Radiology of Huntsville: Laying the Groundwork for Risk Assumption

A private practice in Alabama invests in IT and relationships in advance of participating in a Medicaid regional-care organization.

Other than college football, the State of Alabama is not normally thought of as a change leader. Yet Alabama has joined a few other states in an attempt to control spending in Medicaid programs by turning to accountable-care organizations (ACOs). On May 17, 2013, Act 2013-261 became law.  This law changes the Alabama Medicaid system from a fee-for-service to a managed care program, beginning in October 2016.  Instead of contracting with commercial managed care organizations to deliver care to approximately one million Medicaid beneficiaries, the state is allowing the creation of locally run regional-care organizations (RCOs) to coordinate care delivery.

Why is Alabama embracing this change? Ultimately, the answer is money. More specifically, it is the increasing amount of public dollars allocated to Medicaid expenditures. In 2011, approximately one in five Alabama citizens qualified for Medicaid services. Medicaid covered 53 percent of births, 47 percent of children, and 67 percent of nursing home residents at a cost of $5.63 billion to which the state contributed $1.84 billion. 

How will a State of Alabama RCO operate? Each RCO will have a medical director who is a primary care physician and a governing board of 20 members divided into two categories of risk-bearing and non-risk-bearing members. The governing board will determine how to apportion the payment among the providers for both at-risk and non-risk members. 

Are there antitrust concerns about belonging to an RCO? The state has established legislation that specifically addresses this concern because physicians and hospitals participating in the RCO will be negotiating collectively and bargaining with one another to establish payment models for care delivery. Alabama, through a state action doctrine, provides a Certificate to Collaborate to protect appropriate and necessary collective bargaining.

Are organizations and physicians evolving quickly to respond to this change? Radiology of Huntsville (ROH) has anticipated this change to ACOs and the potential for risk assumption for more than five years and began laying the groundwork in the north Alabama market. ROH consists of 30 radiologists providing specialty radiology coverage to six Alabama hospitals, two breast centers, ten outpatient imaging centers, and multiple physician offices. ROH’s preparation for risk assumption began primarily by deploying technology in the practice and secondarily by working on key relationships with providers throughout the market.

Wiring the practice

ROH made a strategic decision to embrace teleradiology in the practice and throughout the radiology workflow approximately 10 years ago. The initial goal was to use teleradiology to facilitate workload balancing. Teleradiology technology evolved to enable subspecialty reading and consultations. Then, the technology created a conduit to provide off-site, after-hours coverage for outlying hospitals and providers.

ROH took the initiative to link the region’s hospitals and imaging centers to facilitate prior study availability for comparison of patient studies and is now connected to 32 healthcare facilities. In the last year, ROH, in conjunction with a regional radiology workflow information technology provider, moved the practice to a single voice-recognition platform with electronic report distribution to referring physicians and image and report access over the Internet, as well as a mobile-device application. 

The combined effects of these decisions resulted in a radiology workflow that serves as a regional community PACS and ultimately a foundational component for any health information exchange (HIE). These efforts provided the tools to improve patient care via prior image and report availability for both radiologist and referring physicians alike. Efficient access to prior studies across the region allows clinicians to avoid unnecessary repeat studies, lowering costs while avoiding additional patient radiation exposure. The network also provides an efficient conduit for outlying hospitals to transmit images to specialists for review at the tertiary trauma center to allow appropriate management of costly patient transfers.  

Referring physicians and their staffs all have access to results, either through the report portal for the patient reports or directly into the network for reports and images via their smartphone or tablet. Network access requires a connection as well as set-up and training on the application. Facilities may use the network for a nominal fee per study to transmit images and reports between connected facilities. The access fee is substantially less than the cost of burning a CD or printing film and then paying a courier to deliver the information to the other facility. The cost of developing and maintaining the network is borne by ROH to promote community health and add value as the facilities’ radiology professional-services provider.

ROH also upgraded its billing software three years ago to fully automate the billing process and to access business intelligence information. The new billing software allows for data mining of the patient billing data to provide metrics for practice workflow analysis. Metrics, including collections, number of exams, and relative value units (RVUs) are utilized to measure practice productivity by site, by rotation, and by individual radiologist. The billing software also accommodates the gathering of information that will be useful in risk-assumption contracting, such as analysis of imaging utilization by patient age and gender.

Beginning in the fall of 2007 through the summer of 2011, ROH spent more than $750,000 in hardware and software costs to “wire the practice.” ROH has an ongoing annual operating expense of 3% of revenue to maintain the technology. The cost is offset by increased study volume, enhanced radiologist productivity, and competitive advantage resulting in new business. A radiology practice desiring to make such an investment today has the option of utilizing a lower-cost hosted solution. In a hosted solution, a practice would have a substantially lower initial capital outlay and would pay an operating fee-per-study each month.

Efficiency through technology    

To configure technology into a functional workflow that truly improves efficiency, ROH purports that the technology user and provider must have a well-rounded understanding of the technical and functional aspects of the radiology workflow. This understanding allows true efficiency with technology to take place. 

ROH has identified seven basic IT functionalities to improve workflow (see sidebar, page 32), but the glue that holds it all together is its partnership with the regional radiology workflow facilitator to which ROH has outsourced its clinical and office IT functions. ROH’s IT partner takes what radiology workflow technology exists at each facility and ensures seamless communication of radiology information to the radiologists and to the other facilities in the network. Billing and accounting software support is provided by the software providers.

Linchpin of the solution is an integrated radiology information database that provides radiologists with all available information that is accessed through a common viewer that allows true, side-by-side comparisons. This means studies entering into the reading environment must be consistent and normalized through an automated process. It also means electronic receipt of studies rather than CDs.

To accomplish this, we created an imaging gateway through which facilities can securely transmit studies to and from the reading environment via the Internet. As much data as possible is automatically populated to voice-recognition report templates, such as contrast dosage, fluoroscopy time, and radiation exposure.

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Figure 1. A real-time dashboard provides feedback on average radiologist turnaround times (excluding mammography), as well as practice productivity by radiologist, rotation, and facility.

Seamless distribution of the resulting reports is vital. Distribution is handled through the use of critical–test-results management and referring physician iPhone/iPad applications. Additional interface capabilities allow for direct connection to referring physician electronic medical record (EMR) and auto-faxing. Technology provider must agree to provide 24/7/365 support to both the radiologists and the facilities.  Technology downtime impacts not only patient care, but causes a costly asset, the radiologist, to be idle.

Beyond efficiencies, the technology provides a wealth of radiology data, which allows ROH to monitor and manage real-time productivity by radiologist, rotation, or facility and provides performance scorecards (see Figure 1).

Relationship development

One of the most important aspects of preparing for risk assumption is the ongoing development of relationships with referring physicians, hospitals, fellow radiologists, and vendors. ROH’s initial relationship development was focused on its vendors in wiring the practice. The regional radiology-workflow provider was critical in tying together the hardware, software, connectivity, and support to provide a reliable technology infrastructure. The ROH infrastructure allows efficient reading of patient studies and communication of the results back to the referring physicians in the manner that best suits their clinical workflow. 

The simple ability to provide subspecialty reads and electronically communicate the results in a timely manner is the foundational basis to building relationships with the referring physicians, hospitals, and imaging providers that ROH serves. Current market forces promote the commoditization of professional radiology reads by allowing any provider with similar technology to compete solely on price. It is ROH’s belief that these relationships, coupled with excellent service and the technology of an improved radiology workflow, are necessary for the practice to demonstrate quantifiable value and to have a seat at the table when ACOs are being developed and implemented.  

Besides technology preparedness, ROH is taking the following steps to equip the practice for risk participation.

Providing service. ROH provides 24/7/365 service. A ROH radiologist is in-house at all times at the main tertiary care hospital. ROH has a designated radiologist to serve as a liaison for each facility and participate on facility committees.

Demonstrating expertise. ROH provides subspecialty reading as well as comprehensive interventional services. ROH promotes quality by ACR RADPEER participation and provides client hospitals with a quarterly performance scorecard that measures key benchmarks including turnaround times (TAT) by priority level and place of service.  ROH has implemented critical results reporting at one hospital and is working with others to implement this important technology.

Gathering radiology information. ROH utilizes RVU monitoring by site to appropriately staff each practice rotation and provide real-time productivity feedback to each radiologist. By connecting the healthcare providers in northern Alabama, ROH is effectively serving as a repository of patient images and reports, which can be used to eliminate medically unnecessary repeat imaging. Providers can utilize this database of patient demographics and imaging utilization by age and gender to serve as a baseline for capitation contracting.

The data-driven practice

For a true integrated radiology database, the gathering of data must come from many resources. With more than 35 facilities (hospitals, imaging centers, and private practices) connected, many serving the same patient base, it was important for data to flow in a consistent manner into a database, the ROH ecosystem (Figure 2, page 32), that would offer useful, real-time information.

The data are gathered from numerous sources, including RIS, PACS, HIS, EMR, and directly from the study DICOM header. This allows for the accumulation of information regardless of the sophistication of the imaging facility of origin. Once these data is harnessed and normalized, a wealth of information and statistics can be derived.

For example, searching for patients based upon name, date of birth, and gender, allows for cross-facility monitoring of repeat studies. Radiologist TATs can be generated for each facility. Unread studies and their priority can be monitored real-time. Radiologist RVU production also can be evaluated real-time.

 This information allows ROH to instantly see how the overall practice is performing at any point in the day. Since the ROH ecosystem is not dependent upon a specific vendor (PACS, RIS, etc.), the data can be used in a variety of methods, such as EMR interfacing, feeding data to health information exchanges, and client billing reconciliation.

On the horizon

ROH is working to position itself as the patient-imaging consultant for any ACO. ROH will promote clinical decision-support software, such as ACR Select, to determine the most appropriate imaging study and help to ensure that it is ordered. ROH is working to enhance the quality of care by promoting contrast utilization management and dose monitoring in client hospitals. 

The practice also is working with state and local representatives to provide the existing, proven, and cost-sustaining technology to serve as the patient-imaging clearinghouse, or HIE, for the region. ROH has already begun conversations with other radiology groups to develop a statewide medical-services organization (MSO) to lower technology costs for radiology practices in the state. The practice continues to work to be a low-cost, high-value radiology-services provider in a risk-assumption environment.

Changes in healthcare delivery and radiology reimbursement, specifically, are imminent. The legacy pay-for-production environment is not sustainable in the future.  Stewards of public as well as private dollars allocated for healthcare appear universally driven to change the healthcare cost curve through fostering risk assumption by the providers.  

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Figure 2. The Radiology of Huntsville informatics ecosystem encompasses the information systems of all partners and clients.

Payors also desire to increase and improve a patient’s ability to participate in a market-driven healthcare environment. Successful radiology groups must prepare to operate as low-cost, quality providers in these new environments. The market should reward organizations that provide excellent service coupled with innovative technology tools that allow improved radiology services. Technology that allows clinicians the ability to first ascertain if a patient has prior imaging and then retrieve those images and reports will be essential. This technology must be deployed across hospitals, imaging centers, and physician offices, even in very competitive markets. 

Payors will demand that patients receive appropriate, medically necessary imaging if reimbursement is expected. The efficient, cost-effective accessibility to a patient’s imaging data regardless of the provider for those services is tantamount. This technology provides a foundation to incorporate clinical decision-support software to ensure healthcare dollars are spent on appropriate, medically necessary imaging studies. 

Healthcare is slowly entering the world of “big data,” and no service line has a greater volume impact on these data than radiology. The importance of service, technology, and relationships with capable key partners cannot be overstated. This new healthcare market will require improved capabilities in the radiology workflow, and the market will reward those organizations that can meet these demands. 

Even though radiology services reimbursement will most likely continue to decline and the future for radiology is somewhat unnerving, it is important to focus on those aspects of practice over which we have control and to count our blessings, including the joys of college football. Roll Tide and War Eagle!


Joseph Serio, MBA, CPA, FRBMA, FACMPE is chief operating officer, and G. Scott Tucker, MD, is president of Radiology of Huntsville, Huntsville, Alabama.

Seven Basic IT Functionalities to Improve Workflow

Radiology of Huntsville has identified and implemented the following seven basic IT functionalities to improve radiology workflow throughout its service area.

  • A true diagnostic viewer that works well with multisite workflows, over limited bandwidth, and is scalable.
  • Viewing software that offers as much capability as possible for specific functions such as PET fusion and mammography computer-assisted diagnosis.
  • An integrated radiology information database to insure all information is available to the radiologist on the viewer prior to reading a study. This provides a heads-up approach of primarily viewing the image versus searching several locations for necessary information.
  • Communication between radiologists, technologists, and the referring physicians is handled through an instant-messaging system built inside the viewer that allows real-time communication.
  • Dictation through a common voice recognition application that allows radiologists to utilize report templates to create and turn around diagnostic imaging interpretations rapidly.
  • Critical–test-results management (CTRM) software that allows immediate and trackable communication to referring doctors.
  • Mobile device application available to referring physicians for immediate access to reports and images.