Riverside Radiology and Interventional Associates (RRIA), Columbus, Ohio, was an early pioneer in the transition from analog to digital radiology, and radiologist Peter Lafferty, MD, vivdly recalls his first encounter with the interpretation of digital images in the late ‘90s.
Riverside CIO Ron Hosenfeld, who was working for FUJIFILM at the time, showed Lafferty some CT images on a computer monitor for an ER turnaround time (TAT) improvement pilot project. “I remember thinking, ‘Holy cow, what have we been doing reading off film? I want everything on here!’” Lafferty exclaims.
Thus began the practice’s pioneering work to build and optimize a digital reading platform for the 86-radiologist private practice—small at the time with one hospital client—but today a highly complex and subspecialized reading environment involving multiple unrelated hospital campuses.
The building blocks
Not long after its first encounter with digital interpretation, the practice took the then-giant step of investing in its own PACS, Synapse from FUJIFILM, Stamford, Conn, and brought on Ron Hosenfeld.
“I saw this huge underserved patient population,” Hosenfeld says. “The large institutions, Beth Israel and Chicago, could afford to purchase and support PACS, but there was no way my grandmother in Smalltown, USA, could get that same quality of care. I said, ‘Let’s deliver that as a service,' and that is where I came together with the group.”
RRIA began to provide PACS to small community hospitals and imaging centers that couldn’t afford the technology. “That was a big deal,” recalls Hosenfeld.
During the next five years, the practice thrived in its digital incarnation, growing both in number of partners and clients of all sizes. “What really helped us, especially in the early days, is that Fuji was unique in its ability to present the same patient across unrelated databases,” Hosenfeld recalls.
“Provided that the radiologists had the appropriate credentials, they could see across different hospitals that were in fact unrelated business entities, and they could see that patient travel between them,” he continues. “That was something that was really unique, and to this day, remains very unique.”
As the practice grew, the ability to present a single view of patients across the practice’s service area enabled it to ramp up quality, extending subspecialized interpretations to its outlying hospital clients and limiting duplicative imaging and unnecessary exposure to radiation.
Workflow is the thing
By 2005, however, the practice was struggling with workflow.
“We used to have a very sophisticated workflow engine, and it was human beings in a file room,” Lafferty says. “They would take a lot of information and knowledge of what referring physicians wanted and even what patients wanted and make sure that the studies were routed appropriately and at the right time.”
The analog workflow, however, was “all very clunky,” rendering turnaround times (TATs) “on the order of days and sometimes even longer than that,” he recalls. PACS helped reduce TATs, but as the practice grew and covered increasingly more disparate hospitals, radiologists found themselves hopping from workstation to workstation, in order to read.
That was the genesis of the group’s workflow software, RadAssist, which solved the problem of getting the correct study to the right radiologist. “That’s the software that we built that allows a doctor to work in, as Dr. Lafferty says, their wheelhouse,” Hosenfeld explains. “We believe that someone who is an expert at a certain type of study can do more studies faster—and likely better—than if you try to spread that out amongst doctors who only get to see a couple of studies a month or so.”
It also enabled the practice to treat patients based on their criticality regardless of their location. Sophisticated workflow rules allow for everything from prioritizing a stroke patient to backing up the radiologist who is sitting at a small town community hospital and gets stuck in a procedure.
“There are still a lot of practices that are doing [that]: This set of docs has ten windows open and this set of docs has ten windows open and they are their own workflow engine,” Lafferty explains. “They figure out what they want to read, when they want to read it and, invariably, asymmetries develop. Certain facilities receive preferential treatment over others, meaning those patients receive preferential treatment in the timing and or the skill-set that’s used to read them.”
In a patient-centric world, the business imperative can’t override the interest of the patient, Lafferty says. “There are a lot of systems out there that claim load balancing and workflow, but what many of them do is just push an equal amount of ‘data’ to each radiologist,” he says.
“That is great,” he continued. “You can load balance in the sense that the business is load balanced and you keep the workload equal. “What you are not doing is taking care of the patient.”
The element that a lot of people miss or take for granted is the workflow,” Hosenfeld adds. “We never assign work, we only expose it to the next available physician.”
As a result, Riverside has the ability to deliver a consistent level of service across all locations. “We can tout—and then prove—that what we are doing is taking care of the patients in the order they need to be, regardless of where the imaging data originates. Whether it is a small, critical care hospital or a big tertiary care facility, they are going to be cared for in the same way.”
Tools and tactics
Providing radiologists with these tools—the workflow suite and the ability to present that single view of the patient across the Riverside enterprise—on a unified platform that is familiar to Riverside radiologists no matter where they sit has resulted in efficiencies of at least 15% to 20%, Lafferty estimates.
“We did take time to have the developers sit with the radiologists and understand their workflow,” Hosenfeld recalls. “We were owned by the radiologists, employed by them, so it was in our best interest to listen to what they had to say. They were very good about taking a lot of time, explaining to us computer guys why the cases should be ordered in this way or appear in this fashion.”
In the process, the practice reallocated all nonclinical activities away from the radiologists, through software or support personnel. “If I have a radiologist doing nonclinical activities, he is of reduced value to the patient,” Hosenfeld says. “We are missing the opportunity to serve a patient if [the radiologist] has to be an EMR jockey, mess around with data entry, or even track down another physician to relay results.”
The workflow tool also helps radiologists maintain compliance with quality measures, prompting them with reminders or pre-populating specified values into a report when a study is encountered for which certain information must appear.
Additionally, peer-review functionality was built directly into the workflow tool, enabling not just reviews of prior studies, but near–real-time blinded reviews of the reviewer, facilitated by filters that cause an exam to pop up on a desktop with a note that says “review this.” “There is no longer this lag of days or even weeks, as you are doing the review within the clinical window for the patient,” Lafferty says. “We have already seen benefit from that.”
Having optimized its practice for efficiency, RRIA is redoubling efforts to leverage IT in the service of value to its patients and referring physicians. “I don’t want to say we fell away from it, but we got absorbed in infrastructure and other necessary things, and we took a hiatus from some of that,” Hosenfeld says.
A current focus, according to Lafferty, is providing end users—patients and referring physicians—with the ability to communicate with the practice in their preferred mode of communication. “We need to be very creative in the way that we allow our customers access to our radiologists and our images,” Lafferty says. “I think Ron has some pretty exciting tools in development hat will allow us to take communications to the next level.”
Hosenfeld says that it is all about creating the path of least resistance to care for everyone—whether it is the referring physician, the patient or the surgeon— and restoring, electronically, communications lost in the digital transition. “Being able to get all the way back to that very valuable interaction that they used to have in the film room,” suggests Hosenfeld. “How do we get them standing, virtually, shoulder to shoulder again in the care of the patient?”
Increasingly, the patient will be the object of that effort. “We are entering the stage of consumerism from the standpoint of the patient,” Lafferty says. “The patient has to fit into that algorithm, there has to be a legitimate way for the patient to access the physician, in this case, the radiologist.”
He acknowledges that some radiologists are uncomfortable with that notion. “I think the practices that are able to deal with that trend in a substantive way without destroying their productivity and efficiency are going to be the winners,” he says. “It will be huge for business and an incredible marketing tool as well.”