A Day in the Life of Radiology: Taking Advantage of Data for Evidence-based Decisions

In November 2013, Virtual Radiologic (vRad) released its initial set of radiology patient-care (RPCSM) indices, the first findings-based benchmarking measures for imaging activity and utilization based on the global practice’s clinical data repository. Jordan Halter, vice president of solutions for the company, says, “With 23 million studies and growing, vRad’s database reflects practicing radiology on a large scale. That means that we have insight that reflects the national radiology market. vRad wants to use these indices as a way to start a dialogue in radiology. Everyone must start measuring value, quality, and performance as we transition from a fee-for-volume to a fee-for-value model. Until now, nobody quite knew how.”

By using a patent-pending, internally developed approach to normalizing its data, vRad was able to analyze the information associated with more than 750,000 emergency-department CT exams for the first RPC indices that it released publicly. The data, available on the company’s website for free and unrestricted use, can be filtered by age range, hospital type, body region, or geography (with a new state-specific option). “We wanted to show an alternative to drowning in big data and spreadsheets,” Halter says.

“RPC indices are an example of how relevant data, visualized in a fresh manner, can be used to make the case that radiology is anything but a cost center for hospitals,” Halter adds. “While our initial indices were targeted on one imaging modality (CT) in the emergency department, our objective, from the start, was to launch a set of RPC indices much larger in scope—with a much larger impact on the quality, value, and performance of radiology. We’re talking about a 24/7 visualization of all imaging modalities—or a look inside a day in the life of radiology.”

Shift-based Approach

Halter explains that the day-in-the-life concept originated with the realization that radiology workflow and operational decision making could be much better managed with the help of evidence-based insight. “The recession and year-over-year cuts in CMS rates have taken their toll on volume and revenue. Practices, including vRad, can’t wait for things to get better. They won’t. We have to find new ways to survive and thrive,” he says. “It’s no longer OK merely to count how many studies you do, radiologists you have, or hospitals you cover. The days of pulling the obvious lever of working harder by reading more to make more are over; radiologists are reaching their limits.”

Halter continues, “If we don’t understand the economics of radiology, we’re going to continue making knee-jerk, emotional decisions to do more of the same. Opinions are nice; facts are much better. The rules of economics are not suspended simply because we are practicing medicine. We all must use analytics and understand the fundamentals of radiology if we’re truly going to understand our options for survival and growth.”

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vRad’s approach, in the newest RPC index, is to divide a radiology practice’s day into three shifts: on-site, midhawk, and deephawk (Figure 1). Halter explains, “The on-site shift is best understood. It’s the hands-on, high-touch shift when most of the high-value imaging is done.”

He continues, “Midhawk is that 6 pm-to-midnight period when you’re not nocturnal yet, but for a typical practice, you don’t have many radiologists on-site, either. In the deephawk shift, your volume decreases significantly, as you’re primarily serving inpatients and the emergency department.”

Halter explains, “Once we broke it down this way, we realized that nothing was the same. Everything changes during these three shifts, including imaging-modality mix, patient type, and RVU-to-study ratios. This has critical implications for how you actually operate your practice, whether you’re independent or hospital employed.”

An Inconvenient Truth

“Hospitals want lower costs, higher quality, and higher service levels for radiology,” he notes. “Radiology groups want income, autonomy, and lifestyle. That creates a misalignment. Making decisions without the insight provided by the RPC indices is resulting in a widening of the gap—and that’s not healthy for hospitals, radiology groups, or patients.”

Halter explains that many practices are combating falling incomes by taking back the night—staffing and handling the deephawk shifts themselves, during both weekdays and weekends. By looking at the volume levels, payor mixes, study types, and RVUs (or economic value) associated with each of these shifts, however, vRad revealed some inconvenient truths about how radiology is practiced today.

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“For example, not all hours in a day are created equal, for radiology,” Halter says. “The overnight shift accounts for nearly half of all working hours, yet those hours drive only 11% of total RVU value since, they have the lowest RVU-to-study ratio, at 0.73 (Figure 2).”

He adds, “As important, this is the toughest shift to staff and manage. The on-site (daytime) shift is the most productive. Its 35% of total hours accounts for 70% of all RVU value for a practice. This insight has implications for every practice or health system starting its own radiology service line.”

Prescriptions for Practices

Halter’s prescription for practices: Make full use of analytics (such as the RPC indices) on shift differences to educate hospitals on the most efficient way to staff radiology. “We encourage radiology groups to seize the mantle and use analytics to get a seat at the table with their hospitals by providing much-needed insight into the new fee-for-value world.”

Halter continues, “Analytics and evidence-based insight will help practices create a growth-based operating plan that measures and improves value, quality, and performance. For example, stagger start times to cover the on-site shift so you can shift up and take back the higher-RVU activity during the midhawk shift.”

He says, “I know it might sound disingenuous, coming from a provider of teleradiology, but the numbers and implications just don’t support local groups doing their own deephawk coverage. Unless you can reach a scale north of 3 million annual studies at night, it’s expensive, inefficient, and misaligned with the goals of both the hospital and the physicians.”

He adds, “For example, if you let a radiology group that is100% focused on teleradiology cover the deephawk shift with final interpretations, you don’t need to staff radiologists, on-site, doing overreading on Monday morning.” Halter explains that an operating plan based on improving on-site staffing from 7 am to midnight, without adding any radiologists, is a win–win–win proposition for practices, hospital partners, and patients.

Halter adds, “Health systems also need to understand the implications of the data and give radiology staffing flexibility as they remove silent and overt stipends. There are real-life scenarios in which all players can win, using evidence-based insight.”

To groups doing their own deephawk coverage today, Halter says, “Redeploy your nocturnal radiologists to new on-site growth opportunities and use analytics to make your group indispensable to your hospital partners. You will be aligned and accountable, but you’ll also be affordable. This is a great example of how our value-added analytics and teleradiology expertise can help improve alignment between radiologists and hospitals—so that they can grow, together, as efficiently as possible.”

vRad’s shift data are available online for free and unrestricted use at www.vrad.com. The day-in-the-life indices include visualization of RVU value, modality mix, patient type, functional interventional radiology, and reading location—by shift. “In radiology today, studies and shifts are not interchangeable,” Halter concludes. “Once you isolate the data associated with these three shifts and understand the operating implications, you will look at your practice or radiology service line very differently—and make the appropriate changes. The status quo is not an option.”