The Essentials: Information Technology for the Practice

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ARA.jpg - Austin Radiological Association
Austin Radiological Association (ARA) maintains a large IT staff of 40 full-time equivalents that work in four groups: data center operations, desktop and clinical user support, software development and applications management.

Radiology is an IT-intensive specialty, one that mandates an investment in information technology (IT)—and continuous updates— that is substantially greater than other medical specialties. Radiology Business Journal talked with the IT leaders of five Radiology 100 practices to learn about the requirements to support a practice’s clinical, administrative and communications needs.

Our sources agreed that every practice requires the following four IT essentials: a robust, secure infrastructure that allows for rapid response to meet changing business needs; a well-designed system that has multiple layers of redundancy and security; software that accommodates the radiology practice both clinically and operationally; and a competent IT staff.

In addition, it is important that IT recognizes that it represents a service to the professional radiology company. IT priorities and goals should be focused on supporting the core business of professional radiology and how the IT department can bring value to a practice’s overall strategies and goals. 

As a result, IT directors must keep close tabs on the continually changing healthcare regulatory environment, as well as more typical IT concerns of security and hardware and software developments. They need to be able to analyze the many different types of workflows in a practice, and to identify technology that can improve them.

Articulating IT’s value

Nonetheless, it is incumbent upon IT to articulate the importance of strategies that may not be well understood by practice leadership. “The IT team has an obligation to demonstrate to practice leadership how the IT strategies and proposed expenditures support practice goals and thus why they should adequately fund the strategies we recommend,” Ron Mitchell, CIO, Wake Radiology, Raleigh, N.C., notes. “For example, maintaining tight security represents a large annual investment that does not show any financial return. It is a continuous challenge for us and we are constantly developing defenses.”

Joe Moore of Radiology Consultants of Iowa (RCI), Cedar Rapids,  concurs that IT must lead and educate on security matters, in addition to determining what types of technology need to be implemented and used to promote business functions. Moore is supported by tech-savvy entrepreneurial physicians, four of whom are members of the practice’s IT Committee.

“They like to be part of the design and execution of new, innovative tools that help them practice and make radiology more relevant to referring physicians,” Moore says. “They roll their sleeves up with us and champion each new change, making it much more successfully adopted by the rest of the radiologists.”

At Austin Radiological Association (ARA), priorities and projects identified by IT are presented during the budget cycle for funding and approval. That doesn’t mean there won’t be change throughout the course of the year, CIO Todd Thomas says.

“When our radiologists or clinical operations staff make a decision to adopt a new technology—such as digital breast tomosynthesis—we do what is necessary to accommodate it,” he explains. Thomas’ team needs to be ready to manage the transfer and storage of the huge quantities of data that this new technology will generate.

Nanette LaRosee, IT administrator, Rhode Island Medical Imaging (RIMI), East Providence, also acknowledges the need for IT to be flexible and nimble to accommodate priorities that change at a moment’s notice. If resources are not immediately available to accommodate all needs, she recommends prioritizing projects based on patient-care improvements.

Staffing considerations

There is no rule of thumb for sizing a radiology practice’s IT department, and indeed it varied from a staff of 40 at ARA to five at Advanced Medical Imaging Consultants (AMIC), Fort Collins, Colo. At AMIC, being able to cross-cover the work of a colleague is a necessity, CIO Lawrence Long reports.

The 56-radiologist RIMI has a small IT department (7 FTEs) in relation to the size of the business. In addition to the director, there is a software/analytics team (3) and a networking/infrastructure/communications team (3). The PACS administrator oversees all infrastructure/connectivity as well as the PACS. He also manages a data center/telecommunications specialist and a PC technician/web administrator. All team members have hybrid roles and work closely together. LaRosee said that the department has utilized consultative services in the areas of network security, storage and virtualization. 

RCI also uses outsourcing to supplement a five-member team, which consists of two data entry staff, a PACS administrator and two clinical support staff, former RTs who migrated to IT. Projects are outsourced, including network architecture and implementation, systems architecture and security. Moore prefers to maintain a lean staff of industry-specific experts.

“Work is outsourced for occasional or complex projects, and for projects which do not have the volume of work to keep someone proficient,” he explains. “IT is so specialized today, requiring a much higher level of technical expertise. Twenty years ago, one person could do it all, and I was that person, but no more.”

“We have identified excellent resources to perform very critical functions like installing a new server, adding to infrastructure, or doing virtualization,” he continues. “Using outsourced resources frees our IT team to focus on the business, on workflow and on projects that make a difference to the business. The infrastructure hums in the background, and an IT department wants an infrastructure that nobody notices.”

Deploying the troops

Wake Radiology’s 14-member IT staff work in four different teams:

  • IT operations. This team is responsible for servers, desktops and the help desk. The help desk’s routine hours are 7:00 a.m. to 5:30 p.m., on site. From 5:30–11 p.m, there is remote support, and a staff member is on call after that. Support is provided to referring physicians as well as radiologists with questions working after hours.
  • Networking and telecommunications. This team is responsible for the local and wide area networks, the voice over IP telephone systems, three call center operations and IT security.
  • Software development. This team does some custom programming, currently focused on interface engine projects to support electronic ordering and electronic distribution of results to referring providers.
  • Clinical systems. This is the largest group, responsible for RIS, PACS, modality interfaces and clinical workflow.

ARA’s large staff of 40 works for one of four groups: data center operations, including a dedicated server and networking team; desktop and clinical user support; software development; and an applications management group. The department is currently in the process of restructuring to promote teamwork and camaraderie among activity silos.

Enhanced overall cohesion ideally will resolve monitoring of problems that affect more than one of the teams and require vendor resolution. “We have realized that when two or more IT groups are affected by a vendor-related problem, the responsibility of overseeing and working with the vendor and monitoring their progress could be better addressed,” Thomas says. “We are currently at a stage where we need less focus on engineering solutions and more focus on project delivery and end-user support.”

All of the participating practices have internal help desks. Moore summarized the sentiment by saying, “We can provide faster, better, and more personal service to our own physicians and the radiology department staff at the hospitals. We know them, we know our applications, and they know us. That model of service is key to our success.”

Although IT personnel turnover tends to be low in these practices, staffing can be challenging. When AMIC adds positions, usually due to growth, Long determines whether the person needs to have a clinical radiology background or an IT background. Many technologists are interested in moving into an informatics career track, and they often handle user-support duties. For conventional IT positions, Long hires IT professionals with experience in non-healthcare industries.

He says, “It takes about a year for these individuals to truly understand and grasp all the different facets of healthcare IT. The way we train is to first introduce any new IT staff member to a general practice and clinical workflow layout of how we operate. They start by doing part of the clinic system administrator’s job for a short period of time to acquire that knowledge.”

When filling a help desk or clinical support position at ARA, Thomas tries to recruit individuals who have experience with phone support and have good communications skills. Software developers are hired based on their knowledge of specific programming languages that are used. Software development staff is sent to annual training classes to keep their IT skills current. Clinical applications staff is primarily trained by the vendors.

Wake Radiology also relies on vendor and external training resources. Clinical-applications staff positions have been filled successfully with RTs or similar clinical personnel in the past. When hiring for an IT position, Mitchell has had great success with the contractor-to-hire model. Where he can, he brings the candidate in to work as a contractor for six months before considering offering the person an employee position, enabling Mitchell to assess whether the contractor fits well with the team and vice versa.

Meeting diverse needs

Each practice has different ways of prioritizing and meeting its IT needs. All reported focusing on ways to utilize data and analytics software to improve the performance and to enable the practice to adapt to new models of healthcare delivery and payment. Infrastructure, services and customized applications all contribute to this. “I don’t care what kind of storage network you have, if you can’t support the evolution of the core business, you may as well not even be there,” Moore comments.

Data storage is a major focus for ARA. Eleven years ago, the practice began providing RIS and PACS services to area hospitals, including the largest hospital network in Central Texas. It currently manages half a petabyte—500,000 gigabytes—of medical imaging data, and federal data-retention laws governing healthcare data will enable ARA to reclaim some storage in its data center when it begins deleting images in 2015. The time will come, however, when reclaimed storage will be negligible.

Thomas wants to break out of the 4–5 year cycle of purchasing storage equipment—the cost of maintenance contracts escalates so much after warranties end that it is more economical to purchase a new system and migrate images. He hopes to adopt a flat operational expense model so that storage costs can be known year after year while taking into account that storage will continually grow.

Robust security is an ongoing requirement. Several of the practices are segmenting their networks to protect their most critical asset if a breach does occur. Developing new and better patient and physician portals are other projects, as are performing HL-7 interface related projects to make electronic orders transfer from EHRs.

LaRosee noted that it is also important for RIMI’s referral base of physicians to be able to seamlessly view reports and images within their EMRs and also to accommodate mobile tablet viewing. The challenge her team faces is to make sure that there is a solid, secure means of accessing systems to accommodate new technologies.

Long emphasized the need to be able to create customized programs and apps to support total process improvement. Optimization targets include radiologist workflow and the overall business of the practice.

Writing code

As might be expected, ARA writes a lot of code. The development group is divided into three areas. One group of developers works on projects requested by the practice, as well as tools that help the IT department better manage the workload. A second group supports radiologist requests and  Box Workflow, a custom program that makes night and emergency/off-hours reading from the many hospitals it serves more efficient.1 The third group is dedicated to programming HL-7 interfaces.

Long’s IT team at AMIC also does a good amount of internal development. He explained, “When we began to do internal development, we concentrated on taking the process out of the process, such as making the billing process more efficient by maximizing its accuracy and throughput.

“We created a call center for our radiologists and facilities, and then focused on programming to streamline workflow for the radiologist, such as developing some applications to manage the call-report process and allow a radiologist to efficiently communicate with reading room assistants.”

Leveraging IT to deal with the CMS Physician Quality Reporting System (PQRS) isn’t a big deal in these practices because they have either RIS or billing system software that automates the reporting process. Responsibility for PQRS reporting tends to be handled by other practice departments.

Wake Radiology is currently working with ACR to determine how to do this reporting through the ACR registries. Mitchell said that the practice goal would be to do most, if not all of its reporting in 2015 through this mechanism.

The impact of MU

For the most part, working with the Meaningful Use program regulations has been a thorn in the side of practice IT. The requirements weren’t designed for the radiology workflow and compliance has proven cumbersome.. In fact, CMS has granted a hardship exemption to diagnostic radiologists, nuclear medicine specialists, and interventional radiologists (PECOS specialties 30, 36, and 94 respectively) through 2015. The question of signing up or opting out has its pros and cons.

“Radiology providers had to decide if they would invest the time and energy in a certified EMR system that would allow them to participate in this program, which would require changing operational practices to accommodate the gathering of measurement information that may not be pertinent to the patient’s visit,” LaRosee comments. “This was a difficult decision to make because while the present program requirements were known, practices didn’t know what the future stages would dictate. A commitment to a program of this size encompassing several years meant dedicating time, resources and expense to implement and maintain a certified system.”

If a practice chose to be an early adopter with the hope of maximizing incentive payments and avoiding potential penalties down the line, it engaged, she adds. “If you made that decision prior to the final rule allowing radiology an automatic hardship exemption for up to five years, you already allocated resources that might be unrecoverable,” she notes. “The impact on the IT budget would be contingent on your decision and the time frame when you made it.”

Rhode Island Medical Imaging did decide to participate and this year plans to attest for stage 1, year 2 using the 2011 Edition meaningful use certified EHR technology. It is presently evaluating whether to continue participating in the MU program.

Radiology Consultants of Iowa has made the same decision. RCI was evaluating radiology information systems in 2010, and its leading candidate happened to be one of the few RIS that were MU-certified. Moore said, “We felt good about this, being able to be compliant with our new RIS with only the need to purchase an eRx module for interventional radiologists. We attested in 2011, 2012, and 2013, while waiting for the final rules of stage 2. Unfortunately, stage 2 rules are onorous and even less applicable to radiologists. The direct messaging module would be a very expensive module we would not utilize. Our radiologists call referring physicians with critical findings and then document that they called–they wouldn’t use email to do this.”

AMIC’s evaluation of MU determined that it would cost more to participate than not. ARA waited until it replaced its RIS. The practice is in the middle of its stage 1, year 1 reporting period. “If stage 3 rules are too cumbersome, we may drop out,” Long says.

Wake Radiology’s philosophy is different. Mitchell explains,” We are in our second year of stage 1. We chose to participate in MU to understand what our referring physicians were facing. Our RIS vendor chose not to make its RIS fully certified so we retained an outside consulting company that specialized in MU for radiology. It helped us select and install a basic EHR system that we could use. In addition to the cost, it took a lot of internal effort to set this up and to establish the policies and workflow changes needed to meet the attestation requirements.”

He adds, “If we had chosen to take the hardship exemption, we wouldn’t be able to have the conversations we are now having with our referring physicians. We wouldn’t be in any position to understand their requirements or answer their questions, such as the fact that when using a computerized physician order entry (CPOE) system in an EHR (Measure 1), it is not a requirement that the order be electronically transmitted to the radiology provider.”

The outpatient–inpatient factor

Practices with a large number of imaging centers must allocate a greater portion of their budgetary and staff resources to providing help desk support for all the clinical staff at the imaging centers as well as referrers. Also, network infrastructure can be more complex, and telecommunications functionality more robust. Practices with outpatient imaging-center assets are more likely to require more patient support for on-line scheduling and patient portal access.

Another consideration to be aware of for practices that own imaging technology is that if they are scheduling Medicare patients for advanced imaging exams, they will be required to offer CPOE and integrated clinical decision support  (CDS) by January 2017, as mandated by CDS. Private payors may adopt this same requirement.

AMIC provides on-site and remote services to 11 small rural hospitals and clinics located in eastern and northern Colorado, parts of Wyoming and western Nebraska. The practice is currently discussing the business feasibility of providing this service, according to Long, who said that smaller sites may not have the staff resources to make CDS efficient and effective.

Mitchell said that Wake Radiology, which operates 20 imaging centers, will need to assess the percentage of advanced imaging exams ordered by referring physicians who are not using a hospital’s EHR. “This is not the case of ‘If we build it, they will come’,” he observes.

On the other hand, hospital-based practices need to focus on providing ways to add value to the hospital’s business, for which the practice IT department provides critical support. Initiatives tend to be driven by the radiologists, with IT developing custom programs, such as the ARA Box Workflow.

Hospital-based practices should avoid becoming too dependent on the hospital’s IT staff. “It can be very frustrating for a practice that relies too much on a hospital IT department,” Mitchell says. “Wake Radiology has invested quite heavily in IT, specifically so it would have the independence and flexibility to chart its own course.”

Regardless of which environment a practice occupies, it must carefully develop strategies and value-added services beyond just producing a clinical report. “Practices need to be continually looking for ways to differentiate themselves from their competition,” Moore says. “They have to do everything they can to ensure that they are the best option available, regardless of who the customer is. With the right focus, IT can be a big help achieving this.”

Reference

  1. Skoufalos M. ARA’s box workflow redefines the practice-productivity platform. ImagingBiz: Feb. 10, 2012. www.imagingbiz.com/topics/imaging-informatics/ara’s-box-workflow-redef.... Accessed Feb. 4, 2015.