December 2016

Distributive Properties: Enhancing Workflow With Distributed Radiology Services
By Timothy W. Boden, CMPE
Radiology Today
Vol. 17 No. 12 P. 26

After 23 years with the Cleveland Clinic, William "Bill" Lawrence accepted the CEO position at the 118-bed McLaren Central Michigan Hospital. Part of the 12-hospital McLaren Health System, the Mt. Pleasant, Michigan, acute-care hospital has successfully held its own in a competitive environment. McLaren's catchment area encompasses seven ZIP codes with a population of about 60,000. Like many hospitals, it employs about 75% of its medical staff, relying on McLaren's Medical Group for practice management.

When Lawrence arrived at McLaren eight years ago, a three-physician radiology group provided exclusive services under a fairly traditional contract. The CEO didn't notice any particular clinical quality issues, but ordering physicians complained that radiology reports were uneven—inconsistent in delivering the information they needed to make sound decisions. Turnaround times for imaging orders left something to be desired, as well.

Lawrence admits there were some significant gaps in the services and modalities offered at McLaren eight years ago. In other words, McLaren's radiology services were unremarkably average—just about what people had come to expect at a hospital of its size. The CEO suspected they could do better.

Even though McLaren has consistently enjoyed a healthy bottom line and steady 1% to 2% annual growth, its small size prevented the development of sophisticated imaging services using the traditional model of local providers. Small- and medium-sized institutions across the country face a similar dilemma: How can they take advantage of the technology advances driving modern radiology? The price of entry keeps rising.

A number of major vendors—including industry giants like McKesson Corporation—have taken up the challenge to provide world-class services and optimized workflow at the local level. McKesson's Jordan Lister, senior manager of business development for McKesson Medical Imaging Professional Consulting Services, outlines his company's strategy for addressing workflow in the following four areas:
• reducing exam repeat rates;
• developing and managing referral sources;
• providing adequate call coverage; and
• eliminating work that adds no value.

McKesson focuses much of its efforts in improving quality and developing the best possible technology and IT infrastructure for its clients, Lister says. A third component has become critical as well: capacity. Using multiple resources and Lean Six Sigma principles, McKesson's goal is to help clients provide a workforce that is utilized to the degree that meets demand.

Improving Quality
Looking for solutions to improve radiology services, Lawrence contacted radiologist Frank Seidelmann, DO, a recognized leader from his days at the Cleveland Clinic, and learned that Seidelmann, along with radiologist Peter Franklin, MD, had founded Radisphere, a company whose mission was to create a better way to deliver radiology to hospitals and health systems.

The Radisphere solution, Lawrence learned, was to form a large and diverse group of radiologists who could support local medical staffs with 24/7 access to highly respected subspecialized radiologists who accepted accountability for the quality of their work. Developments in broadband technology and teleradiography during the 1990s created a pathway to deliver the goods.

Last year, Radisphere became part of Sheridan Healthcare, the physician services division of AMSURG. Sheridan Vice President of Distributed Radiology Services Glenn Kaplan, MD, says the goal is simple: "It's about having the right radiologist performing the right study at the right time."

To achieve this goal, teleradiology has moved beyond moving images and data around on a network to become something more comprehensive: distributed radiology services. At Radisphere/Sheridan, that means leveraging teleradiological technology to bring the power of a large medical group of more than 400 radiologists to support the physician staff at any hospital—regardless of size or location.

From its earliest days, Radisphere/Sheridan has championed high-quality radiology as one of its top priorities. The founders included accepting accountability for quality as one of the company's absolute core values. Improving outcomes and achieving quality goals are quickly becoming the new holy grail of the American health care system. Improved productivity—the currency of fee-for-service medicine—is about to be replaced as the top priority for measuring provider effectiveness.

As any good CEO would ask, Lawrence wanted to know how much a sophisticated system like Radisphere/Sheridan's offering would cost his hospital. The answer surprised him: Radisphere/Sheridan operates on a fee-for-service basis, so it was willing to shoulder the lion's share of any costs required to get set up and rolling. It didn't take long for McLaren to sign on.

"Our startup costs were negligible," Lawrence says. "Radisphere met us halfway to build the data interfaces."

Lawrence says McLaren has experienced significant quality improvements since contracting with Radisphere/Sheridan. "Turnaround times are stellar," he says. Stat orders are generally filled in one hour or less, and "hyper-stat" orders seldom require more than 20 minutes. Radisphere/Sheridan also maintains a policy of providing detailed error-rate reporting. Using stringent double-blind, peer-review studies, Radisphere/Sheridan keeps overall error rates below 5%, and errors that would have made a difference in diagnosis consistently come in under 1%.

Lawrence says the benefits of contracting with Radisphere/Sheridan have significantly outweighed the costs. Apart from the relatively small startup costs and modest ongoing medical-directorship fees, he says the hospital has "virtually zero radiology costs."

Kaplan says that Radisphere/Sheridan takes on most of the cost burden to provide distributed radiology services for its clients. Using vendor-neutral archives, Radisphere/Sheridan overcomes the challenge of disparate systems sharing data. "The American health system still has a long way to go to achieve the much-discussed goal of complete interoperability," Kaplan says. For the time being, his company employs a strategy of being the flexible end of the interoperability equation, adapting to systems in place—as much as possible—at client hospitals.

Augmenting — Not Replacing — Local Physicians
Radisphere/Sheridan's specialized radiologists bring new possibilities to clinicians—especially at smaller facilities and health care systems, but Kaplan is quick to point out that the company's business model is designed to enhance the work of local doctors, not replace them. Even with highly trained experts available from a distance, radiologists who deal with referrers and rad techs on a face-to-face basis are still needed.

McLaren, for example, has a full-time interventional radiologist who also provides supervision for fluoroscopic studies and guidance for local technologists. McLaren's rad techs adjusted fairly quickly to a different style of supervision that included working with physicians who read images remotely.

IR specialist Rami Safadi, MD, has played a key role in the human interface at McLaren. He has been able to help facilitate smooth-running operations, even while growing his own endovascular and peripheral vascular practice. In fact, his work at the hospital's Heart & Vascular Center has developed into one of McLaren's differentiating service lines. It enjoys a reputation as the place to go for vascular work in the region.

Physicians—especially veteran staff members—often resist rethinking radiology services to such a degree. Both radiologists and ordering physicians worry about losing the collegiality and relationships that make care teams effective. Lawrence observes, "You might hear an old-guard doctor wistfully long for the old days when he could just 'grab a cup of coffee and wander down the hall to talk to "Charlie in radiology" about a case, a problem, or just to shoot the breeze.'" But partnering at a distance doesn't necessarily preclude good, professional relationships.

Lawrence recounts how one of his senior orthopedic surgeons developed a strong personal relationship with Franklin. The orthopedist had access to one of the nation's foremost experts in musculoskeletal imaging, and he deeply appreciated how his own practice was enhanced by the fact that he had Franklin's cell phone number in his pocket.

Radisphere/Sheridan pays attention to the need for that kind of chemistry. Successful radiology groups recognize that not every member of the staff needs to have a lot of interaction with referring physicians. It makes sense to assign front line duties to the personalities who relate easily to other specialists. Radisphere/Sheridan doesn't try to make every one of its 400-plus radiologists directly available to every hospital—except as needed. The company aims for the right combination of onsite presence with offsite size and subspecialty expertise.

Maintaining professional relationships and a culture of care teams helps avoid one of the challenges facing radiologists today: becoming commoditized. Kaplan notes that without a care team approach, "We all risk becoming nothing more than replaceable widgets." No one wants that, so Radisphere/Sheridan makes every effort to ensure that its clients' radiology departments maintain a local flavor and build relationships based on trust and respect. That kind of confidence assures good care continuity.

— Timothy W. Boden, CMPE, has spent 30 years in practice management as an administrator, consultant, journalist, and speaker. He has led medical groups of various specialties, authored or edited eight books and hundreds of articles on practice management, and has made dozens of conference presentations. He resides in Starkville, Mississippi. Contact: tboden@aol.com; 662-616-9978.