David Fuhriman, MBA

In this series, 10 Questions, we ask the same questions to a diverse group of professionals who work in medical imaging. Taking a cue from Twitter, we’ve limited each respondent’s answers to 140 characters.

1. Please state your name, title and the organization you work for.

Tessa Cook, cardiovascular imaging fellow, Hospital of the University of Pennsylvania

Great mentors, hard work, luck, being in the right place at the right time and being willing to try new things.

It's service-oriented, visual, innovative and never boring.

Some combination of clinical work, research, teaching, meetings - They are never "average" weeks!

5. Where do you think radiology is going?

New modalities, integrated practice, restoration of the role of the radiologist as consultant.

6. What one thing would make your job better?

Let's stop talking about how the sky is falling and start focusing on all the amazing resources we've got to fix the problem!

7. What is your favorite thing about radiology?

Just one? It's collaborative. There's always something new and exciting. The potential for innovation is immense.

8. What is your least favorite thing about radiology?

We are the easy scapegoat. Sometimes we focus too much on that and spend time complaining when we could be innovating.

9. What book would you recommend to other professionals in radiology?

One that a colleague recommends. See the world through another's eyes - learn something about them, foster congeniality and collaboration.

10. If you could give the radiology industry one piece of advice, what would it be?

Keep calm and carry on, but don't be afraid of disruptive change. It's an opportunity, not a threat.

. If you would like to be considered for the series, please contact him at 

10 Questions with Eliot Siegel, MD, FACR, FSIIM

10 Questions with Richard Duszak, MD, FACR

10 Questions with Lawrence R. Muroff, MD, FACR

10 Questions with Paul H. Ellenbogen, MD, FACR

10 Questions with Geraldine McGinty, MD, MBA

Articles

10 Questions with Tessa Cook, MD, PhD

Here, we profiled Richard Duszak, MD, FACR.

It's not in my DNA to say “no” to interesting opportunities, and medical imaging abounds with great opportunities!

Radiology's technologic and scientific growth has made it so exciting as both a clinician and health services researcher.

My two half-time jobs (HPI and practice) are both really full-time jobs, so 80+ hours over 7 days is the norm.

Medical imaging will continue to have a huge impact on patient care. What's still unclear is who will be calling the shots.

 as the model of practice, demonstrating our value would be much easier.

It's at the leading edge of both clinical care and payment reform - the two places where I spend most of my time.

Everyone thinks that imaging is a problem, rather than a solution and opportunity - including many folks who don't know much about imaging!

Anything about disruption or leadership. Both get to the core of radiology's and radiologists' role in evolving healthcare delivery systems.

A radiologist's value lies not in a report, but in meaningful and actionable information that improves patient care. They're very different.

For the 10 Questions series, we spoke with Richard Duszak, MD, FACR, about his job and the future of radiology.

Here, we profiled Safwan Halabi, MD, a radiologist with Henry Ford Health System in Detroit.

Safwan Halabi, MD, Director of Imaging Informatics, Henry Ford Hospital

I experienced the transition to PACS and speech recognition systems and wanted to be on the front lines of the health IT revolution.

Medical imaging plays a vital role in every aspect of medical practice. The advancements in radiology were extremely appealing.

50 hours/week clinical work at hospital. 10-20 hours of clinical teleradiology from home. 5-10 hours/week administrative and IT meetings.

Radiology is redefining its role in medicine by branching out to directly communicate to the patient/health consumer.

Better communication (person-to-person) with referring providers and patients

The culture to improve safety and quality through innovation

Overutilization of medical imaging by way of financial incentives (self-referral) and defensive medical practices

Switch: How to Change Things When Change Is Hard

"First, do no harm." It may be better not to do something, or even to do nothing, than to risk causing more harm than good.

If you would like to be considered for the series, please contact David Fuhriman at 

For the 10 Questions series, we spoke with Safwan Halabi, MD, about his job and the future of radiology.

10 Questions with Safwan Halabi, MD

This is the third part in a series analyzing the results of a survey conducted on Diagnostic Imaging regarding use of business analytics in radiology. 

 Click on each chart to explore the interactive data.

What prevents you from improving your business analytics? Please rank in importance.

1. I don’t want to pay high software and implementation costs -2.396
2. I expect my current vendors to provide better reporting; and I want it for free - 2.458
3. I do not have the internal resources to implement and manage business analytics -2.750
4. I expect my current vendors to provide better reporting, but I am willing to pay extra - 2.771
5. I don’t think business analytics can help me in my business - 4.583

The first place to start on this question is the worst performing answer (orange): I don’t think business analytics can help me in my business. It earned an average ranking of 4.583. It was ranked number five 77percent of the time. The response is clear that a vast majority of respondents feel that business analytics can help them in their business.

The rest of the answers divide up the reasons behind not making an investment in analytics. At the core are two things that prevent improving business analytics: return on investment and distribution channel. To compare the remaining answers in the chart below, I removed the last place answer to see how the others compare.

Let’s address first the question of distribution channel. There is a sense in radiology and perhaps health care in general that lack of business analytics is a failure of the existing vendors.

Can existing software and service vendors provide better reporting? Yes, they can, and should. Does this mean that they should provide business analytics? The answer is it depends - but I have my doubts. Business analytics can answer questions like why are things happening, if the trends continue what will happen next (that is, predict), and what is the best that can happen (that is, optimize). This goes beyond just improving reports out of existing systems.

The second highest rating and almost tied for first place is (purple): I expect my current vendors to provide better reporting; and I want it for free. In fourth place (red): I expect my current vendors to provide better reporting, but I am willing to pay extra. It should come as no surprise that free ranks higher than paying extra.

Buying through an existing vendor has a lot of benefits. Sales costs are lower, which can reduce the costs significantly. There is already a relationship, which can increase odds of success. Data structure and content is already known and understood, which will lead to the lower implementation costs. Not to mention you won’t have another vendor relationship to manage.

Buying business analytics through an existing vendor doesn’t come without its own risks, because it isn’t their main business line. It could be like getting a haircut from a pet groomer. They may have all the equipment and they know how to cut hair, but don’t be surprised when you come out looking like a poodle.

This brings us to the next issue, which is return on investment. This ROI risk is why the No. 1 reason for not improving analytics is (green): not wanting to pay high software and implementation costs. Implicit in the reasons preventing respondents from improving business analytics is the risk that the costs exceed the benefit. Fantastic if the insights improve profits $200,000 a year. Not worth it if the costs to gain that insight are $225,000 a year. Value equals quality plus cost. We recognize that business analytics can help - but quality can only be measured after the costs are paid, so value isn’t clear in the beginning.

Another ROI risk is in third place (blue): I do not have the internal resources to implement and manage business analytics. The interesting result from this answer is how flatly it was ranked. It is an underlying concern for everyone. The respondents understand consistently the technical and business specialty needed to provide true insight to make sure that there is a good return on the expenditure.

The results of this survey indicate that there is a great opportunity to take advantage of business analytics in radiology. There is a need for better reporting from clinical and financial systems. Many people believe that they can use their data to improve their operations. Even though there are risks and concerns, the future looks very bright.

What prevents radiology groups from improving business analytics? The final part of our survey analysis explores the barriers.

Barriers to Improving Business Analytics in Radiology

In Part 2 in a series analyzing the results of a recent business analytics survey, I’ll review what respondents would do with better analytics. 

 covered satisfaction with reporting practices. 

(Click on the chart to explore interactive data)

Please rank the items in importance on how you will do more with less, amid declining reimbursements.

• Modify workflow efficiencies to maximize capacity -2.063
• Increase reading radiologists’ productivity -2.854
• Reduce Operation Costs -2.875
• Generate more volume through marketing-3.583
• Improve billing to maximize collections- 3.646

The clear winner is modifying workflow to maximize capacity, with an average rank of 2.063. You can see in the chart how often workflow capacity was ranked as ranked No. 1 or No. 2. As a largely fixed cost business, being able to push more volume through the existing infrastructure would mean improvement directly to the bottom line.

Bundled together in Nos. 2 and 3, but with very different trends, are increasing radiologist productivity and reducing operational costs at 2.854 and 2.875, respectively.

Improving reading radiologist productivity is interesting, because it is ranked highly as one and two (in green) but then has a spike in those that rank it No. 5. Those who ranked it high see the value in reading more cases. This offsets the declining reimbursements or can raise income. But those ranking it as five have probably implemented productivity enhancing processes and don’t see additional productivity that can be squeezed. Others are probably ranking it high to combat the sweatshop attitude, seeing that there are other ways to improve then just chaining a radiologist to the desk.

Reducing operational costs, while close in the average ranking to increasing productivity, has a very different trend. It derives most of its ranking from a strong No. 1 and a very high No. 3 spot and trailing off in four and five. While many may be divided among what should be the top two items, reducing operational costs is very strong at No. 3.

Coming in at a close finish for fourth and fifth places at 3.583 and 3.646 is generating more volume through marketing and improving billing to maximize collections. Notice how the things that are perceived to be more in control within your organization are ranked higher and the things that are influenced by external factors, such as referring physician and payers are ranked lower? We value the things that we feel we can control.

Generating more volume through marketing is s relatively flat response. It loses out in third place, because reducing operational costs does so well. But it has a good showing even in first and second place. I think this is because focusing on marketing has a lot of implications. Getting more volume through marketing is only beneficial if you have the capacity in facilities and in reading radiologist. Those that have the capacity will tend to rank it high, while others see so much more value in other areas.

Coming in at last place is improving billing to maximize collections. This ranking is due primarily to its horrible performance in first and second place; very few people ranked it so high. I attribute this primarily to the gains that have been made in billing in recent years and to the sense that problems with reimbursement lay in large part with struggles with payers.

In the third and final part, I will cover why respondents do not invest in business analytics.

How do radiologists do more with less amid declining reimbursements? Check out Part 2 of the results of our business analytics survey.

How Radiologists Are Doing More with Less

This is the first part in a series analyzing the results of a survey conducted on Diagnostic Imaging regarding use of business analytics in radiology. Part I covers responses on satisfaction with current reporting practices.

Are you satisfied with your ability to analyze data from PACS or RIS?

17% - No, I am virtually unable to get data out of their system.

70% - No, I can generate some reports, but the process is manual and time consuming

9% - Yes, analyzing data is easy, I can generate anything I need

2% - Yes, I have real-time, on-demand analytics

Are you satisfied with the reporting from your billing department or billing company?

34% - No, I have very little insight in billing data

30% - No, I receive a reporting package, but it does not provide me enough insight

15% - Yes, billing provides periodic reporting that provides me everything I need

4% - Yes, I have real-time, on-demand analytics

The first surprise for me is how many are not satisfied with their current reporting. Eight-seven percent are not satisfied with their RIS or PACS reporting and64 percent are not satisfied with their billing reporting. (The billing figure rises to 77 percent after excluding not applicable responses from the results) I should have expected that so many people find reporting and access to data so difficult, as it has been a hot topic at recent conferences I have attended for AHRA, RBMA and at RSNA.

Additional interesting findings come from looking closer at those who seem dissatisfied with reporting from their RIS/PACS. Seventy percent are able to get some data from RIS/PACS, but it is time consuming. Based on many personal conversations I have had, I interpret this to mean that nearly three-fourths of RIS/PACS have at least an ability to export data to Excel, where it has to be manipulated to make the data meaningful. Seventeen percent are unable to get virtually any insight, which probably means their software offers no reporting or export capabilities.

Compare the RIS/PACS answers to the responses from billing, where 34 percent get virtually no insight from their billing department or company. In coming to a conclusion on this 34 percent who get very little insight, let’s exclude the assumption that their role would not benefit from billing data - those are represented in the “not applicable” answer (17 percent) One-third of respondent then are getting virtually zero insight from billing.

I interpret this high percentage of respondents who are getting virtually zero insight as a combination of a failure of billing systems and internal politics restricting the information.T he 30 percent who do get a billing package, but that does not meet their needs, likely means that the billing systems are designed to capture the transactions - as do the RIS/PACS - but do a poor job of opening up the data for analysis.

In the second part, I will cover why respondents do not invest in business analytics and how they could utilize better insight from the analytics.

David Fuhriman, MBA, CPA, is CEO of Bern Medical

A majority of radiologists aren’t satisfied with their RIS/ PACS or billing reporting, our recent survey on business analytics found.

Many Not Satisfied with Business Analytics Reporting

Business analytics can provide insights for radiology groups. With this four-question survey, I want to find any bottlenecks in collecting and analyzing the data. I'll write up a summary here after the survey closes.

 with SurveyMonkey, the world's leading questionnaire tool.

. Bern provides dashboard reporting to iPad/iPhone, billing audits, and other data analysis services.

This four-question survey aims to gather information about radiologists’ views about and obstacles to collecting and analyzing operational data.

Radiology Business Analytics Survey

I recently attended a great session put on by the AHRA on the future of economics in San Diego, Calif., as well as several sessions at the RBMA’s Fall Education Conference in Arizona. The underlying themes were that with financial constraints on the health system, everyone will have to do more with less. Best of breed data analytics will enable us to do more with less, without comprising quality.

We need real-time metrics that provide us with actionable information. We need to marry clinical and financial data. We need to push data to radiologists, technicians, marketers, and billing. We need to use data like other industries are using them. Fast food restaurants, retail, and professional sports all use data better than health care. Some industries live or die by their use of data, such as Internet based companies, financial services and insurance companies.

There is a quality in the tools and in the analysis. We accept that one radiologist can be better than another at interpreting images, even after identical and lengthy schooling and experience. All analytic tools are not equal and all analysts are not equal.

Just because you have reporting or dashboards does not mean that you have a quality tool. Perhaps the most important measurement of a tool is based on what kind of data is available to the tool. Are you analyzing clinical or financial data? Are you able to view various fields, like cash collected by referring physician and turnaround time? Can you visualize the data to tell a story? Can you distribute the reports to the right people? Is the data timely? Can someone manipulate the data before distribution? Or worse, is someone forced to manipulate the data in order to distribute?

Deciding which reports to create and how to interpret the results is a more subtle skill. To demonstrate this, let me show you how to lie using statistics. I can show you how to factually represent underlying data - while simultaneously distorting the meaning. The sample is based on Ascombe’s quartet, four datasets that are identical statistically, but appear very different when viewed graphically.

It is important that they are identical statistically, because this is how you could predict what the next point in the series would be. The trend in the data would suggest a new point along the blue line, even though looking at the existing points, any new point would probably not fall on the line.

Let me give you a quick overview of the chart below. The dots below represent an occurrence of some activity. Let’s assume the x axis (on the bottom) represent months. The y axis (on the left) represents the number of referrals from one physician, by modality during those months. You can see from the trend that it is up and to the right. This is the trend that of course you would like to see from all your referring physicians.



Set 1 - There is some unexplained variation, but with a trend up and to the right. You could see this type of pattern on a month-to-month basis.

How to misrepresent the data: If you are presenting for a high performing month highlight the increase on a month-over-month basis. Ignore the overall trends and focus on the unexplained variance - but create a narrative to support - such as the dinner or golf outing. (For marketers make sure to take credit for months when there is an increase.) If you are presenting for a down month make sure to only show the increase over the first period and year-to date totals, this will hide the unexplained drops.

Set 2 - Here we see a pattern of rising referrals that peak and drop off.

How to misrepresent the data: Make sure that you ignore the drop off and focus on the percentage increase from the beginning of the year. Maybe even group each month into a quarter or most recent three months. The main goal here is to mask the downward trend.

Set 3 – This shows very consistent increasing referrals, with large variance seen in the one month, only to revert back to previous trend.

How to misrepresent the data: Use the aberration to project higher referrals in the future. When an outlier like this occurs, take credit for the increase. Shine a large spotlight on it. Hide the decrease in the following month by just showing year-to-date amounts.

Set 4 - In this set, there is nothing in the beginning, a lot of various modalities referred in one month, nothing for several months, and then a high level of referrals months later.

How to misrepresent the data: You can use all the same tricks as from Sets 2 and 3. The key, however, with this data is to act like it doesn’t exist at all. Lump it in to “other” or exclude it as an outlier.

Doing more with less requires doing better with what you already have. You have a lot of data. Hidden inside the data are the efficiencies that you need for better financial margins. Make sure that you are getting the right data, with the right tools and right analysis.

Interpreting practice data is a subtle skill, and it’s easy to lie using statistics. You must make sure you’re getting the right data and the right analysis.

How the Right Operations Data Leads to the Wrong Analysis

Do you remember the 100 meter finals from the 2008 Olympics? Usain Bolt was so far ahead of all the other runners that he started celebrating before he crossed the finish line and still set the world record. It was an inspiring moment, shown around the world. Many, myself included, looked forward to the 100 meter for the 2012 Olympics in London.

This year Usain Bolt again won the 100m, but the other runners were much closer to him. Look at the times of the finals (below). Pay special attention to the 2012 times of the runners who did not win a medal. The fourth and fifth places from 2012 with times of 9.80 and 9.88, respectively, would have won silver and bronze in the 2008 Olympics.

Now look at the silver, bronze and fourth place times from 2012. Refer back to the 2004 Finals in the 100 meter to get a perspective of how good these times are. Any of these times would have taken gold in the 2004 Olympics. I feel for Tyson Gay, who ran a great time in 2012, but goes home without a medal in the 100 meter. He would have won gold in 2004 and silver in 2008 with the time he ran in 2012.
 

What is the main driver in the performance improvements in the 100 meter? It is the raising of the benchmark by Usain Bolt in 2008. All the other runners knew that they had to improve dramatically to have a chance of beating Bolt. With the new benchmark they worked and they measured their performance. They improved and they are running now running faster than 2004 and 2008.

The runners measured performance each step of the way. The kept track of variables to measure the impact on performance, like what they ate, their sleeping patterns, their weight and the weather. They measured and tracked performance, like weights lifted, repetitions, track times, steps taken, length of stride, and many more. They received immediate feedback on their performance, which helped them focus on the results.

How would the athletes have performed had they not tracked the variables and their performance, or did not have a benchmark? What if they trained on intuition? What if they received their track and weight lifting numbers on a quarterly basis? What if they did not track calories or what they ate at all? Their performance would not be as high as it is.

In radiology we should be pushing the bounds of performance. We should track more variables, have challenging benchmarks, and get immediate feedback on performance. We can learn from the Olympic athletes and push the bounds of performance.

Of course things are getting better. It is easy to look back and see improvements over your career. But, the gold medalist in 1896 in the 100m ran a time of 12.0. When we set benchmarks or expectations too much on historical performance, we will always be behind. Running 11.9 in 1896 would have won you gold, but not today. It is still a world-class time, but it isn’t enough.

With all the challenges and concerns in radiology, such as declining reimbursements and commoditization, improving performance is crucial.

, where he analyzes radiology data to discover under-billings.

Usain Bolt raised the bar for the 100 meter four years ago, so his challengers had to improve by measuring performance at every step. So should radiologists.

What Radiology Can Learn from 2012 Olympics

Early in my career, I was doing some accounting consulting work for a group that had recently purchased a telecom company. Nobody from the original accounting department was left, and it was a mess. I mean a complete mess.

There were a lot of problems with their customers in trying to figure out which invoices had already been paid and which were outstanding. To make matters worse, for the first three months the company ran on Excel until it could implement its own systems. During that time, the business kept working, of course. It was like trying to change the tires on a car while driving down the freeway.

I remember sitting down and trying to figure out what insurances had been paid, what was still owed, and if any amounts had been overpaid. Armed with stacks of invoices, cancelled checks, and spreadsheets calculating the expenses, I started to get to the bottom of the balances.

At one point I had everything figured out to within $0.45. Getting to that point was relatively straightforward, but finding where less than one dollar was took a couple of hours. At that time, early in my career, it seemed ridiculous to pay my hourly rate to find less than one dollar. It seemed that a better strategy was to just write it off (ignore it) and move on to seemingly more important things.

Turns out, what I discovered was that I wasn't as close as I thought. The Excel models had errors in them and the insurance bills were incorrect. So there were a few different errors going in opposite directions - what the client should have paid versus what they did pay. I finally resolved the errors and made sure that everything was accurate and complete.

In accounting, it is important that data and reports be complete, accurate, and timely. It is an essential part running a successful business - and a critical part of the revenue cycle in diagnostic imaging. The main purpose of policies and procedures is to capture complete and accurate information and process it in a timely manner.

Think of how the information is processed in your organization. Know that regardless of all the improvements that have been made in the past, there is always room for improvement, and there always will be more.

Over time each step of the process will contain errors. Perfection is impossible. Not every procedure will be charged. Wrong codes will be used, leading to lower reimbursement or rejections.

Employee turnover and lack of training can cause some of these errors. But want to know the largest cause? We are human. Did you know experienced radiologists make mistakes too? After all that education, continuing education, better tools and even decades of experience they can make mistakes. Best to accept them and go about trying to fix them. New mistakes will be made, which is why the best policy is continuous improvement. Automation and technology can reduce some failures, but these can fail too. Servers crash, networks and hardware fail, interfaces can be set up incorrectly. The list could go on.

So how does a company make things better? Six Sigma has a framework that is helpful to improve any process. The acronym is DMAIC: Define, Measure, Analyze, Improve, and Control. There are a lot of tools and documents that have been developed to help in this process. If they are helpful, then by all means use them. I find that the framework is a sufficient guide on what to do. It can be summarized thus: Find out what could be better. Make sure you can measure what is happening, and then measure it. Figure out how to improve it and then improve it. Then check the measurements to make sure that it is better. 

The steps that are usually done incorrectly in DMAIC are measuring both before and after any changes are made. I am not sure which is worse, not measuring at all or measuring the wrong metric. Both have problems. In my example above about reconciling insurance costs, the metric was not getting to zero differences between what should be paid versus what was paid. The real metric was having everything correct. I could have "plugged" or hidden the $0.45, because it was insignificant. If my metric was getting to zero, then I would have apparent success.

The only thing that you can be sure of is that some portion of your data and processes are incomplete, inaccurate and delayed. Don't worry, it will never be perfect. And never believe anyone who tells you otherwise.

 where he analyzes radiology data to discover under-billings.

It's important that data and reports be complete, accurate, and timely. It's an essential part running a successful business and a critical part of the revenue cycle in diagnostic imaging.