology coverage provider.

After returning from Asia, Bradley mentioned the idea to friend and colleague Paul Berger, MD. With PACS, increased Internet bandwidth, and lossless images fueling the digital transformation,

the idea took hold. Berger nurtured the concept, eventually starting a company with a name that became generic in the industry and synonymous with nocturnal radiology.

“What we started was simple,” Bradley says. “You moved to Sydney. You moved to Zurich—and you worked during the day.”

At present, he reports, 26% of US hospitals are covered by the original company, and 55% of hospitals are covered by one of its 40 competitors.

Over time, and through the adoption of PACS, many traditional radiology practices have embraced teleradiology, not just as customers, but as providers of daytime coverage for contracted hospitals and longdistance and after-hours coverage for rural hospitals and small radiology practices.

Today, for example, UCSD is not only a client of the original after-hours coverage provider, but is also a purveyor of subspecialty teleradiology services. Each day, UCSD radiologists perform 50 to more than 100 teleradiology interpretations; Bradley expects this service line to generate revenues of $1.5 million in 2009.

40 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

When taking on a new hospital client, many radiology groups, such as Radiology Consultants of Iowa (RCI) in Cedar Rapids, keep a close eye on the windshield factor, preferring to contract only with hospitals no farther away than a two-hour drive. Kathryn Epley, RCI’s chief administrative officer, presides over the 27-radiologist RCI group and takes pride in the company’s ability to offer both distance readings and on-site services with a personal touch.

With the continuing rise of subspecialization, high-end MRI, and interventional procedures, Epley points out, it is tough for small, rural hospitals to retain enough radiologists with all the necessary credentials and skills. The highly dispersed population centers of Iowa mean that RCI primarily deals with critical-access hospitals (of 25 or fewer beds) outside its urban home base.

When Epley arrived four years ago, most of those hospitals still had film-based radiology services, and turnaround for routine studies could take days. To make matters worse, radiologists had to spend

TELERADIOLOGY | Crossing Boundaries

time traveling to those hospitals to provide on-site coverage, even for studies that could have been interpreted via PACS (if it had been available).

With the help of an IT committee of four radiologists and a new CIO, Joe Moore, RCI selected a PACS in 2005 and began visiting outreach hospitals. “The most precious resource we have is the doctors’ time,” Epley says. “For them to be driving to outreach sites is a poor use of their time if they can do that same work in a remote reading room.”

The most precious resource we have is the doctors’ time.

Kathryn Epley

Realizing the dream of providing networked, real-time radiology service for all of the contracted outreach hospitals was not easy, but Epley and her staff made steady progress. “Our vision required that those hospitals develop a stronger relationship with us, in terms of trusting us to purchase their PACS through us, which was a real leap of faith,” Epley says.

“Since that time in 2005, every one of our 10 outreach hospitals has come onto what we call RCI Net. We provide a completely turnkey digital system because most of these hospitals don’t have the IT infrastructure necessary for PACS. We also provide 24/7 reading within our group because we have radiologists working all three shifts.”

With those pieces in place, multislice CT, MRI, digital mammography, and more all became portable. From signed contract to go-live date typically takes about 90 days for RCI, in a feat that it has been able to duplicate many times. When small hospitals did not have the RIS in place to place electronic orders properly, the RCI IT committee worked with a programmer to write a mini RIS that fits the bill. Using voice-recognition software (with the vast majority of reports edited by the radiologists), turnaround time has

been dramatically reduced—to minutes, in most cases.

So far, Epley has no plans to expand outside Iowa. While she has not specifically avoided crossing the border, she says that there is still plenty to be done within the state.

Joseph Racanelli, MD, is president of Radiologic Associates, New Windsor, NY, a 16-radiologist group that covers four hospitals and four imaging centers in New York. Like UCSD, Racanelli’s group uses teleradiology to fill its own gaps while also providing teleradiology services for others. For example, Racanelli contracts with a New York-based after-hours service to handle his group’s overnight readings. “In the beginning, we had to use more radiologists than we needed because we did not use teleradiology,” he says. “That was the big problem in staffing. Some places would be dead quiet and others were getting killed, and having radiologists driving around is not economical.”

Most every hospital wants a body on the ground.

Joseph Racanelli, MD

Radiologic Associates currently offers teleradiology services in the surrounding county up to 35 miles away, under a limitation that is largely in place due to hospital desires. “Most every hospital wants a body on the ground,” Racanelli says. “They like to have somebody sitting there for face time to work with the technologists, but instead of having two or three radiologists there, we send one. The overflow is handled via PACS and teleradiology.”

If Racanelli found a potential client that did not require the on-site presence of a radiologist, offering teleradiology services in other states would definitely be a realistic option for the practice. “It would not surprise me if we ended up jumping state lines,” Racanelli says.

“More of our business will be handled over the computer, rather than having a

42 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

radiologist sitting somewhere.”

In a change of attitude that is further opening the door to remote practice, Racanelli says that he increasingly is seeing a willingness on the part of clinicians to talk with radiologists by telephone.

“We’re at the point where the referring clinicians who used to walk in the door and go over cases are getting comfortable with calling and going over the cases,” Racanelli explains. “I get phone calls all the time asking me to look at a case. The caller is in one place and I’m in another— and it really doesn’t matter where we are, because we can both bring up the case at the same time. That used to be the big thing: somebody had to sit there when the doctors came by, but now, that’s not so much the case.”

Regulatory Barriers One other limitation on expansion is state licensing. The good news is that gaining another license is usually just a matter of turning in the paperwork, paying the fee, and waiting the required six to nine months. Beyond marketing services to other areas, gaining the first outof-state teleradiology client is often a matter of mining old contacts. “The way it works is that you may have a friend from residency in Texas who says that he has some extra work,” Racanelli says. “Even though you may be far away, he may ask if you want to do it, rather than having the hospital two counties away do the extra work.”

At RCI, tailoring services to fit each situation is largely a function of geography and mission. In keeping with its strict two-hour–drive policy, RCI provides a medical director for every hospital’s radiology department, and that director attends all the medical staff’s meetings.

“There is a lot of teleradiology out there, but those people are distant, and they rarely come on site,” Epley says. “The local physicians don’t know them, and that makes a difference. Our physicians attend the meetings, and they are there with the local referring doctors to answer questions. If we start expanding outside of more than about a two-hour–drive radius, we are going to lose the ability to do that.”

TELERADIOLOGY | Crossing Boundaries

Epley foresees a day when RCI could partner with other radiology groups, providing them with the technology that her team has developed and starting a joint venture. She is quick to point out, however, that any such move would have to be nonpredatory. “We don’t want to go into hospitals to

that radiologists trained abroad do not read for US providers is that they do not take the US boards, leaving doubt that they are trained to the same standards.

Some countries try to get around such prohibitions through the practice of ghost reading, Bradley says.

Let’s say a group needs half a bone radiologist. Rather than hiring someone like that who would rather be doing 100% bone radiology, it can hire a subspecialty-coverage company.

William J. Bradley, MD, PhD, FACR

boot out the radiologists who are there,” she explains. “That’s not our design. We could provide some top-quality service that they may not be able to provide because we have 27 doctors, the technology, and the culture that makes it all work well.”

Pushing the Boundaries While US-trained physicians residing abroad currently perform readings for cases originating in the United States at night, it is still uncommon for US radiologists to interpret exams that originate outside the country. The barrier is mostly reimbursement. Bradley explains that while European radiologists complete training similar to that of US radiologists, they only garner about half of what US doctors would be paid for a typical night reading.

Indian physicians get approximately 10% of what US radiologists earn. “It does not really pencil out for us to read for anyone other than the US practices, because they just don’t pay enough,” Bradley says. “Other radiologists around the world are not paid as much as US radiologists, so there is no incentive for us to read at night for them.”

Subspecialty daytime teleradiology is another matter. According to Bradley, world-renowned UCSD musculoskeletal radiologist Donald Resnick, MD, gets enough per case from Portugal to make it worthwhile. “I have been doing MRI teleradiology since 1984,” Bradley says. “Initially, it was all MRI. After I moved to UCSD, where everything is subspecialized, I limited my teleradiology to neuroradiology.”

Bradley points out that another reason

He explains, “There is a risk, usually addressed to India, that you will have one US-trained radiologist surrounding himself with 10 Indian-trained radiologists, cranking through cases at hundreds an hour” that are actually being read by radiologists without US training or board certification; the cases are then signed by the US-trained radiologist. “The Indiantrained radiologists could be in the United States or in India. That’s called ghost reading, which is illegal. It’s a possibility, and that is one of the inherent risks of teleradiology,” Bradley says.

Bradley believes that a dozen US teleradiology entities have sent radiologists to the United Kingdom, France, India, Israel, and Australia. Because final readings for Medicare cases cannot be performed outside the United States, coverage providers outside the country provide so-called wet readings in the middle of the night, and a local radiologist does the final interpretations the following morning.

“There is an inherent double reading of every case, which is an opportunity for quality assurance,” Bradley says. “The next morning, the local doctors are rested. They

44 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

have all the films, including films not sent in the middle of the night (because we’re only concerned with emergency findings).

We compare the night reading to the final reading. At UCSD, we have been doing this since we started with night-coverage service. If there is a discrepancy, half the time, the coverage provider is right, and half the time, we are right.”

Most radiology groups that use afterhours services have fewer than 10 radiologists, and therefore are not subspecialized.

“If they are going to see one pulmonary embolism a month, they might miss it,” Bradley says. “Ideally, the local radiologist would read the case without seeing the wet reading and would then compare his or her reading to the night interpretation.

In fact, the local radiologists often know what night service said, so it is not a true comparison of reading capability, but it could be set up that way.”

Thanks to several different coverage services throughout the country, the idea of nighttime subspecialty teleradiology coverage has spread rapidly. In Bradley’s opinion, the after-hours market is just about saturated, but there is still opportunity to be found in daytime subspecialty readings.

The advantage of daytime readings, he says, is that they can be based in the United States and, therefore, can be final readings.

Bradley describes daytime readings as the focus of the new push. He says, “Nighttime is pretty much saturated.

There are too many companies competing for the business, and the price is dropping, but if you can get a good subspecialist radiologist to read, you can save yourself.

Let’s say that a group needs half of a bone radiologist. Rather than hiring someone like that, who would rather be doing 100% bone radiology, it can hire a subspecialty-coverage company.”

Bradley continues, “It will then do the subspecialty readings with fellowshiptrained radiologists. I also see this, really, as an opportunity for academic radiologists to get more business—and we can use teleradiology to help train our fellows.

We can use it to supplement the cases that our fellows see, so it is a win–win all around.”

Greg Thompson is a contributing writer for Radiology Business Journal.

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}

A R K E T place

Handheld Finger-prick Creatinine Test StatSensorTM from ACIST Medical Systems, Eden Prairie, Minn, a Bracco Group company, Princeton, NJ, is a point-of-care, handheld device that analyzes a fingerprick sample of blood for creatinine level (an important indicator of a patient’s renal function). Evaluating a patient’s kidney function can help determine his or her ability to receive IV contrast safely prior to CT and MRI exams. This is an important precaution, especially for patients with risk factors such as diabetes, known kidney impairment, or advanced age. www.acist.com/radiology/stat.asp

Web-based Imaging Workflow Resource Elsevier, Amsterdam, Netherlands, has released Mosby’s Imaging Suite, a fully integrated, Webbased solution for the imaging department or center, designed to enhance quality and productivity. The tool brings together reference, education, and communications capability in one platform for radiologic technologists, managers, and administrators. An online, searchable edition of Merrill’s Atlas of Radiographic Positioning and Procedures is at the core of the suite, which gives technologists access to 70 hours of category-A CE credits, checklists to build competence, and a platform that allows enhanced communications between department management and staff. www.mosbysimagingsuite.com

Women’s Imaging Ultrasound System Royal Philips Electronics, Andover, Mass, has launched a new ultrasound system designed to deliver high-quality imaging for a full range of women’s health needs, including obstetrics, gynecology, and breast imaging. The HD9 system’s features include iSlice (which enables clinicians to focus on specific areas of interest within a volume); spatiotemporal image correlation, for the evaluation of fetal heart anatomy and function; tissue-specific imaging technology (which permits the system to be optimized for a specific patient or exam type); and tissue aberration correction (which compensates for noise in difficult-toimage patients). www.philips.com/HD9

46 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

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A R K E T place

Expanded Imaging Informatics Services FUJIFILM Medical Systems USA, Stamford, Conn, has expanded its Synapse Managed Services offerings to include RIS hosting and tele-RIS capabilities. The company’s Managed Services arm was originally designed to provide Synapse customers with turnkey, high-reliability solutions that include software, system management, PACS hosting, and other disaster-recovery services. Through the company’s expanded partnership with Evolved Digital Solutions, Brentwood, Tenn, and through the use of virtualization technology, the program now includes RIS hosting and tele-RIS functionality, enabling radiology groups that read for multiple facilities to read from a single worklist. www.fujimed.com

Low-dose, Rapid CT Scanner Siemens Healthcare, Malvern, Pa, has introduced the SOMATOM Definition Flash, a swift new dual-source CT scanner with a scan speed of 43 cm per second and a temporal resolution of 75 milliseconds, allowing a complete scan of the chest region in 0.6 seconds. The scanner’s speed also permits a dramatically reduced radiation dose; a spiral heart scan can be performed at a dose of less than 1 mSv. Due to the high scanning speed, it is now possible to acquire scans of the thorax, heart, or both in a fraction of a second, eliminating the need for patients to hold their breaths during the scan. www.siemens.com/healthcare

FDA-approved Brainperfusion Application Ziosoft, Redwood City, Calif, has received FDA 510(k) clearance for a brain-perfusion application available using its thin-client system, Ziostation®. The brain-perfusion application is a powerful analysis tool that provides brainperfusion functionality as a thin-client application using standard commercial hardware. The software option aids in stroke assessment by providing a color map of cerebral blood flow and other perfusion-related parameters from CT of the brain. www.ziosoftinc.com

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{MA R K E T place} 1.5T Magnet With Powerful Gradients GE Healthcare, Waukesha, Wis, received FDA clearance for its new 1.5T MRI scanner, the DiscoveryTM MR450. Built on the company’s short-bore superconducting 1.5T magnet, the new platform features a newly designed digital receiver that extends the dynamic range by four times (compared with the company’s previous 1.5T systems), as well as onboard optical data architecture that boosts the signal-tonoise ratio by 27%. The system also features a new parallel imaging technique that uses a full 3D data kernel for more accurate reconstruction, in addition to several new, advanced applications: SWAN (T2 star-weighted angiography) and a new suite for non–contrastenhanced MR angiography, Inhance. www.gehealthcare.com

Web-based Advanced Visualization Applications Vital Images, Inc, Minneapolis, has released Vitrea® Web, a new solution that provides distributed access to all of Vital’s advanced clinical applications via Web and is available exclusively to ViTAL Enterprise customers. Advanced applications, including tools for measuring coronary plaque, probing a lung nodule, and evaluating brain perfusion on CT, are all accessible through the new release. Vitrea Web supports integration with PACS and the electronic medical record through a standard URL interface and is optimized for low-bandwidth connections so that it will perform well when accessed remotely from home. www.vitalimages.com

Women’s Ultrasound Imaging Applications and Transducer Toshiba America Medical Systems, Tustin, Calif, demonstrated a new proprietary ultrasound technique at RSNA called MicroPureTM, which helps physicians detect breast lesions and microcalcifications more easily. The company also showcased its new 18-MHz, high-resolution Dynamic Micro Slice transducer for imaging superficial structures and identifying lesions; its spatiotemporal image correlation gating technique for fetal heart assessment; and ElastoQ, a work in progress that evaluates tumors based on their stiffness or elasticity. www.medical.toshiba.com 48 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

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Affiliated Professional Services (800) 841-5200 www.affilprof.net ....................................11 American College of Radiology (703) 648-8936 www.acr.org ..........................................27 AMICAS (800) 490-8465 www.amicas.com ......................................3 Codonics (800) 444-1198 www.codonics.com ..................................17 Compressus (202) 742-4297 www.compressus.com ..............................19 Franklin & Seidelmann (866) 437-7237 www.franklin-seidelmann.com ..................45 FUJIFILM Medical Systems (800) 431-1850 www.fujimed.com ....................................5 GE Healthcare (800) 886-0815 www.gehealthcare.com ............................52 Hitachi Medical Systems America (800) 800-3106 www.hitachimed.com ................................2 Imaging Center Institute (714) 832-6400 www.imagingcenterinstitute.com ..............49 Imaging On Call (888) 647-5979 www.imagingoncall.net............................41 Medical Imaging Specialists (800) 510-0680 www.medicalimagingspecialists.com............9 NightHawk Radiology Services (866) 400-4295 www.nighthawkrad.net ............................51 Philips Healthcare www.philips.com/healthcare ......................7 SIIM (703) 723-0432 www.siimweb.org ....................................31 Telerays (866) 972-9362 www.telerays.com ..................................43 Visage Imaging (888) 338-4724 www.visageimaging.com ..........................13

W I

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why i read radiology business journal

the radiologist Richard A. Jensen, MD • Immediate Past President and Partner since 1998, Radiology Associates of Tarrant County, a 57-person practice in Fort Worth, Texas • BS Chemistry, Baylor University, Waco, Texas, Magna Cum Laude, 1984 • MD, University of Texas Southwestern Medical School, Dallas, 1992 • Radiology Residency, Parkland Hospital, Dallas, 1993 • MRI Fellowship, Baylor University Medical Center • Affiliations: ACR, Texas Medical Association, Tarrant County Medical Association, Society of Magnetic Resonance Imaging • Honors: Phi Beta Kappa, National Merit Scholar • Personal Fact: Father of four daughters, two in college, one in high school, and one in middle school

“I think a publication like Radiology Business Journal is long overdue— and timely. It brings a new level of analysis of the economic issues and market forces facing our profession, together with a depth of coverage of important events, both of which were often lacking in the past.

“In my opinion, it’s now the single best resource for the business of radiology, and if anyone wants to get up to speed on the problems and opportunities facing us, I can think of no better place to start than the Radiology Business Journal.”

you too can receive radiology business journal subscribe online today at www.radbizjournal.com

FinalREAD

Highly Functional Imaging Great leadership will distinguish winning imaging organizations from those that struggle

I

By Curtis Kauffman-Pickelle

recently facilitated an all-day retreat for the management staff of a large hospital outpatient division that is part of a wellrespected academic medical center. As I have done on many similar occasions, I asked the group’s members, prior to the meeting, to outline their respective issues and concerns so that we might spend the day working toward alignment around a common vision for future success. It is always a revealing process.

creation of a corporate culture based on accountability, mutual respect, accessibility, service, trust, and communication is perhaps the most significant accomplishment for which any leader can strive. This is especially true in today’s medical imaging profession.

As we worked through the discussion at the retreat, I was fascinated, as I always am, at the assembled group’s ability to grasp the urgent need to find new ways of developing a sense of community and teamwork. In these

The competitive landscape is brutal, and the demands for accountability and efficacy are unrelenting. It is not a profession for the faint of heart.

One thing that became very clear early in the group discussion, in this particular case, was the need to work through the fact that most large integrated health care systems (this one included) have evolved along functional lines in the delivery of care. That is, each department within the typical organization becomes its own functional silo.

Critical to the alignment of these silos is the building of cross-functional teamwork around a common purpose. It’s often easier said than done, and that’s why many organizations opt to have someone help them identify methods of communication that can transcend parochial interests, lest they become codified into protected turf and isolated cultures.

Building a common culture based on mutual understanding of the vision and mission is one area in today’s medical imaging practices, departments, and centers where I believe that I can help the enterprise compete more effectively in an unforgiving market. The

types of settings, the best and the brightest reach out to other departments and segments of the organization as a means of connecting and rising above traditional roles and preconceptions.

The technical staff often feels isolated and disconnected from the business office and administrative staff. The radiologists typically don’t connect with the line staff to help them understand the necessity of the clinical protocols that they develop. Marketers are often at odds with the operations staff and feel that hard-earned referrals are taken for granted and service issues are not taken seriously. Likewise, the operations staff frequently thinks that marketers are constantly making them look bad by bringing bad news from the referring physicians’ offices.

Linking these functional departments through leadership is not easy, but I believe that it will be among the most important elements of a manager’s job description in the future. Whether that manager is running a

50 RADIOLOGY BUSINESS JOURNAL | February/March 2009 | www.radbizjournal.com

private-practice radiology group, a hospital radiology department, an imaging center, or a group of centers, the challenges will be similar in each setting.

The ability to bring this disparate (and often suspicious) group of department heads together frequently—teaching them to communicate more effectively and helping them focus on the battles that need to be fought outside the organization (with competitors, regulators, payors, and others)—is the better part of leadership that will separate tomorrow’s winning imaging organizations from those that will continue to struggle, or will even disappear.

I remain encouraged by the talent, commitment, and level of understanding among the majority of our profession’s front-line managers and leaders. Ours is a profession under siege: a part of the health care delivery system that is fast becoming the bad guy in the eyes and minds of legislators and regulators. The competitive landscape is brutal, and the demands for accountability and efficacy are unrelenting. It is not a profession for the faint of heart. Nevertheless, I see pockets of excellence and examples of leadership that are redefining medical imaging leadership unfolding each day around the country.

As with this most recent day spent with a talented group, it is gratifying for me to be a part of shaping the model that will constitute tomorrow’s successful medical imaging practice, and to nurture leadership focused on good, solid business practices that are built on community and through communication.

Curtis Kauffman-Pickelle is the publisher of Radiology Business Journal and is the CEO of The Imaging Center Institute, Tustin, Calif; ckp@imagingbiz.com.

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