Whitney L. Jackson

For radiologists practicing in free-standing, independent imaging centers, your day-to-day clinical practice probably hasn't changed much in recent years. You go to work, read images, provide a diagnosis, and go home.  But, can you say you've had the same financial stability during this time? Chances are, no, and the reasons behind it are multi-factorial. If you're like a growing number of your colleagues nationwide, you could be wondering if you might have an easier time if you had a partner. It's this prevailing thought that has kept the trend toward consolidation in radiology hot with no signs of cooling. Sometimes the driver behind mergers or acquisitions is a shift in professional culture, but the greater impetus is economic concerns largely due to governmental requirements and regulations. "The trend for mergers and consolidation has existed for many years with radiology practices, but has picked up pace over the past few years due, primarily, to the evolving macro health care environment and the emergence of private equity-backed groups," said Michael Mahoney, an analyst with Provident Healthcare Partners, a health care investment banking firm. "It's been catalyzed by hospital consolidation and shifting payment systems, which have motivated independent radiology groups to seek partners." As radiology practices and groups are falling subject to a growing number of government regulations, pressure to provide an increasing level of service and more analytics and data is also growing. For many in radiology, the only way to meet the demands is to partner up. 

 According to Mahoney, radiology practices have different models to choose from when considering consolidation. Each structure offers different governance and benefits, so it's up to your radiology group to determine which model is most suitable for your specific situation.  

 With this model, your practice opts to join a larger, physician-led group, such as Aris Radiology, Radiology Partners, Riverside Radiology & Interventional Associates, Envision Healthcare, or MEDNAX, assimilating into a structure that offers you streamlined billing, recruiting, IT, marketing, accounting, and other administrative activities. It's also a way to be part of a group that offers a wider array of sub-specialties -- and even super-sub-specialties, which is often very well-received by hospital partners, Mahoney said. Despite the large group size, though, member practices often maintain significant local control over scheduling, workflow, and hospital relationships. In some cases, they also retain partial equity ownership so that radiologists participate financially in the growth up-side of these mega-groups.  

 Popular among other physician specialties, this model involves a group of investors interested in acquiring equity positions in practices, Mahoney said, providing capital and foundational support to encourage growth and contract stability. Overall, investments are largely being made into a radiology group's clinical, administrative, and IT infrastructure, as well as being devoted toward acquiring other practices. Using these funds, it's possible for radiology practices to expand into multi-region or multi-state providers, and radiologists retain partial equity ownership in a private equitable transaction.  Over the past few years, Mahoney said, the private equity community has increased its interest in radiology. For example, Radiology Partners recently announced an additional $200-million investment from their private equity partner, New Enterprise Associates. Additionally, other private equity forms are also seeking new investment opportunities into the specialty, continuing the trend that first touched other hospital-based specialties, such as anesthesia and emergency medicine.  

 As of January 1 this year, the requirement for reporting on quality metrics under MACRA was effective. While you have until January 2019 to comply before the Centers for Medicare & Medicaid Services dings your reimbursement, it's clear radiology will have difficulty meeting these requirements alone because your payments are still tied to how well your referring physicians comply.  Abiding by the law does require a financial investment. So, if you're linked to a large hospital or health system, it will be easier overall for you to fulfill the quality reporting requirements and weather the financial impact, said Matt Richardson, chief operating officer for Aris Radiology, a 140-radiologist, nationwide teleradiology practice.  "Feedback from physicians is that they're looking for a large capital partner like a hospital or health system," he said. "Most providers want to practice medicine rather than worry about the business headaches." 

Compared to other specialties, radiology is tasked to operate at a high technological level. The latest modalities, RIS, PACS, and software requirements that allow for greater interoperability and workflow carry a heavy price tag. The capital investment can be significant, and many smaller or free-standing practices are struggling to meet these professional obligations while maintaining a healthy bottom line. In some cases, these practices face the specter of lowering radiologist pay to stay afloat. If they opt to become part of a larger group or health system, shouldering the cost becomes easier, Mahoney said.  Chad Calendine, MD, Aris Radiology's chief medical officer and practicing radiologist at Nashville-based Premier Radiology, agreed. "The proper technology is very important to workflow and efficiency, and it's not cheap," he said. "Often, radiology requires IT systems beyond what we can get from hospitals alone, so we need to aggregate enough capital to support what we need." 

 This driving force goes hand-in-hand with the cost of technology. Whenever your equipment needs repairs or your practice needs an upgrade, the cost can be heavy. In some cases, making those changes can require more than your practice can support, forcing you to wait for needed maintenance or machines that allow you to offer the best quality services to your patients. A hospital partner can absorb the cost far easier than you can. 

 The pivot in medicine overall toward population health rather than focusing solely on individual patients is also pushing radiology towards consolidation, according to consulting organization GE Health care Camden Group. A growing focus on treating larger groups of patients comes hand-in-hand with having a bigger cadre of providers to offer needed services.   

 When it comes to securing appropriate reimbursement, the size of your practice matters. If your group is small, you're less likely to be able to negotiate higher reimbursement rates for your services. If you consolidate, aligning yourself with a larger practice, hospital or health system -- which already enjoys a higher reimbursement rate because of their round-the-clock services -- helps you piggy-back on their stronger leveraging position with private payers, helping to strengthen your overall financial position.  

 Over the next decade, the industry anticipates a significant number of retirements from long-practicing radiologists. Those taking their places as specialty leaders don't often share the same work mentality. Rather than opting to own and operate a private practice, carrying the responsibility for all business decisions, the younger generation of radiologists is more attracted to being an employee of a larger health group. Doing so allows them to not only focus solely on providing patient care, but it also frees them up for a more attractive work-life balance. 

 As radiology follows this trend, the potential benefits do come with risks, Mahoney said.  

 For many radiologists who are accustomed to running your own practice with your own policies and procedures, consolidation can be a difficult switch. Becoming a hospital employee can be a tough change. You could fear losing your autonomy, but Mahoney said that's unlikely to happen. 

 In scenarios where physician shareholders retain equity in a transaction, he said, there's no guarantee the value of the retained equity will appreciate, and your future economic value is driven by the partnership's success. Your best bet to mitigate this risk is to evaluate all available options to ensure you pick the right partner.  

Changing practice structure can be hard for some radiologists to accept if they are accustomed to or prefer a smaller practice model. If you're considering consolidating with another entity, do your best to get everyone in your practice on board with your decision. It will make the transition earlier, said Aris's Richardson.  

 Radiology is traditionally the specialty that leads the pack when anything new emerges in medicine. This time, however, Caldenine said, radiology is lagging behind -- by nearly a decade. The initial resistance against partnerships or consolidating under a hospital umbrella have made the specialty one of the last to move in this direction.  But, that doesn't mean positive things aren't on the horizon, he said. And, the ultimate benefit will be significant.  Greater consolidation leads to standardized best practices nationwide, better benchmarking, improving branding and marketing changes, stronger IT presences, improved billing and compliance, as well as streamlined workflow. It all points to one thing -- better outcomes for patients, according to Caldenine.  "We're headed toward a greater uniformity for the patient experience," he said. "Having the ability to offer standing solutions for imaging concerns that best suit communities and patients is where we're going." 

Articles

The move toward greater consolidation in radiology is still going strong, and several drivers are behind it.

Consolidation: What's Continuing To Push The Trend?

It's not your radiology residency anymore. Today's residents and fellows are marching through a program that, in some ways, is vastly different from the ones you and your colleagues completed. Whether you've been out of school and in the field for decades or started practicing only a few years ago, radiology residency doesn't look the same. Some changes have already occurred, altering how and when residents receive training in various imaging specialties. Other alternations are still under consideration. The ultimate goal, said McKinley Glover, M.D., chair of the American College of Radiology's Resident & Fellow Committee, is to improve the overall quality of radiology residency programs nationwide. "We want residents to be more marketable for practice groups," he said. "The changes being made to residency programs strengthen their marketability, improves negotiations with payers, and bolsters their credibility and credentials with hospitals." 

 One of the most significant changes has touched the most important test you take as a resident -- the board certification exam. The oral exam you took during your fourth year of residency no longer exists. Instead, today's residents cram hard for a multiple-choice core exam at the end of their third year, said Glover, who is also a neuro-radiologist at Massachusetts General Hospital. Residents are shown cases and are given several diagnostic answers from which to choose.  Some in the industry feel the change has made the test easier, but many industry leaders still contend it makes the final two years of residency stronger.  "The exam is now a core exam that has redistributed how residency programs concentrate their training time," said Liva Andrejeva-Wright, M.D., associate radiology residency program director at the Yale University School of Medicine. Now, instead of spending their final year of training pouring over books and limiting the focus on patient care, residents devote extensive energy to studying and content mastery during the third year. That leaves the fourth year open for targeted, sub-specialty learning.  

 By giving residents the option to choose sub-specialty training during their fourth year -- much like selecting electives in college -- residency programs are turning the final year into mini-fellowships, Glover said, making residents more attractive to potential employers. "This program change ties directly into the job market," he said. "Practices want people who come out of school with sub-specialty training to replace those who are retiring." Acceptable candidates must still be able to provide general radiology services, but the demand for higher skill sets is growing. For schools that have already adopted this format, fourth-year residents can select several sub-specialty areas on which to focus. Some choose to concentrate on the type of imaging they intend to practice, and others take the opportunity to improve their skills in sub-specialities where they haven't had as much success. Depending on the program, each mini-fellowship can last from one month to six months.  It's during these mini-fellowships, Andrejeva-Wright said, that fourth-year residents gain the greatest exposure to patient care. By spending extensive time focused on individual sub-specialty areas, residents not only increase their familiarity with particular types of imaging, but they also increase their reading speed, improving the level of care they're able to offer patients. 

 To accommodate how the fourth year of residency has changed, many programs have also shifted the curriculum structure for the first through third years.  According to Andrejeva-Wright, some of the topics and material covered are the same, but the parameters of how residents work have changed. At Yale, first-year residents are exposed to the basic modalities they will encounter when they're on call, including bone films, body CT, body ultrasound, and nuclear medicine. She referred to these cases as "bread-and-butter" cases because they most commonly pop up. "We try to expose residents to everything in their first year so they have a chance to learn the basics," she said. "Many of these things they'll see when they're on emergency department call or when they start night call in their second year." Many program directors feel night call is no longer appropriate for first-year residents, she said, because they need more experience with complex modalities. And, once they do start call, students are surrounded by a greater number of senior residents and attending providers who can offer support and back-up services.  Instead, night call launches during the second year. Even then, many industry leaders have pushed for these residents to have greater attending supervision, as well. In fact, Glover said, many programs are starting to provide in-house, 24-7 attending coverage for residents. It also helps with turn-around time as residents learn -- patients and referring physicians routinely expect rapid reads. In these cases, residents provide the initial reads, and attending physicians double-check and sign off of the findings. Another big change has occurred in the third year for many residency programs, Andrejeva-Wright said. In an effort to properly prepare residents for the board certification exam, faculty expose residents to a wide variety of imaging modalities. For example, she said, at Yale third-year residents learn more about cardiac MRI, nuclear cardiac imaging, ultrasound, and body and bone MRI. They also take on more on-call responsibilities in hospital emergency departments. Third-year residents at Harvard are introduced to interventional radiology training, Glover said. All of these curriculum changes culminate in giving fourth-year residents the opportunity to choose their concentration areas. This final year is time for residents to develop a specialty, such as breast or musculoskeletal imaging, or to strengthen skills. With each rotation, they also improve their reading skills and their abilities to work with patients. 

Diagnostic-Interventional Radiology Programs

 This 2015 move pushed forward the conversation about merging the diagnostic and interventional radiology specialties. The merits of such a program have long been discussed, and now several programs, including Yale and Harvard, have introduced a dual track for interested residents. These five-year programs offer three years of diagnostic imaging training and two of interventional radiology instruction. When residents finish, they are certified to practice in both specialty areas. Such residency programs are still new, however, so the verdict is out on how many residents will be interested in this track and how many will complete the programs. 

 As with anything new, changes to residency programs come with positives and negatives. On the plus-side, re-structuring resident training gives students greater flexibility to learn more about the type of radiology they'd like to practice before putting a shingle out for patients. The mini-fellowship design also makes it easier for existing practices to determine which candidates have the skill sets they desire when filling open positions.  The biggest challenge, Glover said, is getting buy-in from program administrators that changing their programs is in the best interest not only of their residents, but of the radiology industry, as well. 

 In addition to having the opportunity to get sub-specialty experience while still in residency, today's residents also differ from you in other ways, said fourth-year Yale chief resident Kaitlin Eng, M.D.Today's residency programs are tougher, she said, especially when compared to those from a decade or more ago. "It's pretty difficult because technology has advanced," she said. "We get images from everywhere." Often, she said, experienced radiologists relay stories about reading films and being responsible for roughly three chest CTs a day. Today, she said, residents can be responsible for handling 10 times that much.  Even though the pace of radiology residency is faster now, she said, that doesn't mean that residents come into the program ready to perform at a break-neck pace. "Some attending radiologists are so far out of residency that they forget how little residents know when we come into the program," she said. "It would be nice for them to keep that in mind as we work through our training." 

Today's radiology residency could differ vastly from what you remember.

Radiology Residency: How It's Changing

After a long roller-coaster ride, diagnostic imaging utilization nationwide is finally stabilizing, industry experts say. But, questions still remain about why the leveling out has happened – is it the reigning in of inappropriate imaging? Or are services actually being cut?  At the same time utilization is plateauing, your reimbursement rates are being somewhat whittled away by the continued move toward bundled payments and various reporting requirements. Overall, industry experts say, 2017 brings changes worth watching. 

 Despite its rapid growth in the late 1990s to 2006, diagnostic imaging services have been stringently cut back in recent years. Now, however, said Richard Duszak, Jr., MD, vice chair of health policy and practice at Emory University School of Medicine’s Department of Radiology and Imaging Services and senior research fellow at the Harvey L. Neiman Health Policy Institute, utilization isn’t seeing the same level of curtailing.  Campaigns, such as Image Wisely, have led physicians to double-check whether imaging is necessary, but the decrease has largely leveled off. There are still several factors, though, that drive the use of diagnostic imaging.  1. 

Patients are spending more time educating themselves on imaging options, and they’re coming to appointments ready to discuss possibilities with you. In these situations, remember to advise your referring physicians to adhere as close as possible to Image Wisely, Image Gently, and ALARA principles. 2. 

 This driver is not yet fully understood, Duszak said, but according to recent Neiman Policy Institute research, imaging utilization in EDs is on the rise. According to Neiman Policy 

, the total Medicare cost of imaging in the ED between 2003 to 2014 grew from $243 million to $566 million.  A lack of familiarity between ED providers and patients could be behind increased use. Doctors aren’t as familiar with a patient’s history, and the patient isn’t as confident with a doctor they don’t know, so a diagnostic image could be ordered to assuage worries. “It’s all about how quickly you can get a patient through the ED and maintain satisfaction and workflow,” he said. “Rather than bringing someone in for observation, or potentially keeping them overnight for a costly hospital stay, you can get an quick answer with a CT or other imaging test.” 3. 

Considered a requirement under the Medicare Access & CHIP Reauthorization Act (MACRA), the use of clinical decision support tools by your referring physicians is also impacting imaging utilization, said Ezequiel Silva, III, MD, the Chairman of the American College of Radiology’s Commission on Economics. In some cases, its guidance is eliminating unnecessary services, and in others it’s ensuring you’re asked to perform the correct service. Either way, your reimbursement levels are still tied to whether your referring physicians consulted the tool prior to ordering a study. “It’s still early to know how this legislation will impact payments, but providers need to be aware of the metrics and how they will be judged and processed,” he said. “Bonuses and penalties will be based on performance.” However, there are factors that are keeping utilization at bay, he said. 1. 

More patients have insurance under the Affordable Care Act, but new research shows insurance still doesn’t equal access. In some cases, patients don’t have access to the primary care physicians needed to refer them for imaging studies.   2. 

Unfortunately, a portion of the utilization stabilization stems from the shuttering of some imaging centers nationwide. Other facilities have seen a scale-down because they cannot afford to buy upgraded tools, such as new MRI magnets, that ensure they can deliver needed patient services. 3. 

Affordable Care Act Transparency Initiative: 

This initiative is designed to help patients determine which doctors are more expensive compared to their peers, Duszak said. Referring physicians who order more diagnostic tests could be deemed pricier than their colleagues, potentially making them less attractive to patients. This published data could influence whether physicians opt to order a potentially questionable test. 

 As with previous years, the Centers for Medicare & Medicaid Services (CMS) is alternating using reimbursement as both a carrot and a stick. Whatever the case, your payments aren’t increasing, and you’ll have to continue jumping through hoops to secure your dollars. 1. 

This legislation lays out reporting requirements that will go into full effect in 2019. However, the preparatory phase began on Jan. 1, 2017. There are several ways to participate, but if you are involved for the full year, you can maximize the positive payment adjustment you could receive.  There is concern, though, Silva said, that you and your colleagues, as well as your referring physicians, will become exhausted with the reporting responsibilities. “The increased regulatory burden placed on practices and the increased cost of doing business can create the risk that fewer providers will do it,” he said. “There’s a real concern that radiologists will get overwhelmed and say it’s not worth the effort to participate.” 2. 

Overall, outpatient reimbursement is set to increase 1.65 percent, but under this legislation, the industry is required to continue its phase out of film and computed radiography (CR) X-ray in favor of digital radiography. If you don’t, you’ll experience a 20-percent payment reduction for 2017 with analog X-ray systems, and an equivalent reduction for CR equipment in 2018. 3. 

CMS announced three new bundled payment codes for mammography with computer-aided detection: one for unilateral diagnostic mammography, one for bilateral diagnostic mammography, and one for screening mammography. New payments will go into effect in 2018, allotting for an increasing of the diagnostic mammography payments and no change in the screening mammography payment. Additionally, no change to the technical component payment is anticipated.  4. 

Multiple Procedure Payment Reduction (MPPR):

 According to the Bipartisan Budget Act of 2015, CMS is set to reduce the professional component of MPPR from 25 percent to 5 percent this year.  

 Regardless of the factors driving utilization or reigning it in, as well as the legislation and regulations impacting your reimbursement, you can largely expect the diagnostic imaging playing field to look similar for a while, Duszak said.  “We’ve had stability in imaging over the last few years,” he said. “And, with the aging population continuing to need imaging services, we’ll likely see things staying the same for the foreseeable future.” 

There are several things you should know about what’s driving utilization of your services and your payments for providing them.

What’s Driving Utilization & Your Reimbursement?

CHICAGO-The overarching theme of RSNA 2016 has been deep learning and machine intelligence. Both are designed to help you with your workflow and ability to provide optimal patient care. But, questions still exist about what these tools are and how you can implement them. To answer this question, Vlado Menkovski, a former research scientist with vendor Philips, discussed the differences between these two tools, highlighting how they can be used. “This technology has provided breakthroughs,” he said. “It’s been exciting to see the potential impacts it’s had on imaging analysis.” 

 Simply put, machine learning is akin to writing a computer program to address a known and well-understood problem. For example, scientists can understand the process needed to launch a satellite into space, he said, and they can easily write a program to make it happen. Via machine learning, you can pick apart your data, learn from it, and use it to make predictions about your findings. For example, he said, you can use machine intelligence to create algorithms that predict cancer prognoses. You can program the algorithm to consider tumor size and other characteristic seen in an image to determine whether the patient has a poor prognosis.  

 Overall, deep learning is a method for implementing machine intelligence. The main component is the artificial neural network, designed after the human brain. But, while the neurons of the human brain can fire and connect to each other in any way, the segments of the artificial neural network are connect in specific patterns and discrete layers. Deep learning can rebuild images layer-by-layer, identifying edges, but as use of Big Data increases, you’ll be able to train computer models to do even more. Currently, though, these networks can already be trained to use coordinates for width and height or to segment pixels to identify different organs.  

 Some companies are already jumping into find the best ways to make deep learning and machine intelligence applicable in radiology. One company – Enlitic – has developed a lung nodule detector designed to reach positive predictive values 50 percent higher than those achievable by a radiologist. As the model analyzes images, it learns and, over time, can offer a probability score for malignancy. The company is also investigating whether these tools can be used to identify wrist fractures.According to company chief medical officer Igor Barani, MD, up to 40 percent of fractures are missed, leading to improper healing and pain. The model is being trained to find fractures on X-ray images, overlaying it on a heat map to highlight locations in a conventional PACS viewer. Radiologists are checking for accuracy, and results, so far, are positive.  Eventually, Barani said, Enlitic wants to expand its deep learning and machine intelligence capabilities to CT and MRI scans for a wider variety of medical conditions, incorporating the ACR guidelines along the way. The end-goal, he said, is to build a neural network that uses genomic, clinical, and imaging data factors to evaluate the entire human body and detect pathological states and deviations from normal anatomy.   Much work still needs to be done, and the industry needs to determine how best these tools can be used to augment the services you and your colleagues provide. Deep learning and machine intelligence will be best used, Barani said, when radiologists better understand what these technologies can and cannot do.   “Half the battle has to do with expectation management,” he said. “You have to avoid the hype about deep learning and machine intelligence. It’s very important to help people understand the problems it can help solve and which it can’t.” 

Deep Learning and Machine Intelligence

Per usual, there’s no shortage of acronyms in radiology. But the two that need your close attention now are MACRA and MIPS. Their requirements are many and confusing, and several radiology leaders are wondering what complying with the programs will mean for their practices.

Will working to fulfill these obligations help or hinder you in your daily workflow and pursuit of optimal patient care? Experts addressed these questions at RSNA 2016.

Overall, they said, you should be focused on quality, cost, clinical problem improvements, and advancing care information. But, there are six categories for which you’ll need to pay attention: clinical care, patient safety, care coordination, patient and caregiver experience, prevention and population health, and affordable care.

The buzzwords are familiar, but how they’re supposed to fit together under MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payment System) is unclear. MACRA repeals the Sustainable Growth Rate (SGR) and laid the groundwork for MIPS. MIPS brings the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), and Meaningful Use (MU) together under one umbrella, but it also adds in clinical practice improvement activities.  

“There’s a lot of overlap, so there’s been confusion,” said David Levin, MD, professor and emeritus chairman of radiology at Jefferson Medical College.  

To successfully participate in MACRA and MIPS, you must report on your performance in a wide variety of areas, but you might still be wondering about how much reporting you’ll be asked to do.


In October, the Centers for Medicare & Medicaid Services (CMS) did offer some clarity on how you can best comply with the new regulations. The reporting requirement and preparatory phase begins Jan. 1, 2017, but you won’t be penalized or rewarded for your performance until January 2019.

To ease you into the programs, CMS is giving you three ways to participate:

1. You can report on a full set of required quality metrics for at least 90 days. That means you can postpone any activity until October 2017, and it can still possibly lead to some positive payment adjustments.

2. You can report on at least one required metric in each quality, clinical problem improvement, or advancing care information – but not on cost – for at least 90 days. This can result in a small positive payment adjustment.

3. You can report on one required metric in quality, clinical problem improvement, or advancing care information for any period of time. This is the easiest option, and it lets you avoid a MIPS penalty.

If you participate for the full year, you’ll get the maximum positive payment adjustment, but if you don’t participate in at least one of these options, you’ll incur a penalty in 2019.[[{"type":"media","view_mode":"media_crop","fid":"57254","attributes":{"alt":"Payment models in radiology","class":"media-image media-image-right","id":"media_crop_1961999564174","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7209","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Aha-Soft/Shutterstock.com","typeof":"foaf:Image"}}]]

Be aware, though, Levin said, that, like Meaningful Use, radiology could have a tougher time fully complying with MACRA and MIPS. The administrative and financial burden on you could be substantial because your reimbursement will still be attached to how well your referring physicians comply with the regulations. This could lead to difficulty for small and solo practices, he said.[[{"type":"media","view_mode":"media_crop","fid":"57254","attributes":{"alt":"Paymen models radiology","class":"media-image media-image-right","id":"media_crop_8586127620153","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7209","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" Â©Aha-Soft/Shutterstock.com","typeof":"foaf:Image"}}]]


Radiology’s ultimate goal – as with most programs – is to demonstrate the value it brings to the table – how it improves patient experience and contributes to care delivery alongside referring physicians, said Raymond Geis, MD, vice chair of the American College of Radiology (ACR) Commission on Informatics.

CMS plans to divide providers into two main categories – patient-facing and non-patient facing. In radiology, patient-facing providers will likely be mostly interventional radiologists, but some diagnostic radiologists, such as breast imaging providers, could fall into this category, as well. The lion’s share, though, will be non-patient facing, he said. Those of you in this category will have fewer reporting requirements, and if you work in a hospital, it’s possible you can rely on the hospital’s certified electronic health record (EHR) to document your activities.

And, everyone who participates will be scored on a scale of 0-100. The closer you are to 100, the better your payment adjustment will be. Remember, though, that the program is budget neutral, Geis said, so the adjustments will be shared across the population of high performers.


To help you acclimate to MACRA and MIPS, ACR has several tools at your disposal to make the process less painful.

You’re probably already familiar with this commercially-available tool. It helps with your ordering, working as a web service, integrated into your EHR, that reminds you and your referring physicians of ACR’s appropriateness criteria. Use it, and you’ll show you can treat patients better and cost the health care system less.

 This communication tool makes information flow easier between vendors, individuals, and communities that use ACR products and services. It includes application programming interfaces between vendor products used by facilities local to you, as well as Single Sign On to ACR applications through your ACR ID. The goal is to make your work more efficient and to automate whatever possible.

This clinical decision support program offers structured clinical guidance that can be easily integrated into your daily workflow. It includes raw clinical content and a communication framework that makes content delivery easier. This tool’s intent is to provide content in a structured, vendor-neutral manner that lets reporting vendors offer guidance during interpretation when it’s most useful to a radiologist. It’s anticipated to help you increase your read volume.

 Think of this tool as a stylebook for you and your colleagues to use when you input data and findings into your EHR. It brings together existing ontologies and coding schemes, such as RadLex Playbook, SNOWMED, CPT, and ICD9+ and is organized around scenarios, procedures, and findings. Think of ACRcommon as a phrase book for a trip to a foreign country, Geis said. It has the lexicon you need to make recording results as easy as possible.

These tools are designed to help you with your knowledge management, he said. As electronic deliverables, they will dramatically impact your reading and dictation time. So, even with all the hoops to jump through and twists-and-turns ahead, Geis said, radiologists have a bright future with MACRA and MIPS.

“MACRA will dent things, but it will not wreck us,” he said. “ACR and other radiology informatics organizations are making strides in defining tools that allow us to achieve new data and practice models. I’m cautiously optimistic that, if done right, we might have smooth sailing ahead.”

Radiology leaders are cautiously optimistic about payment programs.

MACRA, MIPS, and Radiology

With the advent of speech recognition software and computer-aided diagnosis (CAD), the question of whether technology will soon replace radiologists has been swirling around for years.

Now, the introduction of deep learning and machine intelligence has re-ignited this discussion, and industry leaders are fervently discussing what might happen to the specialty in the next 20 years.

At RSNA 2016, informatics experts Eliot Siegel, MD, vice chair of imaging informatics at the University of Maryland School of Medicine, and Bradley Erickson, MD, radiology professor with a focus on computer-aided diagnosis at Mayo Clinic, discussed this controversy.


The past two decades have seen significant advancements in digital tools, Erickson said. If this pattern continues, which is expected, radiologists should be worried that machines will soon take away their jobs, Erickson said.

Mammography CAD has shown machines can be effective at identifying radiological findings the human eye can miss. As deep learning becomes more pervasive, machine’s abilities will only expand, he said.

“Deep learning isn’t biased or limited to human intuition,” he said. “It’s taught important signs. It takes broad images and figures out what’s important. Computers can find features that aren’t humanly perceptible, but they reflect important diagnoses.”

For example, deep learning can be instructed to pinpoint and consider genomic properties with reading studies and contributing to diagnoses.


If you want to see what radiology will look like in 20 years, look back over the previous 20, Siegel said. Speech recognition software and mammography CAD may have hit the scene in the late 1990s, but their improvement has been incremental, at best. The radiologist is still integrally involved in the diagnostic process.

“Mammography CAD has been around for 25 years and was introduced as something that would replace the mammographer,” he said. “According to a recent survey, 89% of mammographers do always use CAD, but do they change their opinions based on what it finds? Only 2% do routinely, and 36% do sometimes. Sixty-two percent report rarely or never changing.”

These technological tools simply haven’t risen to the levels anticipated, Siegel said. Medical images are often too complex for these aids. Extrapolating information from medical images is more challenging than doing so with more simplistic images, limiting the tools’ ability to be as effective as possible.

In addition, Siegel said, getting approval for machines to take a radiologist’s place is impractical from a regulatory perspective. The amount of testing and efforts necessary to secure clearance from the Food & Drug Administration for removing the provider and leaving diagnoses to a machine would be overwhelming. Even though the machines can successfully predict some diagnoses, the judgement needed for more complex, nuanced studies is only available with a radiologist.


Both points of view are likely extremes of the pendulum swing, they said. The next 20 years will bring changes, but they’ll be smaller than many in the industry fear.

As they improve, computers will perform quantitative imaging and biomarker measurements. They’ll also create structured reports that radiologists can review and approve, Siegel said. Dozens of applications in workflow, patient safety, communication, quality assessment, and follow-up opportunities will present themselves, he said, but radiologists will be harder to replace than currently anticipated.

For patients, Erickson added, the combination of radiologists and machines will be beneficial. Together, you’ll see more important findings that are subtle. And, as machines assume more responsibilities, you’ll have more time to devote to patient interaction, leading to greater patient satisfaction and improved patient experiences.

Ultimately, Siegel said, any radiology resident concerned about his or her future should breathe easily. Your job is secure.

“I reassure any radiology resident that contacts me to finish their residency. There will be more radiologists – not less – in 20 years,” he said. “The future is secure with machine learning computers that will be trusted friends. Deep learning machines might read preliminary reports, but they won’t be reading by themselves in the United States. Radiologists will still judge, explain, quality check, counsel, teach, and discover in images.”

Experts discuss whether machines will replace radiologists at RSNA 2016.

For Radiology’s Future, Look to its Past

Regardless of your subspecialty, you’ve probably noticed over the last decade that you’re spending more time interacting with your patients than you used to. As health care models continue to grow and change, that trend is expected to continue and, perhaps, grow.

As radiologists, that means you should augment your skills for incorporating more patient- and family-friendly tactics into how you provide care. Industry experts at RSNA 2016 walked through their experiences in integrating a more patient-centered focus into their workflow.

“A patient’s experience is the sum of all their interactions, and it’s shaped by our organizational culture. It influences their perceptions across the continuum of care,” said Layne Mitchell, radiology administrator for Georgia Regents Health System. “Our job is to relay how that culture really is and to be patient with our patients so they can form those perceptions in a more accurate manner.”


In recent years, Georgia Regents has redesigned both its mammography suite into a spa-like environment and its pediatric radiology area into a more kid-friendly zone. Both times, they brought patients to the table to be part of the decision-making process. In these discussions, Mitchell said, it’s important to be open to patient ideas and to avoid over-promising on what you know you can deliver.

The result has been improved patient experiences and satisfaction rates. But, these conversations also prompted the radiology department to make changes from within.

With the mammography suite, patient feedback taught their radiologists and technologist to slow down and take their time with each patient, so the department built a corner suite where providers can talk one-on-one to patients outside of the waiting room. Doing so helped relieve patient fears and got them more engaged with their care.

The department also empowered its staff to answer patient questions about clinic schedules, wait times, and other activities to minimize the time spent waiting for a clinic manager to respond to queries. They also created an open clinic environment where providers and staff alike felt free to speak up with concerns that affect the quality and safety of patient care.

Fostering a more patient-centered focus in the pediatric areas was a more visual endeavor, Mitchell said. The department worked with Phillips to change the clinic’s stainless steel appearance to one with vibrant colors. They also installed an interactive, touchable wall where children can pop balloons, play air hockey, or shoot off fireworks to take their minds off the studies they’re facing.

In addition, they also installed simulation scanners that children can play with to assuage any fears they might have about the diagnostic imaging equipment.

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The end goal of improving your patient- and family-centered focus is a positive one, but you will face challenges along the way, said Lynn Fordham, MD, pediatric imaging division chief at the University of North Carolina at Chapel Hill.

 Depending on your patient’s age, he or she will interact with you differently. Young children might want to touch some of your equipment. Letting them, as best you can, could help them feel more comfortable. As patients age, they’re better equipped to understand the abstract concepts associated with diagnostic imaging, but be sure you explain what will happen in developmentally-appropriate ways.

 Be sensitive to the wide variety of families you might see – traditional, single-parent, same-sex, and multi-generational. In cases in which you aren’t sure, don’t be afraid to clarify who the patient is and who is responsible for him or her.

 Connect to services within your hospital or facility that can provide an interpreter for non-English speaking patients, if necessary. It’s the only way to ensure your patient has a good understanding of his or her care.

 When explaining results, it can be helpful to have an idea about your patient’s occupation and education level. That will help you explain findings in ways they can best understand. For example, if you’re discussing a gastrointestinal blockage with a plumber, referring to pipes being clogged will be an easy metaphor to explain what’s going on, she said.

 You work under time constraints, but resist the urge to deliver your findings and move on to your next appointment. Give your patients time to react to any news you provide and to ask questions. Have them repeat what they heard back to you so you know they understand any findings or next steps.


Even with all the patient surveys and conversations that garner patient feedback, it can be hard for you to understand your patient’s perspective if you’ve never been in their shoes. If you see through their eyes, you could decide to change the way you practice, said Jennifer Kemp, MD, a private-practice body imager with Diversified Radiology of Colorado. The experience she had as a caregiver when her husband developed cancer was a game-changer.

“Was I clueless? I probably was more naÃ¯ve than most radiologists are,” she said. “Being on the other side of medicine has helped me learn to be more empathetic.”

1. Cancer is an emergency for patients. Don’t push your cancer follow-up studies to the bottom of the pile or leave them over the weekend. Your patients are waiting for these results to know whether they need more chemotherapy, if they’re cured, or if they need hospice. Give them answers as soon as you can.

2. Medicine is inherently uncertain, and that can be frustrating for patients who are looking for definite answers. As a radiologist, she said, you know findings can be indeterminate. So, if you can’t rule out certain diagnoses, say so. But, do try to give patients as much specificity as possible.

3. Patients are scared, and that fear often presents in many ways. They might be grouchy or mean. They could appear anxious or irrational. Do your best to remember their actions come out of worry, and try not to take it personally. Keeping your patients informed of what’s going on in the clinic, such as if there’s a delay that will push back their appointment, can also help them manage their emotions. Knowledge helps them feel empowered, she said.

4. Patients wait with bated breath to talk to you. They listen closely to what you say, so try to be as clear as possible when you explain your findings and what will happen next. In their minds, you’re the source of their next plan. Take a few extra minutes to make them part of an in-depth conversation about their care. It could make a big difference in the kind of day they have, Kemp said.

Regardless of the changes you make, though, Mitchell said, don’t ever think you’ve maximized the ways you can augment your patient’s experiences.

“Don’t rest on your heels, and never give up the idea that you have to constantly and continuously improve,” he said. “Stay involved with your patients. Have patient committees. Let them come to staff meetings and talk with staff members. Give them plenty of opportunities for feedback. Hopefully, it will ignite a passion in you to make every day special for every patient that walks through your door.”

Tips on how to become more patient-centered in radiology. 

Promoting Patient-centered Care in Radiology

For the past few years, radiology leaders have talked about the spread of accountable care organizations (ACO) and where radiology can fit into that model. Questions still exist about the role radiology can play, and the general consensus is that the specialty’s participation level is still unclear.

According to Suresh Mukherji, MD, chairman of radiology at Michigan State University, the confusion stems from the wide variety of ACO models that exist and their overarching nature.

“ACOs are designed at a very high level,” he said. “They’re based on an aggregate practice plan that compares practices and departments to a benchmark. But, the benchmark is variable.”

Still, some characteristics of how radiology can operate within the ACO model are coming into shape.


Overall, ACOs assign a patient to a specific health system, channeling all billing for services rendered through that one facility. It’s difficult to tease out individual costs associated with individual procedures, and there’s currently no line item for radiology, Mukherji said.

If you work for an academic practice associated with an ACO, the entire group bills under the same tax ID, so you aren’t responsible for filing your own paperwork. Be sure, though, that you discuss how payments will be distributed if you choose to enter this type of arrangement, he said.

Still, payments aren’t likely to be uniform across all ACOs, Mukherji said. Your reimbursement will be largely tied to your quality performance, but what qualifies as improvement isn’t in sync – it can vary from facility to facility and from payer to payer. For instance, Michigan State University received a value-based bonus from Blue Care Network for a 63.8% drop in outpatient utilization, but the same performance didn’t satisfy improvement criteria under Blue Cross Blue Shield of Michigan.[[{"type":"media","view_mode":"media_crop","fid":"55690","attributes":{"alt":"Physicians","class":"media-image media-image-right","id":"media_crop_6826476479750","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6978","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©attem/Shutterstock.com","typeof":"foaf:Image"}}]]


Moving to the ACO model has created a shift in focus throughout the health care industry. Instead of focusing on the individual patient one encounter at a time, population health is the main concern. It’s a new way of thinking, said James Whitfill, MD, chief medical officer for Scottsdale Health Partners, especially for radiology whose practitioners have spent their professional lives dealing with one study at a time.

Short of reading more scans more quickly, many in the industry have worried how the individual radiologist fits into the ACO model. According to Mukherji, active, effective participation means a change in your daily workflow. ACO-associated radiologists consult with referring physicians more to educate and encourage appropriate imaging utilization while helping facilities side-step inappropriate and redundant studies. It’s your way of helping to control costs and improve patient safety.


As the ACO model has spread, it has continued to draw radiologists out of the reading room, pushing them into more visible roles within their facilities, said Rodney Owen, MD, a private practice radiologist with Scottsdale Medical Imaging.

Whenever possible, he said, you must volunteer to sit as a board member or to serve on a quality improvement or information technology committee. It’s critical, he said, because it gives you and your colleagues a voice in how imaging will be used and viewed going forward. Speaking up can ensure any imaging at your facility will be done appropriately and at a reasonable cost.

In addition, consider adding subspecialists to your department or practice. Having those skills available makes you a more valuable partner to referring physicians.

It’s also important, Mukherji said, to have a firm understanding of how your practice will choose to measure its own quality performance. Knowing the quality and performance metrics will help you stay abreast of how you’re being evaluated.


Although figuring out how radiology fits into an ACO can be confusing, there are things you can do to maximize your performance under this model.

For example, Radiology Consultants of the Midwest devised a three-legged workflow design that has benefited the overall practice, said Patricia A. Helka, MD, the practice’s past president. To ensure the practice offered the best service to referring physicians and patients, providers focused on call reporting, concierge radiology, and traveling interventional radiology.

With call reporting, each provider is required to call a certain number of referring physicians to discuss findings each day. These conversations offer providers the opportunity to build stronger relationships by sharing more nuanced test results, she said.

The practice also offers concierge service, offering subspecialty reads for referring offices on certain days. Having a set schedule has increased patient satisfaction, led to more conversations about appropriateness guidelines, and presented chances for more timely feedback.

By including traveling interventional radiology in its workflow model, Radiology Consultants has been able to expand its service reach to smaller or more rural offices that don’t have these types of providers on staff.

Overall, Helka said, the practice has flourished by changing its workflow to include more than just standard study reads. Within a year of implementing this system, the practice saw a 10% jump in referrals, as well as an uptick in questions about appropriateness guidelines. Patient satisfaction also ballooned by roughly 95% because they received results faster and had more personal contact with the radiologist reading their scans.


While the specific benefits to radiology for being involved in an ACO model are few, participating does get the specialty more involved in the direction health care is headed in the future, Mukherji said. If you sign up to be part of an ACO, you will play a role in how the overall health care industry will complete its paradigm shift toward population health. You’ll also be an active participant in value-based care and won’t be penalized for not contributing.

Still, transitioning to the ACO model hasn’t been easy, he said. The American College of Radiology, through Imaging 3.0, has offered some insight into how several ACOs have tackled the process. However, uniform guidelines for how you’re supposed to organize your daily workflow haven’t been available.

“Departments and practices have been left to decide how to use clinical decision support and make decisions about how to structure their departments,” he said. “Overall, ACO has not been a successful model for radiology.”

While it’s challenging for individual offices or departments to realize significant benefits from being ACO partners, the specialty is supporting the health care industry’s new path by working with referring physicians to control imaging utilization, ensure images performed are appropriate, and control costs. Overall, the impact will be an increase in quality, he said.

If you make sure your practice or department maintains this focus, you’ll be successful ACO partners. Just be sure you devise a strategy that will maximize your quality metrics as you go forward.

“Radiologists must be involved,” Mukherji said. “We have to have a seat at the table and sit down and be involved with any discussions.”

This series focuses on what it’s like to be a radiologist in a variety of settings. Here, we focused on accountable care organizations.

Radiology in ACOs

Maybe you’re in the beginning stages of your residency or maybe you’re about to officially embark on your radiology career. Either way, there’s a chance you have questions about how to best set yourself up for financial success.

Financial experts at RSNA 2016 offered guidance specifically for you. Ross Cameratta, financial advisor with North Star Consultant, Inc., presented tips you can start to implement today.


It’s important to remember, first, that not all debt needs to be repaid immediately unless you can’t bear having it hanging around. Any debt at a 0% to 5% interest rate, such as a mortgage, can actually be beneficial to you in the long run for tax purposes, but debt with interest rates above 8%, including credit cards, should be paid down as quickly as possible.

Your student loans, though, hover in the grey 5% to 8% area, and Cameratta said there are several ways you can choose to pay down these loans. Choose the path that’s best for you.

 This option allows you, based on your income in residency and the size of your loans, to defer payment until after you finish your education. The loan does accrue interest, and it’s added on to the overall amount of the loan once you begin repayment.

 Like a mortgage, you can go to a lender and have your monthly payments calculated out for 5, 10, 15, 20, or 30 years. This would be your payment for the life of the loan.[[{"type":"media","view_mode":"media_crop","fid":"55362","attributes":{"alt":"Ross Cameratta","class":"media-image media-image-right","id":"media_crop_8736718380198","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6930","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Ross Cameratta","typeof":"foaf:Image"}}]]

 This program is a way for you to get out from under your student loan debt within 10 years without having to pay all the money back, but you must fulfill certain requirements. You must make 10 years of on-time, qualifying payments, and you must work for a 501c3 non-profit institution. Prove you’ve done that, and the federal government will forgive the rest of your loan tax free.

You can also take your student loans away from the government and move them into the private market if you choose to go into private practice. Banks might be able to offer you a better interest rate than the government can. Be warned, though, that once a bank buys your loan, the government will never take it back. You could benefit from leaving your loans with the government for six months before deciding if private practice is, indeed, the career path for you.


Saving money during residency is hard, Cameratta said, but it’s necessary. Your goal should be to build up between 3 months and 6 months of on-hand cash reserves either in checking, savings, or money-market accounts. This money can protect you and keep you afloat in case anything unforeseen happens in your life.

Get into the habit early, he said, of automatically putting away at least $50 into savings. It helps form a habit, and you can increase the amount as your income grows. It can also help you kick-start your retirement savings.


There are policies that are meant to simply protect you from things you don’t see coming – disability, life, auto/home, and umbrella insurance.

 This type of insurance can be particularly helpful, especially if you are the breadwinner in your family. If you lose the ability to work, disability insurance can help you and your family maintain your lifestyle without descending into debt. Shop around for the best policy that will meet your needs.

 You can choose between term insurance for 10, 20, or 30 years, or you can choose a whole-life policy that stays with you forever. Premium rates, based on your health rating, are locked in, so your payments stay the same. 

 These are largely required by state law wherever you live. Check your state requirement to ensure you’re covered at least to the minimum standard.

 Largely overlooked, umbrella insurance can come in handy if you’re ever sued or involved in an accident. It can protect your major assets, such as your home or income, by adding an additional layer of insurance coverage.


At the beginning of your career, the end of your career seems far away. But, it will be here sooner than you think, Cameratta said. Making plans for retirement now will only help you in the longer run.

Overall, he said, you should try to save 20% of your income for your retirement years. Take advantage of every avenue available to you to pad your nest egg.

If your employer offers a match, do it – it’s free money. If not, a Roth IRA is a good option. You can put up to $5,500 into it annually. Other employer-sponsored programs, such as the 401k and 403b, also work well. You can put a maximum of $18,000 into them yearly pre-tax, reducing your taxable income.


Planning for your financial future can be complicated and overwhelming, especially as you’re starting a career. There are common pitfalls you can avoid to stack the deck in your favor and set yourself up for greater success.

1. Don’t overbuy your first home. Keep the sticker price to between 2-to-2.5 times your family income.

2. Don’t spend too much or put away too little money into savings.

3. Don’t put off saving money. Start now.

4. Choose a strategy for your debt and risk management.

5. Engage in estate planning. Set up a will or trust.

6. Automate your savings contributions. The more you spend the money, the harder it will be to convince yourself to save it.

7. There’s never a “right” time to start building your financial strategy. Get started now.

8. Don’t go it alone. Educate yourself and work with a professional who can guide you on which options and strategies are best for you.

9. Avoid getting all your financial education from Google. As a healthcare provider, your financial needs are different, and most financial advice won’t apply to you.

10. Make provisions for your retirement on your own. Don’t assume employer-based retirement plans will be enough to sustain you.

: North Star Consultants, Inc. - Insurance Products and Services.  CRI Securities, LLC (CRI) - Securities and Investments. Securian Financial Services, Inc. (Securian) - Variable Products and Securities.  North Star Resource Group (NSRG) offers securities and investment advisory services through CRI and Securian, Members FINRA/SIPC.  CRI is affiliated with Securian and NSRG.  NSRG is not affiliated with Securian. NSRG is independently owned and operated. 2701 University Ave. SE Minneapolis, MN 55414.  Ross is a registered representative and investment advisor representative of CRI and Securian. 1896637/09-2017

Financial planning for radiologists, from RSNA 2016.

Finance 101 for New Radiologists

It’s almost become old hat. Another year, another electronic data breach. You might not be surprised anymore, but you should still be worried. Not only is the number of patients affected when a health care facility is infiltrated growing, but the types of cyberattacks are also changing.

And according to industry leaders at RSNA 2016, health care isn’t paying close enough attention to how best to handle the problem.

“Health care IT security has the wrong mission and the wrong approach,” said James Whitfill, MD, chief medical officer for Scottsdale Health Partners. “It’s focused on medical records and compliance. It’s not worried about events. Regulations have been the only motivator, and it’s a lousy one. Regulations don’t work well because they only protect against the most unsophisticated attacks.”


Over the past year, health care has seen an uptick in a new type of cyberattack called Ransomware. This attack infiltrates your system through an innocuous-looking email and installs software behind the scenes to encrypt data. Once it controls all your information, the system is locked, and hackers demand payment to release it.

More and more hospitals are falling victim, Whitfill said, and the problem is two-fold. Not only is your patients’ private health information – including diagnostic images – in jeopardy, but you’re also prevented from providing care because you can’t access medical records or any other programs.[[{"type":"media","view_mode":"media_crop","fid":"55302","attributes":{"alt":"James Whitfill, MD","class":"media-image media-image-right","id":"media_crop_6603239845501","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6921","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 170px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"James Whitfill, MD","typeof":"foaf:Image"}}]]

If you don’t pay to have your hijacked system unlocked, he said, it could be sold to the highest bidder. On the black market, the medical record for one patient costs approximately $50. Multiply that by the number of patients seen at a typical hospital, and the price tag balloons. Some electronic medical record databases can sell for more than $100,000.


In the past, financial gain was the main impetus for stealing health data, Whitfill said. It could either be sold for identity theft, used for extortion among celebrities or politicians, or used for fraudulent billing. The danger has grown, though, to include attacks on public health.

It’s now possible for nation states and terrorists to gain access to large swaths of private health care data. The information could be used for both targeted and untargeted attacks.

This type of data breach is particularly dangerous because it grinds your ability to provide care to a halt. You can’t perform any diagnostic studies, and if the shutdown continues for an extended time, that could put patients’ lives at risk, he said.


Once Ransomware infects your system, there’s virtually no way to uninstall it yourself. So, your priority must be preventing infiltration, Whitfill said. Unfortunately, it’s getting harder to identify the fraudulent emails hackers use to gain access to your records. The best defense might be to trick your own employees in the name of education.

“One of the primary things you can do is educate your employees by sending out your own false email to see who clicks on them, and then go talk with these folks,” he said. “The days of issuing the general warnings of ‘Don’t click on things that look funny,’ are over. These things are very difficult to figure out.”

As radiologists, you can help protect your institutions, though. Take and support anticipatory steps to lead the charge:

1. Assume you’ll be hacked at some point, and keep an eye out for any tracks that can show you how it happened.

2. Make the case for keeping your security and IT departments separate. They have different goals and should operate independently.

3. Don’t allow any unprotected USB devices to be used in your network.

4. Consider keeping your patient information on a separate network from any other information you use in your practice.

Cybersecurity in radiology, from RSNA 2016.