Nearly seven years ago, Hackensack Radiology Group in northern New Jersey discovered a clever way to leverage data with its client hospital, one that would throw the door open to an expansive new partnership.
Aware of their overlapping interests in controlling radiation dose and ensuring first-rate patient care, the independent radiology group and the hospital began jointly collecting data for the American College of Radiology’s dose index registry. In addition to allowing the two providers to compare their CT dose indices to regional and national values, the joint effort offered a channel to fulfill reporting requirements for the Physician Quality Reporting System and, several years later, for the Merit-based Incentive Payment System (MIPS).
When Hackensack Radiology suggested an initiative to track and benchmark turnaround times for all radiology reports, the hospital was again all ears.
And so began a performance-driven program to gather and track a trove of data through the hospital’s electronic health records.
“We were the first department at the hospital to intensively look at data sharing to find commonality where we could support them, and they could support our quality reporting measures to commercial or Medicare payers,” recalls Gregory Nicola, MD, a member of Hackensack Radiology Group’s executive committee and the creative force behind the growing collaboration. “Once that was accomplished, we were able to move on to more sophisticated data analytics that required their support to get access to Epic or hospital datasets.”
Nicola’s determined efforts around partnership-building strike a particularly resonant chord at a time when value-based care is shifting the tectonic plates under our health system.
With radiologists increasingly compelled to compete on the basis of cost and quality metrics, the steps they take now to forge the strongest possible ties to their affiliate hospitals and healthcare systems could well determine their success or failure.
As Lauren Golding, MD, of Triad Radiology Associates in Winston-Salem, NC, and vice-chair of ACR’s MACRA committee, puts it: “If practices hope to survive in a dog-eat-dog world of consolidation and corporatization, the key will be to become the best partner they can be with their hospitals so they’re seen as a vital part of the team. The days of just sitting around dictating your reports and not really participating in the greater health system are over.”
Avenues of Alliance
The touchpoints around which radiology practices and client hospitals can unite are expanding, helped along in no small way by CMS, which has aggressively pushed for a team-based approach.
Indeed, beginning in 2019, clinicians who bill more than 75% of their services in a hospital setting, including on-campus outpatient radiology departments, can elect to use the hospital’s score in the agency’s Value-Based Purchasing Program—instead of their own MIPS quality and cost scores—to fulfill their MIPS reporting requirements in these categories. Many see this change as encouraging a needed sense of esprit de corps.
More broadly, common pathways are emerging through:
▲ Programs to improve imaging appropriateness (like ACR’s R-SCAN);
▲ Joint ventures that often involve development of outpatient imaging centers;
▲ Clinically integrated networks (CINs) allowing for improved quality and cost control;
▲ Co-marketing projects; and
▲ Active roles for radiologists on hospital boards, committees and other decision-making forums.
These kinds of efforts are increasingly founded on the realization that group-based radiologists need to anticipate the needs of their health system partners and then go the extra mile to meet them.
Given how strapped hospital IT departments are nowadays for bandwidth, data sharing is often a mechanism by which radiologists can demonstrate to executives how they’re able to add measurable value.
One of Triad Radiology Associates’ client hospitals, for example, began copying the practice on prostate pathology as part of a joint pilot program to flag cases in which MRI exams produced findings noticeably different from those of treating physicians.
“When their pathology comes back negative for a prostate cancer patient we determined to be a PIRAD 5, we can now get on the phone with the urologist who took the sample and ask, ‘What’s going on?’” explains Tom Smith, CIO at Triad Radiology, which serves eight hospitals and nine outpatient clinics around Winston-Salem. “Sometimes things get missed, and this is a way of catching them by improving communications between radiology and pathology. Bigger picture, it’s a way of showing we can work together to really make a difference and improve the care we give patients by ensuring the right outcomes.”
Triad plans to use the success of its prostate MRI pilot to explore other avenues of collaboration with the hospital’s executive team.
Data Opens Doors
The drive to leverage data for strengthening ties with client hospitals isn’t hard to spot at Hackensack Radiology Group.
Case in point: When the thoracic surgery department at its hospital affiliate expressed an interest in jointly building their lung cancer and incidental pulmonology nodule business, the imager smelled opportunity—and a pathway soon emerged. Realizing the complex logistics of following up on ER patients shown to have pulmonary nodules, Hackensack explored ways to effectively track these cases.
“Ideally, the hospital would have a natural language processing program to audit our reports and make sure any patient with nodules is being captured and followed up with by the appropriate physicians,” says Nicola, who guided the effort.
When it turned out the hospital didn’t have the bandwidth needed to pursue that ideal, Nicola found someone who did: people at the company Hackensack Radiology contracts for billing, Healthcare Administrative Partners. Now all reports are audited for pulmonology nodules any larger than 6 mm. These patients are then urged by the hospital to follow up, either through their primary care physician or the hospital’s pulmonary nodule clinic.
Two years into this program, the upshot is a significant uptick in cases seen by pulmonologists at the clinic and, when lung cancer is diagnosed, in patients referred to the hospital’s thoracic surgery department.
“The key for us was thinking outside the box,” says Nicola, who chairs ACR’s MACRA committee and serves as vice-chair of ACR’s economics commission. “There are many ways to retrieve this kind of data, whether it’s through a billing company similar to what we did, through the hospital or through your voice recognition system. The important thing is that you try all doors with the goal of getting a program started.”
In fact, an aggressive approach to data sharing has benefits for radiology groups that can percolate down to the bottom line.
Consider this scenario: Your practice is about to bid on a new hospital contract, but it needs a way to differentiate itself from a field competing on the standard platforms of price and quality reads.
“Everybody touts quality,” Smith points out, “but we’re able to say, ‘Here’s how we’ll ensure that quality is actually being delivered. We can provide you with metrics and supporting data, and by working closely with you on reporting and on critical notifications.’ These range all the way to incidental findings we weren’t even looking for that can now be followed up with by primary care providers.”
In this way and in others, Triad is “not only helping the hospital drive quality and enhanced patient care, but also driving downstream revenue by making sure these follow-up recommendations are being appropriately delivered and acted on,” Smith adds. “That’s a message any hospital is happy to hear.”
Seen and Heard
Beyond data, one of the most potent ways radiologists can weave themselves into the fabric of the hospital or health system is to simply take a seat at the table—literally. This means pursuing active, high visibility roles on hospital boards and committees in which major decisions are made on matters affecting quality, cost, clinical practice and the future of patient care.
When the ACR asked hospital CEOs several years ago to define a successful radiology group, the common thread was whether or not that group was aligned with its hospital’s priorities. (For RBJ’s reporting on the exercise, see October/November 2017, “Taking a Seat at the Table: 5 Ways Radiologists Can Demonstrate Value and Increase Their Influence.”)
Getting seen and heard is a way to negotiate such alignment.
“I’m able to see the quality areas the hospital network is trying to promote, then work to align radiology with those,” remarks Ryan Lee, MD, MBA, section chief of neuroradiology at Philadelphia-based Einstein Healthcare Network, who chairs his institution’s MACRA committee. “Radiology doesn’t operate in a vacuum. It’s critical for any radiology group, whether it’s in the hospital or outside, to have visibility within the network if it’s going to affect radiology-specific measures.”
Hackensack’s Nicola is also strategically positioned to have his voice heard. The radiology executive was asked by his client hospital to be part of its patient care improvement committee and subsequently named finance chair as well as board member for its clinically integrated network. He also has leveraged his expertise with MACRA to help the network build various reimbursement models. Looking back, Nicola credits the high profile he’s achieved to the inroads his group made with ACR’s dose index registry—and the reputation that program conferred on them as leaders for promoting quality and safety.
CDS, R-SCAN: Ripe & Ready
Increasingly, discussions at hospital planning tables are turning to clinical decision support (CDS) systems and how these can help clinicians across all specialties wade through rivers of data to arrive at the best treatment plan for their patients, avoiding duplicative testing and potential errors in the process.
Radiology has been a driver of CDS, particularly since 2014 passage of the Protecting Access of Medicare Act (PAMA), which mandated its use as of January 2020 for advanced imaging studies in outpatient settings and in the emergency room for non-life-threatening conditions. Radiologists are further affected through their ability to use CDS to help satisfy two of the four reporting requirements under MIPS: promoting interoperability and practice improvement activities.
Clinical decision support has thus given radiology a broad platform to engage hospital leadership over cost, care quality and patient safety.
“CDS is a big slice of the quality pie within healthcare today,” affirms Lee, “and we worked closely with our hospital to nail it down.” To be sure, Einstein is a recognized leader in the emerging field of CDS, having developed a streamlined program for managing evidence-based clinical decision support across its network of three hospitals, 13 outpatient centers and 36 primary care practice locations. Integral to that effort has been an ongoing pilot involving more than 300 physicians from a host of specialties. “We’ve spent the last couple years tweaking the system to make it more user-friendly,” says Lee, who was part of the effort, “and that required the ongoing support of administration.”
In similar fashion, R-SCAN—the ACR’s Radiology Support, Communication and Alignment Network—is paving the way for a greater pairing of radiology and hospital/physician interests. “R-SCAN is trying to ensure that imaging utilization is appropriate, not just with clinical decision support software but with an actual interaction between the radiologist and their referring clinician,” points out Golding. As proponents stress, R-SCAN gives radiologists a vital new tool to demonstrate the value they bring to patient care, which happens to be a primary focus of MACRA’s value-based payment structures.
R-SCAN is “a wonderful way to empower radiologists to be more involved in care coordination—to be part of the care team,” says Nicola. “It shows we care about our patients and the appropriateness of the studies we do, and that’s an area we really should be leaders in.”
It’s also a way to keep radiology’s value top of mind in U.S. healthcare. At an event organized by Medicare’s Transforming Clinical Practice Initiative this past summer, Nicola described an R-SCAN initiative at his own affiliate hospital to reduce unnecessary imaging for low back pain in the emergency department by bringing together orthopedic surgery, pain management, emergency-med physicians and radiology. An analysis of ordering patters and chart reviews using R-SCAN’s customized tools culminated invaluable feedback for emergency physicians on whether their low-back imaging was appropriate.
For clinically integrated networks looking to expand their footprint, joint venturing with an experienced radiology partner to launch an outpatient imaging center can make eminent business sense.
For hospitals, partnering means minimizing risk and maximizing revenue potential by teaming up with another provider who often has a solid track record developing and managing outpatient facilities. Not lost on hospitals expecting accountable care organizations (ACOs) to take greater responsibility for medical costs is the fact these outpatient centers could provide a low-cost imaging option within their networks.
As for radiology practices, joint venturing can mean a new revenue stream and, not insignificantly, the chance to expand relationships with client hospitals.
If infrastructure development is a leap for radiologists looking to expand their hospital alliances, then initiatives like data sharing and joint registry reporting are the discreet baby steps needed to get there, according to those who know the terrain.
“I never go to the hospital and say this is what I need,” advises Nicola. “I go to them and say this is what you need, and it helps if we can work on it together. As radiologists, we need to hear their message and then align our goals with that message as quickly as possible to be successful.”