Richard Woodcock, MD

The monthly numbers. All businesses have them. And everyone worries over them. For radiology, everyone wants to see total study numbers, total billed dollars and reimbursement. It’s natural. But it is insufficient.

A few additional pieces will give you and your group much greater clarity about the practice’s health.

• Year to year comparison is essential. We commonly see a drop in reimbursement in January and August, and everyone is alarmed when they compare to the prior month. But when you look year to year, the numbers may actually be up. The numbers are down due to seasonal variation and contraction. In fact, business is good. Ideally these can be benchmarked with national trends for similar reasons. It is one thing if everyone in your region (or nationally) is losing ground; quite another if it is just your practice.

• Aggregate data is great. But some granularity is needed. Your practice might see growth overall, but where is it coming from? You may have a drop from one center and a rise in another, with a net increase. That’s great, but doesn’t help you figure out where to turn your attention and who is sending you more or less business.  Do you have in- and outpatient business? Give data for both. Do you provide service for independent outpatient centers? Hospitals? Both? Split out data for each.

• Exam numbers are also great. But can be misleading. We’ve had days, weeks or months with big numbers, but sometimes due to tons of plain films. Provide these by modality and center, if at all possible.

• Provide each group member with total reads for themselves and the group average. Each individual’s data need not be shared. Include gross studies, RVUs, billed and reimbursed dollars for the greatest breadth of understanding the meaning. Again, use of national benchmarks is ideal.

• Keep track of and include your payor mix - are you seeing a drop in one area? A rise? This can guide your marketing efforts and allow you to intervene if you’ve been dropped from a provider list.

• Show everyone reimbursement rates for different centers or contracts. Are you seeing growth in contracts with fixed reimbursement? Are those rates good compared to the reimbursement you are seeing for those you bill insurance? Are you getting increased numbers where you have slightly better (or worse) payor mix?

Seem like a lot of work? It is to set up, but once you have a methodology to extract the data, it actually is not onerous. You can’t make good informed business decisions on staffing, marketing and business development without data such as this. If you try to, you’ll just be lucky if you hit the mark. A well-run business is knowledgeable about itself.

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To run your practice well, you need to know your practice well.

The Numbers in Radiology

Earlier this year, some of my neighbors asked me about an op-ed they had read in the 

. In it, the commentator made observations about the overuse of radiation in medical testing. For these friends the responses were, to me, both rational and irrational concerns and questions. One of them observed that she would never forgive herself if her child, who had a head CT after a concussion, developed cancer one day. So it’s good that it started a dialogue about an important topic, but also concerning that it might result in people being hesitant about getting necessary tests.

Lots of attention recently has been directed at the use of radiation in medicine. In part, this stems from increasing availability of information. It also stems, in part, from recent commentaries, like that op-ed piece earlier this year. The concerns are related to the noticeable increase in use of CT in particular, from several population studies suggesting possible increase in cancer rate from use of medical radiation, and from several cases of radiation injury. While it is true we image far more than we did 30 years ago, that is somewhat unfair given that CT is new, and CT scanners have improved in quality and geographic distribution, improving their availability and utility. In addition, pretty much all forms of technology are used way more decades after development, (are we over using airplanes? – we use them way more than we did in 1970 – and there are more accidents). But we also use radiation to diagnose aortic dissection, pulmonary embolism, intracranial hemorrhage and accurately diagnose diverticulitis, and appendicitis, earlier, with better outcomes, for patients with those diseases.

Looking at CT as an overused cancer-causing technology clearly only looks at one side of the coin. CT quite simply saves lives, cost and time. That has to be weighed against any potential risk. What we should not do is incite a general panic and resistance to use of the technology. What we can and should do, is be cognizant of its limitations, improve its safety – reducing its risk – and educate users, both patients and providers. You say you are not a policy maker or blogger? Maybe so, but that doesn’t mean you can’t have an impact. Here is a brief action plan anyone can follow.

• Support public education on doses and appropriate use of medical imaging with radiation

• Educate providers about non-radiation options and encourage them to engage patients who have had multiple tests as to further options

• Insist on patient advocacy to your colleagues and referring practices, and act as a gatekeeper

• Support society and national standards and regulation of same

• Promote and support research regarding radiation effects, especially in defining what is presently only a loose association between use of radiation and cancer in historical population data

• Remain vigilant and cognizant about overuse and be particularly sensitive to that in our youngest patients and in the chronically ill, who can accrue larger doses of radiation over time

• Continue to emphasize safe use of CT to your friends and patients, and its undoubtable importance in medical imaging as well as reduction in morbidity and mortality

• Hold society and politicians feet to the fire in forming reasonable malpractice standards to avoid the use of radiation-requiring tests for medico-legal reasons

• Be active in development of reasonable appropriateness standards, tied to outcomes that might form a basis for third party approvals or denials and reimbursement 

Radiologists need to play their part in educating the public about radiation. 

Radiologists Can Help Put Fear of Radiation in Perspective 

Many of you have heard of Schrodinger's cat. It’s the hypothetical physics problem that posits a cat in a box could be both alive and dead simultaneously, until you open the box, observe it and find out which is true. Like this, radiologists often send out reports to the netherworld of physician offices, never knowing if they are helpful or not, and thus not knowing how well we are doing our job - because we rarely observe the end product’s results.

For years we’ve thought of measuring ourselves by productivity. Doing this with the number of studies read, or RVUs or billed or reimbursed dollars and comparing them internally or to statistical norms very well may still be a valid part of determining value; I think it is. But that is not the whole story, and may not provide the right incentives all the time. Quality of care, communication skills and relationship creation and management, administrative and business task completion and leadership, all form parts of the value of a radiologist. The days of “I just want to come in and do my work” (ie, read films), may have passed. Those that want to work that way better be really productive, or they are a liability. For your practice, that can be a challenge, as those providers who read a lot often see themselves as most valuable, and have a hard time seeing or measuring the benefits indirect or non-clinical care can offer. It is critical for practices to emphasize that in the end, it is not the amount of work done, or technical proficiency, (what you might call our ‘input’), but actually how useful the work we do is to our patients and clinicians that is our true value (what you might call our ‘output’). Like the cat, what we are, is how we are looked at after the report arrives and the patient is managed.

When analyzing the totality of contribution, some metric for direct work productivity is a necessity, and a combination is probably best. Again, number of studies read, reimbursed dollars or RVUs are important. Quality metrics are critical too. They include basics like turnaround time (TAT). Other factors must be included but are tougher to come by. Measuring the quality of care in those direct interactions is trickier but doable. Data on peer review is a start. Whatever the scale, keeping track of how each provider measures against others with regard to minor and major disagreements is helpful. Information on quality of communication is also a challenge but available for those who want to get it. For instance, survey referring physicians - how often does the provider call you when you think they should? How are your interactions with them? How would you grade the usefulness of reports? So too, must there be feedback on interactions with imaging partners such as hospitals and imaging centers with which you work. Measuring administrative tasks has always been contentious in my experience. Some things are more banal and might be amenable to measurement as simply ‘hours worked.’ But for most things, there should be some effort to regularly determine how effective the administrator is. Measure business growth year to year, but use industry comparisons as benchmarks to account for business cycles. Survey the practice partners to assess communication skills, innovation, confidence and leadership for one another. Ask how useful and necessary certain administrative tasks are felt to be.

This is only a start and a meager one at that, I’d guess. In the long run, we should be looking to find out what measurable impact our radiology work and practice efforts have on improving the care of patients, something we have a very poor handle on at present. A system that accrues data for when a radiology report alters care might help us determine this clinically. Measuring our benefit in less clinical ways is also challenging at present. We have, as a surrogate, how useful our work seems to referring providers and colleagues by qualitative methods as I mentioned above.

So why is it valuable to do this? Because not evaluating it leads to stagnation. Like Schrodinger’s cat, when we look at something, it becomes defined for us. The ‘something’ here is our output (ie, or usefulness, not our input, ie, effort). Once any aspect of our output is measured, there is natural human instinct to improve on the measurement. That measurement has to go beyond the easy direct stuff. Because including indirect components validates the methodology for everyone, and vests people of more diverse productivity types into the process. Refining it will only help us all continually improve our usefulness. That should be the goal for us all.

Our original measurement of productivity no longer defines how useful we are.

How Do We Determine The Radiologist’s Value? 

Two financial news items grabbed the attention of many of us recently. First, an annual salary survey showed that radiologist salaries are declining. The reasons for that are myriad and we’ll talk about them another time. Second, CMS released physician payment data. Of course, at these times I reflect on why I chose medicine and radiology. I chose medicine because I honestly think my role is to make the lives of others better and easier. I probably chose radiology for several reasons: intellectual stimulation, interest in technology and its increased use in healthcare and a little hesitancy about how I’d handle close personal relationships with patients. We’ll leave the last one for a blog on psychology.

Right now I keep refocusing myself on the other reasons I chose medicine and radiology; that is, non-monetary rewards. It definitely frustrates me at times to see that there are industries where it is apparently fine with society to suck the financial life from the rest of us. But when it comes to medicine, that is frowned upon. I stared at my Medicare average pay per patient the other day (yes, if you haven’t done it, it is super easy to see your CMS data) and didn’t know if I should laugh or cry. It was $50–$60 per patient. I had just had a repair guy come to fix my garage door. He “required” $75 just to look at the door - you know, a diagnostic evaluation. Seriously, the system allows him to charge more than I do?

After paying back $120K in debt, and giving up 20 percent of my adult earning years to training, I’m pretty confident that this is not financially right. So what does that mean? Why am I doing this? The answer is back in why I started doing this. I’m not going to pretend I didn’t expect (and get) a good salary. But I knew when I started this, it wasn’t the easiest or best way to make a buck. Rewards come in all sizes and shapes. I get them from professional respect from patients, peers, friends and co-workers. I get them from job and intellectual satisfaction. I get them from knowing I tried to help someone every day, really and tangibly. I get them from integrity - staying true to myself.

I’m not suffering financially... and I’m not soaking every penny I can from society either. That doesn't mean I won’t try to get paid every dollar I’m worth in society’s eyes, using the current system. But it does mean the yardstick I compare myself to isn’t the electrician, the investment banker or anyone else.

Radiology might not be the best way to make a buck, but its rewards come in all shapes and sizes.

The CMS Data - Should I Laugh or Cry?

How do you strengthen your relationship with your technical partners? Be part of their work and effort to grow their business.

Be a visible part of the radiology enterprise.

 The traditional ways of doing this would be things like business cards and perhaps lunchtime visits to practices with marketers. Those still have their place and if you have a marketing partnership, have your marketer carry the cards and visit with them. But I’ve found the bang for the buck is pretty low with that.

So what might work better? Make it easy for people to find you. Consider putting your cell phone number and e-mail on reports. Yep, you might get a call or two from patients; but that might not be bad either. Hesitant to do it? Try it for 90 days and see what happens. You can always rein it in. You’ll be surprised that people like knowing they have access to you, even if they don’t use it alot. Along those same lines, connect with your referring peers on Linked-in and Facebook or other social networks. Catch up with a couple of them for breakfast, coffee, or dinner. Commit to some regular amount of contact and check yourself regularly to be sure time doesn’t slip away. Think about going to local subspecialty meetings and even presenting there. Emphasize not only your strengths but the strengths of your technical partners.

Find synergies that allow you to show value.

 Technical partners need expert evaluation and feedback on staff. Don’t hesitate to offer to do that for them. Fill out staff evaluations and offer suggestions. You’ll be seen as more of a partner. They need education as well, so offer talks or other ways to educate them. Look for areas or niches where you can help them gain market share. Do you have someone in the practice who can learn vascular imaging or has some other niche? Trumpet it. Have the marketer point it out to referring physicians. Go to marketing meetings for your partner and see where they need help. They are looking for sales angles and you have the inside information on what is hot. Examples right now include emphasis on dose safety and specialty expertise or ease of access.

 Above all else communicate freely with your technical partners. Tell them when you find problems or when you reach out to referring offices. Make suggestions and be involved in their culture. You’ll start to see more and more areas where you can help. Radiologists are steeped in process improvement, whether you know it or not. So you can offer lots of help in improving processes. To do this, you should help establish clear lines of responsibility and adhere to them. Work together to improve communication with your referring physician practices as well. Collect information on how practices prefer to receive results and important calls and use them be it Short Message Service (i.e. text messages), cell, or back line. The more actively you do this, the more it will make contact easy. You’ll not only deliver results, you can seek feedback and share it with your technical partners to make the whole process work better.

Here are three simple ways you can strengthen your relationship with your practice's technical partners.

Strengthen Your Radiology Technical Partner Relationship: 3 Strategies

So it’s the end of one of the most popular sports seasons again. It’s SuperBowl time. In the NFL, the process of figuring out who is doing well is a straightforward march through playoffs to the SuperBowl.

Knowing you are doing a good job is easy. Did you make the playoffs? Win? Other industries like the music industry use award shows.

Last I checked, though, there are no playoffs for radiology and no Grammy’s. In fact, we look at things the other way. We note when things don’t go right. This is painful but should be viewed as a strength and opportunity.

A great observation I heard on this is that Wile E. Coyote didn’t realize he was running in the air over a canyon until he fell, but the observers around him did. Unless our peers help us to improve, we don’t even know when we’ve fallen into the canyon.

What method should be used? A combination is best. Here are few types:

Traditional, retrospective review: That’s where you review others work when they are used for comparison most commonly. It’s fairly random, but through the retrospectroscope.

Double reading: It’s ideal and prospective but expensive; suitable for certain studies.

Satisfactory use of standards: Good for things with standards like assessment of nodules, renal cysts, ovarian lesions, but not everything has a standard.

Focused review: That’s when someone points out an error. Can be very helpful, but needs a standardized process and review, including appeals, as it can be a tool for targeting.

Audit/correlative: Using path, surgical findings or clinical outcome to find out if you are right. It’s only suitable for certain types of cases; it may become easier with central accumulation of data and EMRs. Remember, too, the “gold” standard is not always right.

Clinical feedback: This is information from a referring about the nature/type of reporting and style. If done in an organized way, can be very helpful on several levels.

Education: That is looking for regular errors throughout the practice or in certain modalities. Looks for systematic problems and globally improves practice as whole, not just individuals.

Combining some or all of these helps mute limitations of each method, and aids in subspecialties where few peers are available.

There is a sense of unfairness or randomness

It may be unsupported by references (i.e. opinions)

Increasingly complex studies mean it’s harder to find peers to review

Should be anonymous - central accumulation of data; radial distribution

Should be random - try having everyone use the first case with a comparison one day each week

Should be focused on outcome and improvement, not the error

Should be constructive, become part of data collection over time and be use to direct education

Can be incentivized to help encourage its use

Should be assessed and measured to show improvements - Remember there are MOC and PQR benefits.

Peer review is part of a focus on quality of patient care. It’s accepted throughout medical industry and with increased attention on medical errors and demand for accountability, it will be part of a broader QA/QI process. It is needed and desired by technical partners and is an opportunity for value added by the radiology practice. Soon, it also may be necessary to obtain reimbursement or maximize reimbursement.

Moreover, peer review is our best way to find out how we are doing and to push us to improve. At least until there is an award show for radiology.

Peer review can help radiologists improve. Here are some methods for peer review and solutions for barriers your group may face.

How to Do Peer Review in Radiology

I recently visited Philadelphia, and while there, I came across some of Ben Franklin’s more famous quotations, including this well-known one: “Those who live in glass houses shouldn’t throw stones.”

I’ve relied on that notion many times as a radiologist. Why? Because to me we are in the most humbling of specialties. We all make errors and our errors are usually in plain evidence in perpetuity. So, I’ve been hesitant to be overly critical of others’ mistakes.

But lately I’ve started to think a lot more about that position. Isn’t that also an abdication of responsibility of quality in my profession? Specifically I’ve come across poor quality reports that have led to over-imaging (often read by non-radiologists) or incorrect treatment. While I’ve made my share of errors, I know about them because they are pointed out to me; and as a result, I am able to consider what I can do to improve. 

But what about when someone orders their own test and reads it, or one of their partners reads it? Is there oversight for this? There’s no one else typically to feed back an “over-read” disagreement if you read your own stuff. Do those readers find out what mistakes they made? Moreover, are they challenged to improve and held to any standards for this? I think this is an area where health imaging is sorely lacking.

First is the importance of peer review for all readers - and peer review with consequences. Every imaging facility needs to provide a system for peer review and to create a system that allows for verification of errors by second or more peer reviews. To me, there should be grading not only of accuracy, but clinical relevance. For those errors that are clinically relevant, and that are agreed upon by reviewers, there should be some form of education and redirection. For repeated errors, there should be mandatory CME or otherwise documentation of competency.

Second is the use of peer review data in the careful development of quality metrics in radiology performance. Such metrics would cover far more ground than just report accuracy, and include a variety of service errors, omissions or dysfunction, but should include elements of accuracy and report completeness. Metrics we are all aware of are things like turn-around-time, but can include far more than this, including safety data and regularity of fulfilling documentation requirements. Such metrics should emphatically be directed at items that improve the patient experience or safety.

We owe our patients this much. And we certainly can’t be critical of the quality of anyone else, if do not firs have our own house in order.

Every imaging facility should have a solid peer review system, and peer review data should be used in the careful development of quality metrics in radiology performance. 

The Importance of Peer Review and Metrics

Patient checklists have gained popularity in operating rooms and inpatient centers in recent years. The World Health Organization advises their use in a several environments, even for well child checks. At their core such checklists take a complex process and make it fundamentally reliable in some core way, that either the user determines or that a consensus of users determine.

For a radiology practice, that might include content of reports in a consistent way, use of comparison studies, or reminders for regular checking of report status. They improve safety and are, for many, a no-brainer.

Although we all believe ourselves to be safe and effective at our jobs, there is no question that we lapse into a false sense of security at times. At the same time we are all faced with a world requiring our increased efficiency and attention.

First, that may not be a bad thing. Slowing down means taking a second look and avoiding an oversight. Lots of psychological studies also show that we see what we expect to see. The popular show “Brain Games” right now reminds me of this each time I watch. But when you put a checklist in front of me, it re-centers me on core functions and ensures none of those are omitted.

We also have memories that can be influenced by our expectations. Believe it or not, there is evidence that we “mis-remember” (for fans of Roger Clemens)  what we’ve done many times, including things we consider basic, partially because they are so rote for us that we assume we’ve addressed them. So checklists step in and make you review those core principles.

But worklists can be made to work for you in other ways, helping to promote cost-effectiveness, and efficiency, not just safety. Ensuring that all needed tasks are taken care of before a study comes to you for a read means there are fewer times you view something not ready to read. And having an orderly efficient process in writing means there is no wasted effort or extra phone calls or notes. Last, risk managers (read: insurers) love them. They help document your process and avoid errors.

In short, checklists are good for safety and for your efficiency. Look into them. They are likely to cross your desk sooner rather than later.

Patient checklists are gaining popularity, and they are a no-brainer for radiologists to improve safety and efficiency. Look into them.

Radiologists Should Adopt Checklists

My kids are always pointing out things society could do better or that would be cool to have. They say we should have flying cars or use recycling to fuel engines or make robots that will clean our rooms. They usually tell me, then, that it’s too bad they can’t do these things all by themselves. My response is that they are exactly who can do this themselves.

An old adage is that you change the world one step at a time and that you have to be the change you want to see. I realize I face this every time I shake my head when someone orders something inappropriate as a radiology test. Sure, there are factors outside our control like patients who demand tests of our referring MDs or referring offices that ask not to have orders amended or questioned. But even these factors can be slowly changed or improved. So here’s how you might do it.

- Consider adding ACR appropriateness criteria scores to our reports. This would be a big change for us and referring providers. The data is out there but not everyone wants to see it or they may feel like their ordering practices are being critiqued. The good news is that if you do it, especially if the ACR were to recommend it officially, you can justifiably explain that it is just inclusion of standards and not a criticism. It’s only an effort at helping the system work better. Change is never easy, but over time people adapt to it.

- Be aware of the landscape. Have you read through the Choosing Wisely? Many referring doctors have and so have patients. We need to be educated on this and similar advice from the medical community. It advises on use of imaging for back pain and in osteoporosis screening. The site is becoming increasingly popular and concepts like this will be growing. You need to be out ahead of them.

- Behind the scenes, you can offer to work with insurers on appropriate use. This has been in place for years, and insurers make recommendations and approvals with some criteria, but many MDs don’t want to work with whom they see as the enemy. Ultimately, we are all working toward at least one goal: cost-effective medicine. So, consider offering your services to help in the process.

- Consult willingly with referring MD offices, and talk to all levels of providers. Let the practices you work with know you are available to consult and, then, be happy to do so.

- Create quick reference guides with appropriateness guidelines for your office staff in your centers. They can provide quick guides when staff call from referring offices to make sure the right test is ordered.

- Make recommendations for follow-up and additional imaging clear in your reports. One critique universally held by referring MDs is hedging or being unclear as to follow-up. Most want us to tell them exactly how to do it and what to order, so don't hesitate. Once in a while you’ll get someone who doesn’t want your advice, but that shouldn't stop you. One other benefit is that your advice is there for the patient to see, as well as any other providers they visit.

- Have your practice create newsletters, blogs, or other media that cover common topics (focus on misunderstood or misused ones) or new updates in radiological problem solving or ordering. It’s a good way to add value and help educate about what tests to order.

As long as you are emphasizing better patient care, you are doing your patients, referring doctors, and the health system a big favor when you help make improved and cost-effective choices. 

Making changes in radiology can happen one step -- and one provider -- at a time.

Be The Change

With football season here, all levels of players are learning a new playbook. Without it, new players on any team would be confused and slow to figure out the routine. Radiology practices are no different, but many of us don’t have a playbook.

Just recently, a tech called me to ask about a study protocol that was a little uncommon, but about which we had talked before. After giving her the information, I asked why she didn’t just use the standard we had talked about previously. Her reply was one I hear from techs all the time: that they just can’t keep track of all the different needs and desires of radiologists and there is no one place they can easily find them.

Shortly thereafter, I heard from a referring physician that they were unable to schedule someone for a study we had recently started to do. The schedulers said they hadn’t heard of it, and it wasn’t something the radiologists do. Like a lot of us, these situations made me frustrated. But they also made me wonder why there was a breakdown in communication. Much of it comes down to accessibility of the information and its reliability.

We can all use a playbook, and for us, it can be a “knowledge center” – a place the staff goes to find out new information and check individual providers’ preferences. It goes beyond this, though, as we have to take the added step of informing the staff of changes and keeping them in the loop.

A few plays should be included in all playbooks. For starters:

 This one is pretty straightforward at first thought. Most of us keep protocols for routine studies. But they need to be regularly updated for changes in equipment, such as 3T scanners, for new techniques in the industry, and for new applications. Remember that the techs may not know about newer techniques, even those that are a few years old. So take some time on slow days to fill them in. Or better yet, have a regular session to bring them up to date, twice a year. And for anything the group doesn’t agree on, add notes for each individual provider preferences. It’s okay to practice differently in some cases. But it is better for the staff to know where and when you want something done differently if you are the one responsible.

 Keep a list of procedures your group does. Keep the list public and online or in a notebook. It won’t take long, but it makes a quick easy reference to check for the staff. This is especially important if you practice with a large technical center that may use several reading groups. When you add a procedure or find one that is confusing or unusual, update the list, and inform the schedulers. Meet with them regularly, and be sure there no questions. You can fill them in on new procedures.

 Many are common and certainly every practice and center needs a standard operating manual. But some areas are not as straightforward, and the preferences of the practicing providers can be written down to keep things working well.

In the end, having a playbook means less confusion, better, more efficient patient service, less frustrated staff and referring physicians, and fewer phone calls and questions for you.

Just like any other team, radiology practices could benefit from a manual to keep provider preferences and practices organized.