'Scientific management' takes over radiology

November 1, 2007

My physician friend "Bob" recently got fed up with his traditional family medicine practice and dropped out. He didn't quit medicine but decided to buck the rules and reimbursement schedules of third-party payers and create a boutique medical practice.

My physician friend "Bob" recently got fed up with his traditional family medicine practice and dropped out. He didn't quit medicine but decided to buck the rules and reimbursement schedules of third-party payers and create a boutique medical practice.

He argued that third-party payers had transformed his practice into an assembly line, where patients were treated like widgets and rapidly matriculated through his practice on predefined cycles. If a patient came in for a blood pressure check and adjustment of medication, that person was largely relegated to the nurse, who consulted with Bob for 30 seconds. The patient was then sent on his or her way, prescription in hand. A new patient coming into the practice for a routine history and physical would be given the "first available appointment" three months later.

At that point, if patients were still desperate and healthy enough to wait, they were first given a detailed medical history questionnaire to fill out (after completing the requisite insurance forms), followed by a personal interview and vital signs check by the nurse, and then a quick "pop in" by Bob, who within a five-minute span simultaneously introduced himself, exchanged pleasantries, reviewed the medical history, and did a physical exam. Any patient who had an active medical problem or complaint would be told that this would have to be deferred to a follow-up appointment.

Bob was not a happy camper, and neither were his patients. While everyone rationalized that modern medical care had largely been redefined by a combination of changing medical economics, increased dependence on technology, heightened medicolegal risk and associated skyrocketing malpractice insurance costs, and depersonalization, none of this justified the transformation. Increasingly frustrated, Bob decided to make a wholesale change and shut the doors on his traditional medical practice. He was too young to retire, had a young family to support, and still felt passion for his chosen profession.

Bob decided to tell the insurance companies he would no longer accept their payment plans and created a prepaid medical practice: Patients would pay an upfront fee in cash for admittance, along with a nominal back-end fee, depending on the scope of required services. By transforming his medical practice from assembly line to custom order, Bob rediscovered his passion for medicine, reconnected with his patients, and actually had more money in the bank after overhead expenses were paid. He had taken a major leap of faith and defied conventional logic as defined by the third-party payers. In the process, he defined his success in terms of quality, rather than quantity.

While this story is refreshing and inspirational, the scenario may seem improbable and unrealistic. Readers could argue that the current system is not designed to reward quality but forces us to maintain economic viability through high-volume output. After all, there are two simple ways to boost profitability: increase revenue and reduce costs. Since profit margins are largely fixed by third parties and constantly trend downward, a basic tenet of Marxist economic theory, the only practical means to increase profitability is to increase volume and/or reduce operational costs. We see these two strategies in everyday practice, regardless of medical specialty-including radiology.

By leveraging technology and automation, physicians can become more productive and achieve higher levels of output, thereby generating more revenue. At the same time, they can cut operational expenses by reducing personnel needs and expenses through automation and outsourcing. Hiring a radiology assistant to replace a retiring radiologist or using computerized decision support technologies such as CAD is an example of this approach.

Technology has become a great enabler of the assembly line radiology practice, for it has transformed workflow from time-intensive, human-driven tasks to time-efficient, computer-driven tasks. Many examples of this transformation can be seen throughout all phases of the imaging cycle, which begins with the ordering of an exam and ends with the receipt of the report.

It wasn't so long ago that paper, film, and sneakers were the modus operandi. Within the hospital imaging department, hand-carried paper requisitions were submitted for the ordering of a study. A clerical staff person would take the paper requisition and manually transfer the order information into a book, where a technologist or administrator would be assigned the task of scheduling the exam at the appropriate modality.

In addition to the potential inefficiencies that come with multiple hands in the pot, the process took several days from the time of the initial order to exam completion. This created backlogs in the imaging queue and lost revenue from order cancellation. If not performed promptly, a head CT request for headaches was often canceled once the symptoms spontaneously resolved. The advent of computerized order entry, integrated with the radiology information system, PACS, and electronic medical record have made the ordering process automated, efficient, and timely. The electronic order submitted at 9 a.m. typically results in exam completion by 11 a.m. and a generated report by 3 p.m.

ASSEMBLY LINE PARADIGM

From the technologist perspective, the new paradigm of assembly line radiology has resulted in optimized workflow. The technologist is no longer tasked with clerical chores such as scheduling, film/report retrieval, film processing, collating, and hanging and can now dedicate time to image acquisition and quality assurance. While this creates greater operational efficiencies, technologists often complain of fatigue and frustration as productivity measures and patient throughput take on greater emphasis.

Administrators often assess individual technologist performance based on quantitative measures, such as annual exams per full-time equivalent, which in turn are often tied to economic compensation in the form of bonuses and salary increases, perpetuating the focus on quantity over quality. This preoccupation with quantity is further aggravated by the relative conflict of interest that exists with current quality assurance practice, which assigns primary QA responsibilities to the same technologist who performed a study. If that technologist is being evaluated and compensated based on quantitative measures, there is a direct motivation to limit retakes in order to enhance productivity. The lack of rigorous QA oversight and standards further perpetuates the quantity over quality mindset that permeates the existing imaging practice mentality.

One would think that the proverbial buck would stop with the radiologist, who as the de facto imaging expert would ensure that quality concerns and vigilance are maintained. Unfortunately, in most practice environments, radiologists are as consumed as their administrative and technologist counterparts with productivity measures. A radiologist who "stops the assembly line" to request a repeated exam not only slows down his or her own workflow but also risks alienating colleagues who perceive the quality-centric radiologist as a disruptive force intruding on operational efficiency. The QA culture within each enterprise can create an environment of permissiveness as it relates to suboptimal quality, in which radiologists learn it is far easier to "read whatever comes your way" than to mandate change and accountability.

Radiologists learn subconsciously to compensate for these quality inefficiencies by introducing ambiguity and uncertainty into their reports, along with recommendations for follow-up imaging studies. While this practice may be counterproductive in terms of optimal patient care, it maintains the speed of the assembly line (i.e., operational costs), while potentially increasing revenue through additional follow-up imaging studies. A repeat exam costs time and money to the operator (economic loss), while a follow-up exam generates additional money (economic gain).

This quantity over quality philosophy permeates radiology, but it may change with the impending introduction of pay for performance (P4P) programs, which mandate a portion of reimbursements be tied to quality metrics. The success or failure of this quality transformation will in all likelihood depend on the proportion of total payment tied to quality metrics and the rigor and objectivity of the quality metrics themselves.

If a radiology provider determines in his or her own cost-benefit analysis that it is not cost-efficient to spend additional time, energy, and resources on improving quality metrics, that person may elect to continue with the existing assembly line practice paradigm. Another provider, on the other hand, may determine that quality measures are critical in both economic and philosophic terms and invest the necessary resources to improve quality.

QUALITY PRACTICE MEASURES

Just as technology has created new opportunities for workflow optimization and productivity gains, it also has the potential to transform quality practice measures. The creation of universal QA standards, objective QA metrics, and searchable QA databases provides the means to track and analyze QA deliverables in reproducible terms. At the same time, new computerized technologies can provide tools to improve quality performance in everyday practice. Examples of such technologies include artificial intelligence for diagnosis (e.g., CAD), natural language processing and robots for database mining, and automated templates to standardize and objectify QA image review and analysis.

The end result of this quality-focused synergy may be the creation of an imaging provider registry where radiology consumers may shop for services, balancing their competing expectations for quality and cost-efficiency. An individual patient, for example, who would be willing to pay a premium price for superior service could use the publicly disseminated quality data mandated by P4P legislation to select the appropriate provider. Another consumer could select a provider with a lower quality profile who offers services at a lower cost.

Consumers may define the trade-offs they are willing to accept between cost and quality. This can promote teleradiology on a global scale, with the introduction of objective and standardized quality metrics to prevent radiology from becoming a simple commodity.

Such a radiology registry also provides the means by which radiology providers can extend their breadth of services beyond image interpretation. Radiologists can become true imaging consultants, offering a bevy of billable services that differentiate them from their clinical colleagues, many of whom believe they can interpret medical imaging studies as well as or better than their radiologist colleagues. These services can include radiation safety, quality assurance, image processing, decision support, and imaging economics.

Radiologists who would like to extend their roles as consultants, patient advocates, researchers, and educators would now have the opportunity to be paid for their efforts in accordance with what the market would bear. The market would determine what these services are worth and reward those practitioners creating the greatest value for their customer base. At the same time, technology vendors could provide a marketplace more receptive to developing new quality-centric technologies that can be added to the current crop of such technologies.

The net result is not far removed from the boutique practice Bob has created and prospered in. He elected to remove himself from the assembly line practice mentality and focus on individualized, quality-centric practice. In return for this improved and personalized service, his patients have agreed to pay a premium.

While radiology providers do not have the luxury of their own patient practices, they do have the ability to redirect their practice from assembly line, quantity-oriented practices to more futuristic, quality-oriented practices. The marketplace will determine how economically viable this approach is and whether it can withstand the scrutiny and wrath of politicians and insurance companies. I relish the opportunity to slow down and do it right.

Dr. Reiner is director of research at the Baltimore VA Medical Center in Maryland.