Radiology: Hospitals' biggest opportunity needs a quality standard

Radiology is one of the largest spend categories at most hospitals, representing nearly 10 percent of annual commercial healthcare spending in the United States. It is also a rapidly growing category: The Advisory Board Company expects that total radiology spend will increase by nine percent year-over-year through 2018.

The potential economic value of the radiology department should not be underestimated. Imaging is the largest source of outpatient profit for many hospitals, contributing as much as 35 percent to the bottom line. That figure is almost three times that of the nearest service line.

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The importance of radiology services becomes even clearer when one considers the critical role it plays in so many different fields of medicine. Because radiology touches nearly every patient and disease category at hospitals, the specialty is a leading driver of hospital success on critical metrics like patient safety, referral patterns, emergency department throughput, length of stay and the overall patient experience. When considered in its entirety, it becomes clear that the influence of radiology on the cost and quality of care across the entire health system is even larger than profit statistics suggest.

The challenge for hospitals

It is clear that the significant growth in radiology represents a major opportunity for hospitals to improve their critical metrics while also increasing profitability. Actually achieving these results means overcoming significant challenges. Despite the importance of patient care to hospital economics, radiology lags substantially behind other healthcare practices in terms of efficiency, quality standards, effectiveness of service and even the scalability of its basic delivery model. There is no recognized governing body for radiology that has clearly defined what acceptable (or, for that matter, exceptional) procedure should look like. This makes it difficult for hospitals to implement and measure successful programs, which in turn prevents them from enjoying the benefits of radiology’s growth.

In addition to process and quality control challenges, staffing and specialization also present obstacles. Because radiology encompasses so many subspecialties, it can be difficult for a hospital to develop a staff that can cost-effectively address all their potential patient needs. The Journal of the American College of Radiology estimates that a practice of at least 20 radiologists would be required to cover all the fields of radiology with adequate subspecialty expertise. This sort of scale is out of reach for many institutions, which means that most imaging studies end up being read by general radiologists.

Some specialty reads are subcontracted to private practices, but the fragmentation of the provider landscape prevents that from solving the scaling problem; there are more than 25,000 radiologists in private practice and more than 3,000 radiology groups, and only 15 of the largest practices in the United States have more than 65 radiologists.

Costs of ignoring the problem 

Staffing challenges eat up management time and lead to two interrelated problems that transform radiology from a growth opportunity into a drag on profitability. The first problem is an increase in the rate of erroneous reads caused by inadequate subspecialization resources. Recent research has indicated an average documented error rate in radiology of 4.4 percent across modalities and up to 9.2 percent depending on the type of studies interpreted, modality mix and subspecialty expertise. This high volume of potentially misdiagnosed cases leads to significant increases in downstream healthcare costs, which will gain increased urgency as incentives align under risk-based reimbursement and new delivery models.

As an example, consider the use of MRI to diagnose patients with suspected lumbar disk herniations. In such a case, a misdiagnosis caused by a poorly interpreted image could lead to an unnecessary back surgery costing more than $30,000. The implications of this error for both quality of care and cost are obvious.

This increased error rate is compounded by the second problem: overutilization of radiology resources by other departments. JAMA Internal Medicine estimates that between 20 and 50 percent of inpatient diagnostic imaging is clinically unnecessary, and this overutilization is receiving increased attention as the healthcare industry moves towards risk-sharing and value-based models of care. Overutilization also increases risks for the patient, as it subjects them to unnecessary and excessive radiation exposure.

Inconsistent standards and fragmentation

All of these issues are exacerbated by the fact that radiology lacks any common standards or benchmarks for basic service levels. Hospitals looking to improve their performance must do so largely on their own, as external standards do not exist for turnaround times, consultations or even the communication of critical findings (which is the leading cause of malpractice claims for both radiologists and hospitals).

Even among the hospitals in a given health system, several different and incompatible quality measures, technologies and operational approaches may exist. It is not uncommon to find health systems that are operating in a highly fragmented environment where each hospital has its own local radiology group, each of which operates without any common standards or reporting platforms.

This system becomes even more fragmented once the individual radiology groups begin managing their own contracts with third-party after-hours reading services that help fill in schedule gaps and subspecialty needs. Standards of care quality — assuming they exist in any meaningful way — become more variable as multiple different subcontractors (overseen by completely separate teams) begin providing reading services for the health system.

Profitability also drops as out of pocket expenses for preliminary reading services, such as stipends, nighthawk service fees, transcription services and extra technology expenses, increase. These costs can range from $250,000 to $500,000 for the average community hospital; when aggregated across a large health system, those additional costs become multimillion dollar expenses.

This scenario leaves the health system with a disjointed, inefficient radiology infrastructure that offers the worst of both worlds: inadequate and inconsistent patient outcomes combined with out of control costs. This all occurs in a department that should, by any clear estimation, be highly profitable.

Building a new standard for radiology

In recent years, senior management teams at health systems have recognized that the issues and problems highlighted throughout this article necessitate the development of a new standard for radiology. This new standard is a strategic imperative for all health systems and hospitals. Healthcare organizations must aim to establish best practice criteria and set measurable performance goals for radiology, and these goals should be overseen at the highest possible level of the organization. Ignoring the challenges and maintaining the status quo will not work; the impact of radiology on the quality and cost of care is simply too high.

It has already been shown that, except in very large scale health networks, it is nearly impossible to cost effectively meet or beat baseline standards entirely with in-house staff; it is too expensive to offer the necessary subspecialization capabilities around the clock without impacting quality of care. This means that enabling a standards-based delivery model that offers a full suite of subspecialties can only be accomplished through scale and technology. Because radiology primarily concerns the transmission and interpretation of digital images, it benefits much more from improvements in technology and telecommunications than other services (such as emergency medicine or anesthesiology) do. When standardized, these technology improvements can be easily scaled to serve all the hospitals and radiology groups within the health system.

The benefits that radiology enjoys from technology and standardization make telemedicine platforms a particularly useful tool for implementing radiology standards. A telemedicine platform that incorporates "hard-coded" quality programs and offers instantaneous and reliable support from top subspecialists allows health systems to increase the quality of patient care while simultaneously reducing cost. Systems with their own radiology subspecialists on staff can make them available to the entire system via the platform, leveraging the subspecialists' expertise across all their hospitals.

As demonstrated previously, radiology operations typically become more fragmented as the health system grows and each hospital develops its own solution. With a telemedicine infrastructure in place, standardizing processes across hospitals becomes simple, which turns scale from an obstacle into a benefit — the more scale a health system has, the better, and more specialized, its services can get.

Telemedicine platforms also eliminate the old constraints of geography and time, which both have a negative effect on patient care. When hospital-based radiologists are connected with a system-wide and comprehensive support network of subspecialists, the highest standard of patient care becomes available around the clock. The optimal delivery model incorporates hundreds of radiologists across every subspecialty — and if only 15 of the largest US radiology practices have more than 65 radiologists, it becomes clear that a cloud-based telemedicine platform is an absolutely necessary part of achieving that goal.

To enable a health system to take advantage of the opportunity radiology presents, a telemedicine platform must include five key functionalities:

1. Workflow routing that ensures the right radiologists are reading the right studies every time, taking into account subspecialty expertise, availability, payer regulations and more;

2. Integrated quality processes (such as double-blind and secondary reviews for high risk cases) into all studies where they are needed;

3. Real-time decision support and live subspecialty consultations at the point of care;

4. Data standardization for reporting, benchmarking, and analytics by facility, referring physician, radiologist, modality and patient setting; and

5. Mobile capabilities, including delivery of critical findings for faster communication, access to radiologists for on-demand consultations and access to patient information including final reports, addendums and images.

Seizing the radiology opportunity

The first-order benefits of adopting a consistent radiology standard supported by a comprehensive telemedicine platform are clear and well documented. Robust real-time Quality Assurance programs are a key element of a progressive radiology group, with constant learning from mistakes and true continuous improvement. Health systems that have institutionalized these standards and implemented real-time Quality Assurance programs have seen 80 percent reductions in error rates and improved turnaround times, as well as the opportunity for real outpatient growth through greater service levels and marketing of renowned subspecialists.

Creating and reaping the benefits of standardization is an imperative for health systems that want to take advantage of the tremendous opportunity that radiology presents. In conjunction with a telemedicine platform, rigorous standardization and subspecialized radiologist expertise can solve the problems that radiology departments face and help health systems generate significant savings by avoiding unnecessary follow-up exams or intervention, thereby reducing downstream spending. In addition, efficient back office support systems can further streamline this workflow, simultaneously improving both productivity and accuracy.

As providers and patients continue to share more risk in the delivery of healthcare, the value of standardized radiology services will only increase. Health systems that evolve their radiology models to incorporate rigorous standards and advanced telemedicine capabilities will be uniquely positioned to seize the opportunity that the growth of radiology presents. They will also out-compete their peers in both cost and patient care.

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