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• 16 tips for improving your practice

• Recommendations can help radiology practices win the games that payers play

• Practical solutions begin with forming a strategic plan

Boom times don't necessarily mean good times for radiologists. The demand for medical imaging stimulated by an expanding spiral of clinical applications has never been higher, but these high volumes present problems for understaffed practices. Referring physicians expect to be able to order any exam any time, and want prompt turnaround on reports. Radiologists find they are working harder than ever to keep up.

For some, early retirement made possible by a strong economy is proving more attractive than the process of changing life-long habits. When the practices they leave behind try to replace them, that same economy with its accompanying hot job market makes replacements tough to find, much less recruit. It's all most groups can do simply to maintain existing business.

"Every radiology group we're working with is understaffed and having a difficult time. The recruiting environment is dismal," said Scott Raymond, vice president of AGI Healthcare Consulting in Carlsbad, CA. "Economic, operational, and practice factors combined are putting the thumbscrews on radiologists. It isn't even an issue of making more money. It's quality of life."

This state of affairs also puts stress on the relationship between radiologists and hospitals. From the hospital perspective, productivity and staffing are the practice's problems. What counts is performance: efficient operations and happy referring physicians.

That track record counts when hospitals, prompted by new payment rules, such as ambulatory payment classifications (APCs) and hospital outpatient prospective payment (HOPPS), go looking for joint-venture partners.

"You've got hospitals saying, 'I'm not sure I want this group as a partner because it can't even provide the existing service that we expect,'" Raymond said.

What steps can radiologists take to improve their practices, increase efficiency, and grow their business? To find out, Diagnostic Imaging queried consultants, physicians, business managers, and administrators about their experiences working with and among private practices, imaging centers, and radiology departments.

The resulting tips target nearly every aspect of practice, from recruiting new partners to identifying and integrating PACS and information technology solutions, making better use of clinical time, and taking advantage of common communications tools like pagers and e-mail. Some require long-term planning or rethinking of the way critical decisions are made. Others can be adopted right away.

1. Accentuate the clinical

Evaluate how radiologists in the practice spend their day. How much time is spent reading films and consulting, and how much is wasted editing reports, hanging films, and performing other nonclinical tasks?

"When we do a productivity analysis, it stems from the belief that radiologists ought to do radiology, technologists ought to do technologist tasks, and support folks do everything else," Raymond said. "Considering that a radiologist's reason for being is to provide a safe and accurate diagnosis, what is he or she doing during the day that does not contribute to that goal? How can the process be restructured so that nonclinical tasks are more streamlined?"

Consider hiring an additional support person to relieve radiologists of nonclinical tasks. Here's justification: If each physician in a 10-member radiology group spends an hour a day on nonclinical tasks, over a year that becomes equivalent to another full-time radiologist. Compare the average radiologist's salary of $300,000 with the cost of hiring a professional assistant at $50,000, and the value of incremental time savings becomes clear.

2. Minimize reading room disruption

Whether it's consults, questions, requests for films, or clarifications on reports, radiologists are constantly interrupted in the reading room, where finding a rhythm and routine to interpretation is an important part of productivity. Some interruptions are unavoidable but many involve noncritical issues that can be dealt with later or even handled by someone else.

A simple tool such as e-mail can play a big part in streamlining reading room operations. A radiologist can choose a time to respond to e-mail on administrative issues, instead of being interrupted, and review e-mail requests for consults while taking a break.

E-mail allows the radiologist to decide what sorts of requests require an immediate response, permitting better use of time. That's a lot more control than answering every page, phone call, and knock at the reading room door.

"Some interruptions don't have anything to do with medicine or aren't relevant to that radiologist's subspecialty," Raymond said. "With e-mail, those can be triaged to the right person, at the right level in the operation: a technologist, support person, or another radiologist. The ability to get into a groove while reading an exam and know you are not going to be interrupted every five minutes is going to result in more exams being read."

3. Designate a "go-to" radiologist

Relatively low-tech tools such as pagers and cell phones can be put to use in making the radiologist's time more efficient while at the hospital.

Requests for call reports and consults are an important service any practice provides, for example, but it's not unusual for a radiologist to sit on hold waiting for staff to track down the referring physician with a query.

Some groups set up a paging system for call reports, with a single number made available to referring physicians and their offices. When a consult is requested, a page is sent, and an administrative staffer from the radiology group triages the request for the radiologists.

Alternatively, groups can designate a "go-to" radiologist who wears the dedicated consult pager. That person is going to be less productive, but the system frees up others from being bothered.

"It's just recognized under that scenario that the particular rotation on that day is not going to be as productive," Raymond said. "But it's better than having 10 physicians being interrupted all the time."

4. Evaluate reading room ergonomics

In addition to assessing how radiologists use their time, it's also important to evaluate the room in which they spend most of that time.

The "silent killer" of efficiency is dysfunctional space planning, according to Kenneth Johnson, president of Kenneth Johnson and Associates, a radiology and managed-care consulting firm in Columbus, OH.

"Lighting, the height of standing counters, window location, and phone placement can all have a phenomenal impact on the ability to function efficiently, as well as affecting the quality of care you're providing," Johnson said.

For soft-copy reading especially, the need to create reading rooms that provide the best possible ergonomics is often overlooked, according to Cynthia E. Keen, a PACS consultant with i.t. Communications in Sanibel, FL.

"Spot lighting in the ceiling, for example, should illuminate a dictation system or provide the ability to read papers that might accompany the soft-copy image, without creating a glare on somebody else's monitor," she said.

Other tips: If a workstation cart is to be used, make sure it's designed for ultraheavy 2K monitors; such carts may cost four times as much as less sturdy models. Invest in chairs appropriate for soft-copy reading.

"Often you're going to need more space for soft-copy reading than you did for film," Keen said. "If you're dealing with an RIS terminal and, potentially, a voice recognition system as well as a workstation, you don't want keyboards to go crashing to the floor. Spend money to create a real reading room to maximize your investment."

5. Boost throughput with standardized tools

Cross-training technologists to perform scans on both CT and MRI equipment can increase productivity and throughput. Standardized user interfaces on emerging technologies can make the learning curve a little less steep.

At Shannon Medical Center in Shannon, TX, use of Siemens Medical Systems' Syngo system has made such cross-training easier, according to Maribel Rois, director of radiology. The hospital has a year's worth of experience using Syngo, which was introduced at the 1999 RSNA meeting and is a standards-based common software for CT, MRI, nuclear medicine, and PACS workstations.

First installed in conjunction with a new Siemens CT scanner, the Syngo system was put to use by the department with its MRI unit in June. There it has contributed to increased MRI throughput. During an eight-hour day, the department is able to scan 15 or 16 patients, or one every 30 minutes. Prior to the installation of Syngo, scanning that many patients would have taken up to 13 hours, Rois said. The system was easy for the Windows-literate technologists to learn, and the intuitive interface has made cross-training easier.

"We have two techs who do not have any MRI experience, only CT," she said. "We're going to be training them in a whole new modality, which is something we would not have been able to do before."

6. Revise scanning protocols

When it comes to scanning itself, judicious use of protocols may increase utilization and throughput for some types of exams. At Beth Israel Deaconess Medical Center in Boston, adoption of a scan-and-go protocol for elective CT studies resulted in a 43% increase in study volume and eliminated a scheduling backlog, without adversely affecting patient care.

Prior to implementation, radiologists monitored every CT study. Under the new policy, radiologists select from among 30 body CT protocols in advance, based on clinical indications. The protocols include parameters such as injection volume, contrast, injection rate, scan delay, and filming. Technologists review each exam at the scanner and perform four monitoring checks of each study. Attending radiologists, assisted by residents and fellows, completely review accumulated CT studies twice daily. Only five out of more than 4000 patients scanned during the first six months of the new policy had to return due to an inadequate exam.

Instead of a 10-day scheduling backlog, CT scans are performed within 24 hours of scheduling, according to Dr. Kevin Reynolds, an assistant professor of radiology.

The increase in study volume is achieved through savings in scanning time. Average study time declined from 19.5 minutes before the policy to 12.5 minutes after. The seven-minute decrease permitted a 43% increase in study volume, from 2853 exams in the six months prior to the policy to 4089 in the six months afterward, without a concurrent increase in technologists or scanners.

7. Make the most of your Web site

While not all practices are equipped to launch a full-fledged Internet initiative, it's easy to establish a presence with a Web site. Consider using the site as a way to collect administrative information in advance to save time when patients arrive for scheduled appointments.

Patients can be directed to the site for preregistration, according to Karen Zupko, president of Karen Zupko & Associates of Chicago. If the practice lacks the infrastructure for Web-based submissions, patients can download the form, fill it out, and fax it back to the office.

For patients without Internet access, administrative staff can mail or fax the forms to patients. Preregistering patients via the Internet saves time and money, while allowing practices to collect insurance data and other pertinent information with little effort.

For Summit Radiology, a 24-physician practice in Indianapolis, the group's Web site serves as a marketing and communications tool for referring physicians. The site (www.summitradiology.com) highlights specialty procedures performed by radiologists in the group as well as substantial background information. It's geared for referring physicians but is also accessible to curious patients.

"We service seven hospitals over a wide area, and we're finding that for many of the physicians in outlying communities, this is a great way to introduce them to a service," said Jim Bode, Summit's administrator. "If they desire, they can provide that information to patients by printing it out or direct patients to the site directly."

Bode intends to eventually provide a reference to the Web site to patients during the exam scheduling process, but doing so requires collaborating with the hospital, since most of the group's procedures are performed and scheduled there.

"These days, a group of our size would be conspicuous if it didn't have a Web site," he said. "But we wanted to provide more utility than just a boilerplate Web brochure."

8. Choose the right information management tools

In addition to a basic assessment and reorganization of how practices operate on a daily basis, there's no question that new information and image management technologies can help practices become more productive. From radiology information systems to voice recognition, PACS, and ASPs, a host of tools exist that can bring incremental gains in efficiency and even revenue. But choosing the right ones to implement, and how, can be challenging. Those new tools won't make much of an impact unless they're purchased with a clear goal in mind.

"We do a lot of work on the front end, asking practices what they want to do with PACS, for example," Raymond said. "A PACS is going to have a dramatic impact on operations and finance, and you need to understand what that impact is going to be. Nine times out of 10, when people stub their toes, it's because they didn't do their homework, not because they bought the wrong system."

Even small practices that wouldn't have considered PACS a few years ago are taking another look at the technology today. That's due in part to the fact that PACS are easier to integrate with newer, native DICOM modalities, according to Keen.

"The major vendors have all introduced some small, high-quality systems that can be interfaced with a brand-new modality," she said. "And many vendors are negotiating soft-copy workstations as part of the replacement price of new imaging modalities."

Application service providers (ASPs) represent another reason why smaller practices are reconsidering PACS. Most major vendors now offer an ASP option with their PACS.

"So the potential exists, if a practice works with a particular vendor, to be able to get a miniPACS from that vendor and use an ASP for their archive needs," Keen said.

Whether the goal is going filmless or just investing in new management software, the first step for any practice interested in new technology is to know itself from the perspective of five core elements: personnel, technology, physical space, time, and money, according to Johnson.

"In every practice, there's a balancing act going on between these five elements," he said. "You may be strong in one or two and weak in the rest. These resources need to be assessed in the context of your customers' needs and desires."

Once a practice has a sense of direction, it is in a better position to enter into negotiations with vendors, many of which have developed economic models that help define whether new technologies will provide solutions or pose new problems.

One of the lessons learned in integrating the RIS at the University of Pittsburgh Medical Center was that individual sites have individual needs, and an integrated system may not be as flexible as an interfaced one, according to Victoria Bedel, applications manager for the radiology information system in use at seven linked sites at UPMC. The difference?

"Interface means that you have a stand-alone application that receives and sends information over the system. The system relies on these interfaces to keep it up and running," she said. "Integrated, at first blush, means that once everything is entered, it's present on all levels of the system. All elements should talk to each other and exchange the same information set about a given patient, whether it's the pharmacy, radiology department, or the lab. But it doesn't always work that way."

9. Write an RFP that reflects the practice

UPMC's RIS installation offers a model for others ready to take the RIS/PACS plunge. Critical to the process is writing an RFP for vendors that accurately reflects the real needs of the existing operation and the desired functionality of the future system, Bedel said.

Radiology managers and information technology specialists should collaborate in developing the RFP. In drafting the functional requirements of the desired system, diagram all the steps in patient care from the time the person first walks in the door. Then assess how, under an automated system, those steps will be accomplished if the system is down.

"Take baby steps on functional requirements. Consider them in the context of the flow of your current operations-how patients come and go," she said.

In scoring vendor responses, consider a company's place in the radiology market, and the vendor's level of commitment to research and development. Institute a rigid system for scoring, and accept no substitutes for mission-critical functionality. Vendors with multiple applications "in development" should be able to show their track record for bringing beta products to market, Bedel said.

"For each of the functional components of a given system, we ask whether the system is live today, and if so, where?" she said. "If it's in test, what is the date of the general release? This is where the resources that have been committed to development become most important."

Site visits play a critical role in the vendor evaluation process. The installation you visit should mirror your own setup. Ask users, what are the key strengths and weaknesses of the application? How does the system meet functional requirements?

As part of the package, ask vendors about service contracts: how much and what's covered. Too often, according to Keen, practices skimp on service because of its high cost.

"The happiest practices are those that have found a local computer support company, which is paid to undergo training with the vendor, to supply off-hours service and support," Keen said. "That way the group is covered regardless of when they need service help, often at a cost that's less than the blanket vendor service contract."

10. Ask about ASPs

ASP models for storing and distributing images can make PACS more affordable for small to midsize practices that, in the past, couldn't cost-justify the technology. ASP models based on Web technology are being used to support image storage (temporary or long-term) and distribution (either local or wide area) among diagnostic facilities or between radiologists and referring physicians.

For radiologists, the key benefit of Web-based ASP models is the ability to focus on their core interest-diagnostic image generation and interpretation-while outsourcing nonclinical work such as image storage, retrieval, and distribution. Costs are usually levied on a monthly or transaction basis, or a combination of the two.

Summit Radiology in Indianapolis is one of the first groups in the nation to rely on an ASP for image storage and distribution. The system is linked to the group's Web site, which referring physicians use as a gateway to log in to the ASP central server, maintained by eMed of Lexington, MA.

Summit is initially using the service only for MRI and CT images generated at its three imaging centers, totaling 1500 studies per month, but the group plans to expand to include other modalities and the local hospital radiology department.

"Bringing the hospital-based modalities online poses its own challenges, primarily from a volume perspective," Bode said. "Imaging centers tend to offer more control, and you also have less volume. It's a good place to start in testing this kind of system."

Summit's ASP is geared largely toward referring physician convenience, allowing physicians to pull up nondiagnostic-quality images and reports on standard PCs.

"But if you want to eliminate film and make PACS work at the hospital level, you have to get physicians reading these images on monitors in the OR and other departments," he said. "It's the referral base that needs to be reading these images online."

That observation jibes with one made by consultant Raymond, who reiterates the importance of practices knowing what problem it is they wish their PACS application to solve.

"We get a lot of calls from groups that say they only need us to do the RFP for the PACS they want to buy," he said. "Then we get there and find out that not all of the radiologists are ready to read soft copy. And even if they are, they still plan on printing film because they think 90% of the referring community wants film. Why would you get into archiving and buying workstations if you're going to keep printing film?"

For Summit, the decision to install a PACS with an ASP option was an economic one. The monthly subscription and transaction fee agreement allows the group to offer enhanced services without concerns about equipment obsolescence, software upgrades, and internal support staff, Bode said. Emed assumes responsibility for all equipment requirements, maintenance, and support.

"PACS allows us to move images around the system to more fully utilize staff and to off-load studies to other sites for reading when one site is busy," Bode said. "So from a workflow perspective, it gives us many more options. And now our radiologists can do real-time consultations online."

The group hopes to develop a more directed ASP model to capitalize on the benefits of moving images between sites and radiologists. Summit is trying to determine a way to send all MRI studies to a single radiologist at a given site, for example.

11. Balance the workload

Whether it's an ASP or traditional PACS, practices shouldn't miss the opportunity to develop a workload-sharing plan such as the one at Summit. Many groups invest in costly image management systems, however, without exploring the full range of productivity possibilities.

"Perhaps the biggest beneficiary of workload sharing is the two-or- more-person, midsize radiology group that is providing coverage at several different clinics," Keen said. "If you have to have someone on-site for interventions or to cover ultrasound exams, but maybe they're not being fully utilized, you can send exams to them digitally. With the increase in productivity, the practice might do some marketing to attract additional business, increase its strength in the market, and provide better service to referring physicians."

12. Become a power PACS user

The inherent efficiencies of PACS are within reach of most groups that install the systems. But some find ways to push PACS even harder in terms of productivity.

At the VA Maryland Health System, for example, the impact of a filmless radiology system has increased radiology productivity by 40% and technologist productivity by 25%, according to Dr. Eliot Siegel, director of radiology. One reason is the decreasing number of interruptions for clinical consultations and film retrievals now that referring physicians can access images online.

Purchasing an ample training package from vendors at the outset or negotiating supplemental training beyond the standard package provided is one of the best ways to optimize the investment in a PACS, according to Keen. She contends that there is a direct correlation between well-trained users from the outset of implementation and successful use of PACS.

Supplemental training can help radiologists experienced with soft-copy reading turn into workstation power users.

"Does everyone need to become a power user? Probably not," she said. "But do radiologists reach a point where, if they received a little extra training, they could jump a level in productivity? Absolutely."

13. Implement voice recognition slowly

Voice recognition can be a wonderful tool-for hospitals. Voice recognition allows hospitals to reduce report turnaround times from 12 hours to, in some cases, 20 minutes, with fewer transcription staff.

Voice recognition benefits radiology practices as well. The fact that reports are created on the computer means that they can be paired with collaborative data available on the same system: prior exams, visits, and images. All data work toward the goal of providing patient information that is comprehensive.

Key to reaping these benefits, however, is implementing the technology with the right measure of training, radiologist commitment, and a substantial phase-in period. Otherwise, what could be a great efficiency tool ends up wreaking havoc with radiologists' productivity.

Take the example of the hospital that installed voice recognition systems and promptly fired its transcriptionists, Raymond said. The radiologists were not only dictating reports but also editing them and trying to learn a new technology-that is not without its kinks-at the same time.

"I've seen places where the radiologist was ready to throw the system out the window," he said. "It has to be implemented right. Don't fire your transcriptionists. Perhaps they become editors for a while. Ease into the technology."

14. Address investment opportunities

As important as maximizing clinical time is, it shouldn't come at the expense of critical administrative time. That means designating someone within the group, and alloting the necessary chunk of time, to scope out business opportunities and to meet with potential joint-venture partners.

"If everybody is reading films all the time, then no one is looking at the practice and evaluating communication with the hospital or thinking how to increase exposure among referring physicians," Raymond said.

Practices need to create a structure so that group partners have time, and pay for that time if need be, to perform strategic planning and solidify relationships. Evaluate the strengths and weaknesses of group partners and determine who would be best to perform this diplomatic role in the local healthcare community.

15. Get governed

Restructuring to allow time for strategic planning ties into another oft-overlooked aspect of practice operations that can affect both current and future business: governance.

"All groups need an effective governance structure that allows 80% of the decisions to be made by 20% of the people," Raymond said. "The other 20% of decisions are the key ones that can be made by the entire group."

Because every partner in a practice has a vested financial interest in decision-making, it's not uncommon for even the most trivial issues to be debated by all members of the group. A tentative decision is reached, but then the issue is rehashed the following month. A practice can provide the highest quality service in the local community, but if it can't make effective decisions internally, and exude cohesiveness outwardly with hospitals and payers, the group's long-term business will be affected, Raymond said.

"We're always hearing from administrators or business managers, 'We can't make a decision to save our life,'" he said. "The key to effective decision-making is group governance. It's a huge issue."

16. Recruit like you mean it

Good radiologists are hard to find in a strong economy and hot job market. To lure recruits, practices and departments are offering higher salaries, longer vacations, and shorter working hours, according to Michael Taylor, senior vice president at Cejka and Company, a recruiting firm based in the Midwest.

Typical offerings from practices to new recruits today include two years to partnership with low buy-in (between virtually no investment to five figures), 10 to 13 weeks' vacation, and base compensation of $250,000 in the first year, at least in the Midwest, with potential income averaging $400,000, Taylor said.

"It's a job-seekers' market," he said. "It's just as hard to keep people as it is to recruit new ones. Retention begins with recruiting, which means knowing what you want in a new hire and why you want it."

In talking with candidates, be able to identify what drives your group, the characteristics that make it strong, and any obstacles to future business opportunities that will be overcome, Taylor said.

Groups that have been most successful in recruiting are those that devote time and resources to the task, according to Raymond. Get the whole staff involved in recruiting and go beyond merely placing an ad. Make recruitment an active part of everyone's responsibilities.

When candidates show up on the doorstep, be ready for them, Raymond said. Roll out the red carpet. Provide a tour of the area to a spouse or partner, while the candidate meets with members of the practice.

"But don't try to dress up a duck and make it look like an eagle," Raymond said. "The best recruiting tool you have is to be a strong, cohesive group and to act it and live it."

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