The Practice CIO: Driving Business Innovation
CIOs are playing a key role in moving the clinical and business operations of the radiology practice into the 21st century A funny thing happened on the way to PACS: As large radiology practices adopted the software and technology to create distributed reading solutions for multiple clients, they found themselves contending with a growing number of issues concerning servers, software, and networks. Initially, these practices hired an IT person, whose duties became increasingly complex as IT solutions were applied to an expanding array of clinical, business, and operational problems. When chief executives and shareholders recognized that IT touched every aspect of their practices, some of them made a place in the executive suite for a CIO. Radiology Business Journal gathered the CIOs of four of the country’s leading radiology and outpatient imaging practices for an electronic roundtable discussion focused on their executive roles in their respective practices. Their experiences illuminate the transformative impact that IT is having on the modern delivery of radiology services. RBJ: What are you working on now? Whitfill: Today, my key responsibilities include ensuring that the overall information-services operations of our practice are running well and that we use technology in a manner that supports our practice’s primary mission: to be nationally recognized leaders in medical imaging. Within that, I ensure that all people and departments have the correct tools for using technology to advance their goals. As a physician, I also serve as a trusted conduit between physicians and information services—someone who can understand both sides of the information-services equation. Data analysis and workflow analysis are essential to the optimal use of our technology for strategic and operational excellence. Today, our department has five times the staff and 20 times the number of pieces of equipment and software tools as when I started. I used to be able to be an expert in every part of the department, but today, I rely on my team leaders to be those experts; I ensure they have the support to excel in what they do. Today, I am more of a conduit between all of these pieces than an expert in some. That also means I have to filter through a huge amount of information and work across a more complex organization to ensure that we are all aligned on the same goals. Thomas: My staff and I are working on a number of different projects: We are expanding our storage area network infrastructure; moving ahead with our virtual-infrastructure direction by beginning to migrate a number of production servers to virtual servers; rolling out server-based computing and thin clients to our remote users (and in future phases, we hope, slowly migrating our entire environment to thin clients); redoing our Border Gateway Protocol routes; and implementing an email archival appliance. My immediate staff and I also are training to become Information Technology Infrastructure Library (ITIL) Foundation certified. Mitchell: As usual, there are many items on my plate. Right now, I am working on implementing voice recognition for radiologists in our systems. I am also assessing the impact of the American Recovery and Reinvestment Act of 2009 (ARRA) on our practice. In addition, I am on the North Carolina Health Information Exchange Council, helping to define the health information exchange (HIE) structure within North Carolina. Whelan: My focus is on fulfilling our e-business strategy and moving nearly every transaction online. RBJ: What are your key responsibilities? How have they changed since you joined the practice? Whelan: Key areas of responsibility include telecommunications, network engineering, data-center management, PC/help-desk operations, and applications development. In addition to these operational responsibilities, I am spending more and more time on developing strategies that differentiate our services and product from those of our competitors. These include the debut of a multimedia radiology report; online CME for referring physicians within our referring-physician portal; and Pre-cert Tracker, an online tool for referring offices to use in managing exams requiring preauthorization. We also have a number of initiatives that will transition our IT team from a cost center to a revenue-generating business. Thomas: My key responsibilities are to act as a liaison between the business units and the IT department; implement business strategy through technology; and ensure complete satisfaction, among our clients, with the services IT provides. My role has become more strategic than tactical: I plan and my staff executes. I don’t fix a PC because a person cannot do his or her job without one; I think in broader terms: What can I do to ensure that person can do the job without any interruptions at all? Mitchell: My key responsibilities are to provide a reliable, secure, robust, and responsive set of systems that ensure a quality experience for our patients and enable our radiologists and staff to complete their tasks in a timely manner and without interruption. When I joined the practice, we were still using paper for most of our workflow. At that time, my major responsibility was to replace the paper with online systems. RBJ: With all eyes trained on the bottom line, how does the CIO support the gathering of business intelligence? In what other ways are you affecting the financial management of the practice? Mitchell: I am keeping my budget as lean as possible and looking for less expensive alternatives. I am also looking at more flexible tools to analyze business data to provide executives with slice-and-dice and drill-down tools they can use in a dynamic way. Whitfill: During the past 10 years, we have worked to get open access to our data. The next step is being able to translate those data into meaningful and reliable results that are accessible to leaders in our company without having to have information services generate time-consuming reports. In addition, a major pitfall for any firm is not understanding how the data are structured within each system. Without this piece, linking together disparate data sources can easily lead to inaccurate conclusions. When this is done correctly, a practice can more efficiently plan staffing needs and equipment purchases, and it can support management decisions that used to be made using only a gut feeling. Technology often is suggested as a means to improve productivity within any company, but it can be expensive to support. As CIO, it is critical to understand the increased information-services overhead attached to any new project and weigh that against the gains made in other areas. Whelan: IT and finance are driving the development of our Shields Dashboard. We are in the process of defining our business-intelligence data needs for all levels of the organization. We hope to implement a Web-based dashboard that will have an executive view and manager view and will include metrics for every department. By design, the solution will be interactive, allowing executives and staff to drill down into information that may be needed to answer a particular question or make a particular decision. If we stay on track with our roadmap, we will complete the evaluation of our data-reporting needs and select our business-intelligence tool within the next month or so. Thomas: Business intelligence, data warehouses, datamarts, and the like seem to be the next big thing in how radiology groups manage their practices. I agree with Whitfill’s comment that IT shouldn’t be in the business of generating the reports. Looking at a set of numbers generated might not mean much to the person generating the report; are the numbers higher or lower than usual? Do they look accurate? Much like our Microsoft SharePoint implementation, IT should design and implement the foundation for business intelligence, and let the business analysts (who, in our organization, report to the office of the CFO) crunch through the data. RBJ: As a member of the practice’s administrative executive team, is the CIO involved in the strategic management of the practice at your organization? What is the structure for CIO input into the analysis, innovation, and growth of the business? Mitchell: CIO involvement in forming the strategies of the organization is essential. The C-level executives meet weekly to review strategic issues. I am also a member of the operations committee and the marketing/new business committee. Thomas: The CEO, CIO, chief clinical officer, and business-development director meet regularly to discuss how to execute the radiologists’ business plan, put together once a year, strategically. There is a weekly meeting of all senior management (officers and directors). Aside from these meetings, the CIO also sits on an IT subcommittee, where representatives from the different business units (as well as the physicians) make recommendations to our executive committee on IT initiatives to drive business transformation. Whelan: Until about 3 years ago, my office was located in the same location as our data center, and the CIO did not have an office at corporate headquarters. That was when I moved to our corporate headquarters in Quincy, Mass. I actively participate in all senior-management meetings and am held accountable for achieving annual goals and objectives. I also attend all board meetings with joint-venture partners. I am responsible for developing the innovations that can lock in business and connect with patients. For example, we have an initiative, right now, to design the best report in the marketplace, and we have just rolled out our radiation-oncology virtual tours on Whitfill: As the CIO, I attend the board of directors’ meetings, chair the information-services steering committee, and report directly to our CAO. As such, my role is to balance the solicitation of new ideas from members of these groups, as well as to bring forward novel solutions that they may not be aware of, or that are being used in other industries. RBJ: Tell us about your practice’s online strategy and some recent and future initiatives. Thomas: Prior to implementing PACS, ARA had made a decision to embrace Web technologies—deciding that our RIS and PACS should be Web enabled to facilitate a quick rollout to the referring community. Our PACS application has been available online for referring physicians since its installation roughly seven years ago. From that direction, we also enhanced our corporate presence on the Internet. From 2007 to the end of 2008, visits to our corporate Web site were up 30% annually; visits to our referring physicians’ portal were up 33% annually. Time spent on the sites is up as well (2.5% and 16%, respectively). If we have more visitors spending more time on our Web sites, we need to implement reasons to keep them there. I think the more we can have the patients do online—before and after the exam—the more streamlined operations can become. To that end, we have implemented an online scheduling application (for mammography only) and an online bill-payment application. In the future, we hope to drive referring physicians to request exams online, allow more exams to be scheduled online, and implement our forms—such as feedback forms and exam forms—as more interfaced with our back-end office systems, and not just static PDFs. Whelan: The majority of our work today focuses not on the Internet, but on integration. There’s an important difference. For physician practices today, it’s not enough to have a Web portal where referrers access results with a user name and password. The physicians want to see results in their format, on their electronic medical record (EMR). It’s really about integration and not the Internet. It has been an interesting change for us to make that shift. To date, we have completed interfaces with every major medical center in each of our major markets. Having the Internet is good, but we are moving into the next evolutionary stage, and that is the physician-practice integration piece. The e-business strategy at Shields will have an impact on every department at Shields, from finance to operations to the clinical departments. In finance, for example, we hope, through working with the insurance payors in the state of Massachusetts, that we’ll be able to display the deductible amount the patient has left to pay in our patient portal. With regard to operations, patients can request a CD online through the patient portal. At the moment, we still require them to come in and pick it up because we’d like to see their identification. In the future, we will use identity-verification software that will add an additional layer of security and will allow us to offer the option to burn a CD from the online portal. Clinically, Shields hopes to launch a multimedia report in fall 2009. I feel very strongly that to be competitive in this outpatient imaging market, we have to change the product of radiology. In my opinion, the product of radiology is a left-margined book report whose format has limited utility in an environment where referring clinicians are busier than ever. We hope to move forward with a report that includes tables, values, measurements, and positive and negative classifications. Mitchell: My IT strategies are multifaceted, but driven by three main objectives: increase volume (since most of our costs are fixed); improve the productivity of the radiologists (to reduce costs); and maintain or improve patient safety, the quality of the patient experience, and our interpretations. To increase volume, we have implemented online viewing of reports and images for more than 1,000 referring physicians. We also have made online mammography scheduling available to our patients, and we are planning a new Web site. To improve radiologists’ productivity, we will be implementing voice-recognition software and installing software for better communications with other radiologists, technologists, and referring physicians. To improve the quality of our interpretations, we are providing a paperless environment for the radiologists. This allows for subspecialty reads, even though the subspecialist is not physically located in the imaging facility. RBJ: How does the CIO shape initiatives that affect clinical care, such as decision support, quality-assurance programs, clinical trials, or utilization management? Whelan: We have made advances in each of these areas. We have folded decision support into our larger business-intelligence strategy. Our quality-assurance programs vary, whether for radiology or radiation oncology, but each area has its own specific systems solution for managing quality assurance. Our radiologists continue to support and participate in clinical trials, although this activity is done with one partner, and other than connectivity, has not demanded much IT time. Utilization management is on the opposite end of the spectrum. IT has designed a very specific program for utilization management and will report outcomes as part of this program. We also have plans to develop an insurance portal for large insurers to view utilization-management data and run reports at their convenience. Mitchell: Fully one third of the staff members in my IT department are clinical analysts, and most of them are ex-technologists. This group has high credibility with the radiologists and operational staff. We have made modifications, large and small, to the workflow and systems to improve clinical care. Having said that, much of the impetus for clinical-care innovations such as qualilty-assurance programs, utilization management, and radiation-dose tracking comes from the outside—the ACR, CMS, or other regulatory sources. We have influenced or directed the implementation of these solutions, however. For example, we are writing our own peer-review program rather than using the ACR program or other commercial programs. Whitfill: We are fortunate to have radiologists and staff members who see these roles as critical to our success and take a strong leadership role within areas such as clinical trials and quality assurance. As such, the information-services staff at SMIL plays a more supportive role, ensuring that these leaders have the tools they need to carry out their visions for this area. RBJ: As practices grow, are there opportunities for IT to improve communications, streamline processes, and reduce variability in processes? Whelan: Let’s hope so, or we don’t have much of a future. I see tremendous opportunities, and the role of the radiology practice will continue to be an important one, as radiology is often the first stop in the care process. It is the diagnostic tool that leads to the development of a treatment plan for patients. Thomas: I believe the only way to grow an organization effectively while containing costs is to look for opportunities where IT can be used. For example, to improve communications, we’ve implemented voice over Internet protocol and instant messaging. Both of these technologies have only been in production less than five years. Recently, my staff and I have been discussing implementing a private version of Twitter throughout IT to see what impact that could have on departmental communication—not something we would have considered five years ago, when there were fewer than 23 people in IT. To streamline processes, for 2009, IT has been given a directive to implement as many HL7 interfaces to EMRs as we can, both for inbound orders and for outbound results. We’ve implemented Microsoft SharePoint to facilitate putting forth communications and updated documents throughout the company; no longer do business units need to rely on IT to publish information. As our operation grows, our business units are coming up with creative ways to do more with less, and those projects consistently involve ways to implement IT to streamline operations. Hence, our development team is the fastest-growing section of IT today. As organizations become larger, these dependencies on IT to create improved communications and streamlined processes create a need for IT to maintain high-quality, repeatable processes that correspond to the objectives of the business. Most organizations turn to ITIL as a means of implementing a set of best practices to reduce variability in how IT provides its services to the organization. Whitfill: There is a role for IT, but it must be done in conjunction with some type of process-improvement program that can get at challenges in underlying workflow. Just putting in new IT systems without this often results in more complexity and fragmentation of communication, as well as frustration for the end users. Another way to put this is that IT without understanding workflow can hurt more than help. Thus, we in information services must be excellent and patient listeners, rather than just technicians who install and maintain new products. In the end, we hope that we hear what the needs and challenges are, and we offer tools to meet those needs in a workable and affordable manner. Mitchell: We have an ongoing program to connect to local PACS in hospitals, practices, and the county health systems. This includes directly competitive radiology practices. In some cases, we can query/retrieve images to our PACS, but we mostly ask them to push images to us. This allows our radiologists to see prior images, no matter where they were taken. I also am working with local hospitals and other providers to discuss setting up a [North Carolina Research] Triangle-wide HIE. RBJ: Are there opportunities for practices to work with hospital sites to improve patient care within the guidelines of the president’s stimulus package? Mitchell: I am actively working with a statewide organization (North Carolina Healthcare Information and Communications Alliance) to develop an HIE architecture for North Carolina. We hope to leverage ARRA funds to assist in this effort. I am very enthusiastic about this activity: Connection to an HIE would enable us to retrieve patient history, medications, allergies, lab results, and prior studies (no matter where they were done). In addition, we would make our results and images available to health care professionals when and where needed. This would reduce unnecessary duplicative exams and therefore reduce emergency-department lengths of stay. This would also provide relevant prior images, which could lead to better outcomes. Referring physicians should be able to order from us directly via their EMRs, and we should be able to send results, both reports and images, directly into their EMRs. If we wanted to do that now, we would need to develop a specific and expensive interface directly between our system and the EMR. Each one would be different. When an HIE is in place, a single interface from us and a single interface from the referring practice’s EMR to the HIE would do the trick. Whitfill: I think there will be a great deal of activity in the coming years related to the president’s stimulus package, but there will be great upheaval as well. Until some of the latter is fleshed out, I think we will see lots of discussion followed by more clarity about what really is going to happen. At that point, how these relationships will function will become clearer. One certainty, I think, is that with the adoption of EMRs across all physicians, the issue of exchanging health information between practices will come to a head. To date, there has not been a great solution outside of a single entity that controls all of these data, like Kaiser Permanente or the VA health system. While many types of regional health information organizations have been attempted, the issue of funding (along with those of privacy and interoperability) keeps raising its ugly head. I liken this to the crisis in imaging that exists today, whereby each radiology group or hospital gives a patient a CD in the name of exchanging information. While this seems to be an easy and cheap way to share patient data, when you try to scale this up, we end up with a very cumbersome and incomplete way to care for our patients. RBJ: If money, time, and support were no object, name an IT project that would have the greatest transformative effect on your business. Thomas: It would be a fully integrated RIS/PACS/practice-management system running on a common database, with a scheduling module that would integrate with our phone system and Web site. Whitfill: It would be a tool that interacts with data across the organization and that can not only mine data for business intelligence, but also allow for driving workflow (and can therefore update those data, whether they are image or text based), with the ability to be customized to the best practices of each department or end user. Whelan: I see two answers here: one that represents the transformative effect on our business, and one that I would say would be the greatest transformative effect in our market. For our business a few years ago, I might have said HL7 and DICOM PACS interfaces to our partners and physician practice EMRs, as we have had a referring physician portal since 2002. Today, there’s a lot to choose from—cloud computing, data-center and desktop virtualization, and Web-site development—but for us, it’s back to basics. We need to replace a 20-year-old RIS that has been economical and served us well, but is not allowing us to leverage current technology solutions to streamline operations. As far as our market goes, if money were no object, I would like to lead a statewide initiative that develops the Kelley Blue Book of Health Care Services. It makes me crazy that we have better online tools and data to buy a used car than we do for pricing and quality measures for a knee replacement. A cohesive view of health care services and prices is needed in the state of Massachusetts, where high-deductible plans seem to be the growing trend. Mitchell: I don’t even have to think about this. The word is aggregation. As well as reading exams performed at our offices, our radiologists also read for three hospitals. Each of the four entities has its own RIS, PACS, and dictation system. Half of the time, I cannot get them to operate on the same workstation, and if they do, it’s usually only until the next upgrade. In the ideal aggregation system, we would get HL7 order feeds from each of the four entities and would use one combined worklist for the radiologists, one PACS viewer, and one dictation system. Results would be sent back via HL7 to the RIS and/or PACS of the originating entity. It turns out that this is a very expensive proposition that would require significant hospital cooperation and vendor resources to accomplish.