Value-added Radiology, Defined

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If on-site radiologists want to distinguish themselves from other image-reading specialists or teleradiologists, they must be more than image readers, according to Vijay Rao, MD, David C. Levin professor and radiology chair at Jefferson University Hospitals (Philadelphia, Pennsylvania). On December 1, 2011, she presented “Value-added Services of Hospital-based Radiology Groups” in Chicago, Illinois, at the annual meeting of the RSNA. Rao outlines the reasons that might tempt a hospital to replace an on-site radiology group with a teleradiology group and then counters them with a list of on-site radiology’s value-added services. “Hospitals may be attracted to a teleradiology company or tempted to give away privileges because they didn’t really understand the value that we have— or we haven’t educated them enough,” Rao says. “Sometimes, maybe we aren’t adding the value we should be adding.” Perhaps the group does not provide the subspecialty expertise that clinicians are asking for, or maybe the service level is poor in the areas of turnaround times and willingness to sit on hospital committees. “It is possible that the radiologists own an imaging center that competes with the hospital,” Rao says. The hospital might wish to give turf to specialties that make image interpretation a condition for referring patients to the hospital (economic credentialing); might desire more control over physicians in support of quality and cost-containment initiatives; and might want a share of the radiology professional component. “The hospital may want to bill globally (and have the radiologist on a salary) so it can benefit from the professional component,” Rao suggests. Not only must hospital-based radiologists deliver the entire continuum of services to the institution, but they also must market their value-added services to the administration. Rao divides radiology’s value-added services into six categories. Patient safety: Imaging patients face potential risks from exposure to radiation, magnetic fields, and contrast media. Vigilance by well-trained physicians is needed to minimize those risks, Rao says, and radiologists are the only physicians who get formal training in radiation biology, radiation safety, and how to treat contrast reactions. Radiologists are on-site in the department and available to deal with these issues when problems arise. Exam quality: Quality is increasingly important in this era of pay for performance. Rao has been a strong proponent of an overarching quality/ safety committee that would oversee all interventional procedures. Radiologists receive formal training in the physics and technical aspects of imaging equipment and also are able to ensure that the patient gets the right exam done. “Urologists at your institution may have privileges for CT, but they are not in the best position to determine whether MRI would be the more appropriate exam because they only look at stones,” she says. “They are not trained in MRI. We know all of the modalities and can advise” referrers and patients. Other important image-quality services provided by radiologists include optimizing imaging protocols, supervising and providing education for technologists, and overseeing the process of gaining and maintaining accreditation. “Do you think other physicians or teleradiologists can do this?” Rao asks. “Only on-site radiologists do this.” Interpretation quality: In training, radiologists spend a minimum of five years exclusively studying imaging, and they are commonly urged by professors to find the four corners of the image. “We can interpret the entire image, not just one organ,” Rao says. “The problem with cardiologists who want to do cardiac CT, for example, is that they may miss lesions in the lung, potentially the cause of the patient’s symptoms.” Arriving at a diagnosis might entail integrating images from all modalities— something at which radiologists are adept. “When we are looking at a patient’s record, and we are on the MRI service, we are reading the MRI—but we are looking at CT, ultrasound, and plain films. The specialists are not going to do that. They are just going to look at their little piece of information and move on,” Rao explains. In addition, many departments employ a peer-review process for interpretations. At Jefferson University Hospitals, that entails sending data to the ACR® for benchmarking against data from other practices. “Do you think the other specialists would do that?” Rao asks. Patient/referrer service: A key service provided by on-site radiologists is the physician consultation. While PACS use means that fewer consultations happen in the department, more of them are occurring as overreading of outside images in multidisciplinary and tumor conferences. “That piece of our work is actually growing because patients like to get their imaging close to their homes, and then they come into the tertiary-care facilities to see their clinicians,” Rao explains. “The tertiary-care clinicians want their radiologists to look at the images. We are giving second interpretations on these cases, and we are not getting paid for that. That is a value-added service that we provide to the hospital so that its clinicians are satisfied.” Meeting an increasing number of turnaround benchmarks and targets is another key aspect of service. Not incidentally, tracking these measures also can be in the interest of radiologists who want to maintain their share of business. At Jefferson University Hospitals, vascular surgeons wanted privileges to read vascular studies and were given privileges three days a week (to radiology’s two), but only if the studies were read within 12 hours. Rao says, “Guess what: Last year, vascular surgeons read very few cases because they were unable to hit those targets. We actually have grown the business, even though it looked like a turf issue, initially. It’s become a wonderful team. They would much rather be doing procedures.” Because radiologists’ incomes depend on the number of patients seen in a day, radiologists are highly motivated to maximize department throughput, Rao says, with important dividends for institutions trying to decrease lengths of stay. Radiologists huddle with technologists every morning to prioritize the day’s cases. “Hospitals want to decrease their lengths of stay,” Rao says. “We clearly participate and help with that.” In addition, the department regularly conducts patient- and physician-satisfaction surveys. Cost containment: “What are the buzzwords for any hospital today?” Rao asks. “Patient safety and quality at lower cost: We are able to help contain costs by maximizing patient throughput, keeping the unit cost down. We do head-to-toe imaging, not just a limited scope of practice. If you have a CT scanner in cardiology, where they do only cardiac work, you can’t keep the CT scanner in full use.” In addition to working with the administration to ascertain the optimal level of staffing for the department, radiologists can assist hospitals with technology assessment and imaging-appropriateness initiatives, ensuring that imaging systems are available for necessary studies. “Have you ever witnessed vascular surgeons shopping for a vascular suite?” Rao asks. “The vendor says it does this, this, and that, and the vascular surgeons want it all, even though they may not use half of it. We’ve experienced this. We value hospitals’ capital dollars like our money. That’s been our culture, and we don’t want that to be eroded.” Business building: An engaged on-site radiology group can attract referrals from all specialty groups in the community. “In the hospital, you will not attract referrals from other cardiology groups if just your own cardiology group is doing the cardiac imaging—because they compete for the same patients. We are not a threat to any of the clinicians.” An unrelated area of potential value-added service is health IT. “We are leaders, we need to prove we are leaders, and we need to show we add value there,” Rao says. Radiologists also have proven to be excellent partners in joint-venture imaging centers. When Rao became chair 10 years ago, Jefferson University Hospitals opened one joint-venture imaging center with the radiologists; today, it has five. “We’ve really grown that business in the outreach areas and given the hospital visibility there,” she notes. “We have become a port of entry. When we make a diagnosis, those patients may come to Jefferson University Hospitals for their care.” Rao concludes, “We have to remain radiologists, not image readers. We can’t just talk about it; we have to stand behind our word and show added value. That is what is going to keep our specialty strong in the future.