What Community Hospitals Want: A Conversation With David Harrison, RT, MBA

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Richard HarrisonCommunity hospitals have a unique set of needs when it comes to imaging. Though they also once faced a corresponding set of challenges, advances in telecommunications have, to some degree, leveled the playing field, enabling them to provide radiology services on par with those of their larger peers. ImagingBiz.com spoke with David Harrison, RT, MBA, imaging services manager at Wooster Community Hospital (WCH) in Ohio, about what community hospitals want from their radiologists. ImagingBiz.com: As imaging services manager at WCH, which aspect of your radiology provider’s service is most important to you? Harrison: It’s very difficult to pin that down; there are multiple facets to be concerned about—we want rapid report-turnaround time, but as a community hospital, we need to be able to provide on-site service for our patients. We need a radiologist on-site who can do fluoroscopy, and in our community, we also want to provide interventional procedures. If I have great report-turnaround times, that’s good, but if I still need to send patients away for procedures we can’t provide, the community loses out on a complete radiology service department; if I can do interventional procedures here, but my turnaround times are two weeks, that won’t work, either. We need to balance on-site services with interventional capabilities and report-turnaround time to provide our patients with the complete package. ImagingBiz.com: How are you tracking report-turnaround times, and what are your expectations? Harrison: We have it broken down into several classifications. We like to have routine studies turned around in 24 hours, and with our current group, the average turnaround time is around seven hours. We have another classification, known as expedited: Those would be the inpatients who are stable, but we prefer a short length of stay, so we would rather not wait 24 hours for the results. Generally, the expedited cases are back within four to six hours. The big one is, of course, the stat-case category, because stat exams are the catch-all: everything from the emergency department to potentially serious issues spotted by a referring physician in the office. We want those turned around as quickly as possible. At WCH, our fourth-quarter 2010 numbers showed 86% back within 30 minutes, with an average of 22 minutes for all cases, once they were received by the radiology group. The last classification is hyperacute, and that could be any life-threatening situation. Those are required back in less than 30 minutes, and we’re hitting that mark. ImagingBiz.com: How do you approach critical findings? Harrison: I got lucky on this one, because we’re working with Radisphere (Beachwood, Ohio), and their system for handling critical results is great. If there is a critical finding determined by the radiologist, he or she (or his or her designee) will make contact with the referring physician, and will relay the finding. What’s exceptionally nice about the way this is handled, for us, is that if you look at WCH final reports, there’s documentation that the critical-finding results were relayed to the right person, at the right time. To me, that’s huge, because it makes the tracking required by the Joint Commission much easier. ImagingBiz.com: What kind of peer-review process do you have? Harrison: We have a couple of things in place. With our general radiologists, about 2.5% of cases are pulled and evaluated in a peer-review process. A second radiologist overreads the study; if he or she concurs with the finding, the review is complete, but if there’s a disagreement, a second radiologist is involved. If Radisphere finds a perceived error, it will review the case and make sure to achieve consensus among the individuals on its quality-assurance (QA) committee before talking to the radiologist. It provides checks and balances. The other option I like is that if I get a call from a referring physician questioning the results of a study, I can submit that case for QA review, and the study goes for double-blind overreading. I get documentation back that says the case was reviewed and shares the outcome, and if an addendum is required, the referring physician is contacted. I also receive a quarterly report on the radiologists who read for me, showing the cases reviewed and the percentage of errors (classified according to the acuteness level of the patient’s condition). ImagingBiz.com: Is there a way to quantify radiology’s level of service to other hospital physicians? How important is their input? Harrison: Their input is very important. There are some changes we’ve put into place based on recommendations from the emergency department and from surgery. We used to have the emergency department review our plain-film radiographs between 5 pm and 7 am, and we would perform the final interpretation later. With Radisphere, we’ve changed this to a process where the emergency-department physician looks at those images and enters electronically his or her preliminary interpretation; then, when the radiologist brings up the case, he or she sees what the emergency-department physician says and can check that against the images to see whether he or she agrees or disagrees. This workflow provides improved accuracy for the patients’ clinical management. We had a similar situation with the surgeons. They are used to looking at a report and interpretation that includes the complete report text, so they requested that the radiologists comment about the appendix every time. The radiology group uses canned text, so the surgeons’ recommendation resulted in a change. Now, there is a segment that identifies the appendix, and whether it’s normal or abnormal in every study. I take physician feedback very seriously. We’re not in agreement all the time because it’s hard to make physicians agree, but we do the best we can to communicate and make things cohesive. ImagingBiz.com: What are your radiology deal breakers? Harrison: The physician on-site has to be the medical director of radiology. He or she must provide medical direction on all things radiology related. It’s also important for us to offer interventional procedures. If we did not have strong direction and a skilled physician with the ability to do those interventional procedures, that would be a deal breaker. Something that often goes on, with radiology groups, is the need to meet increased demands for service, resulting in increased expenses. They have to provide interpretations after hours, they have to use voice recognition, and so on; and the radiology group will often attempt to pass that cost along to the hospital. Personally, I don’t think that should take place. They’re collecting the professional-component reimbursement. The hospital is getting the technical component. The hospital has some patients unable to pay; therefore, a certain number of my clients are charity care, and we just eat the expense. More and more, it seems to me that radiology groups want to try to increase their profits by passing some of that pain of declining reimbursement along to the hospital. Those things add up, and it winds up being the hospital’s expense. We are heavily dependent on our radiologists. Good radiologists are hard to find, and they deserve to be compensated for their work. When you’re talking about a business decision, though, I think it needs to be a joint venture. They shouldn’t be asking the hospital to supplement their incomes. ImagingBiz.com: Describe your current radiology service and why you selected it. What do you have now that you didn’t have in the past? Harrison: What we have now is a unified workflow, and that’s important to me. Regardless of whether it’s 8 am, 8 pm, or even 3:30 am, my technologists follow the same process. Before, the time of day drove how to handle the study. Another important factor is that our organization could not purchase voice recognition. It would have been very expensive, and who knows whether we would have gotten compliance from the radiologists? Radisphere was able to bring in its voice recognition; we use its system with a VPN connection, and that has allowed us to reduce our transcription needs. In 2010, there were over 53,000 reports (out of 58,000) done via voice recognition, which is how our turnaround time came down so quickly. The third and final thing is that Radisphere has radiologists all over the United States with subspecialty abilities. Understand this actual scenario: A local high-school athlete hurt his ankle and had an unusual finding, and the majority of radiologists might have missed it, but because it went to the ankle specialist at Radisphere, he received an accurate diagnosis. Our local physician received a study read by a radiologist who also reads for professional sports organizations. Having that capability allows WCH to provide better care for our patients. Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.