Page 1


The Third Annual Ranking of

December 2010

The 50 Largest P r i vat e R a d i o lo g y P r ac t i c e s Ranked by number of radiologists, and including number of employees, studies, and imaging centers

Featured in this issue Strategic Acquisition of Imaging Technology | page 22 CMS Rolls the Dice on Decision Support | page 35 Building a Stroke Network: Radiology’s Role | page 64


The Third Annual Ranking of

December 2010

The 50 Largest P r i vat e R a d i o lo g y P r ac t i c e s Ranked by number of radiologists, and including number of employees, studies, and imaging centers

Featured in this issue Strategic Acquisition of Imaging Technology | page 22 CMS Rolls the Dice on Decision Support | page 35 Building a Stroke Network: Radiology’s Role | page 64


December 2010 | Volume 3, Number 6




Strategic Technology Acquisition in the Era of Accountable Care

By Brian C. Maher, MPH Radiology leaders must adopt a new rigor in technology assessment as they adapt to new payment models and reimbursement realities, yet prepare for the future.


The 50 Largest Private Radiology Practices

By Cheryl Proval Our third annual survey reveals that overall, the nation’s largest radiology practices continue to increase in size, and imaging-center ownership is consolidating among the very largest.

35 Medicare Imaging Demonstration Project: CMS Rolls the Dice on Decision Support


By George Wiley The challenges of meeting the requirements of the Medicare Imaging Demonstration Project might create some strange bedfellows.


Unlocking the Business-intelligence Vaults in Radiology

By Janice Honeyman-Buck, PhD, FSIIM The legal, regulatory, and reimbursement climate in health care makes it imperative for practice and department leaders in radiology to have access to relevant data.

54 The Sorcerer’s Apprentice: A Conversation With Jeff C. Goldsmith, PhD

By Cheryl Proval In a new book on medical imaging, the dysfunctional payment system, unproductive turf battles, the fusing of diagnostics and therapy, and the future of the profession are all on the table.

64 Saving Brain: Building the LA Stroke Network

4 Radiology Business Journal | December 2010 |

By Erin Burke Nowhere is radiology’s role in the team approach to health care more critical than it is in stroke response.

Healthcare organized by patient. Brilliant. PACS, RIS, Cardio – all the data for each patient – on one virtual desktop. Synapse® PACS, RIS and Cardiovascular have a lot in common. They’re all designed by Fujifilm. They’re all leaders in their fields. And, this is a big deal; they all have related architecture, tools and interfaces. These three impressive systems work together so you can get the information you need from a single workstation. With Synapse organizing your data by patient, everything is at your fingertips. So your job is less administrative, more diagnostic. And that’s an idea worth sharing. Call 1-866-879-0006 or visit ©2010 FUJIFILM Medical Systems USA, Inc.


December 2010 | Volume 3, Number 6


Publisher Curtis Kauffman-Pickelle



EDitor Cheryl Proval

A Pollyanna Interlude By Cheryl Proval


Art Director Patrick R. Walling

The Bottom Line

Facing the Revolution


Priors 12 Reimbursement | The Good-news, Bad-news Economic Scenario 14 Practice Management | Implementing Next-generation

Technical Editor Kris Kyes

By Lynn Elliott, MBA

Radiologist Workflow By Jon Copeland 18 Clinical Research | Imaging in Clinical Trials: Endpoints, Biomarkers, and Methods By Amit Mehta, MD 20 Numeric | Shortage of Radiation Oncologists Predicted


Advertiser Index


Final Read

Associate Editor Cat Vasko Contributing Writers Erin Burke; Jon Copeland; Lynn Elliott, MBA; Janice Honeyman-Buck, PhD, FSIIM; Brian C. Maher, MPH; Amit Mehta, MD; George Wiley Sales & Marketing Director Sharon Fitzgerald Production Coordinator Jean Lavich Corporate Office imagingBiz 17291 Irvine Blvd., Suite 406, Tustin, CA 92780 (714) 832-6400

A Corner Turned By Curtis Kauffman-Pickelle


PResident/CEO Curtis Kauffman-Pickelle VP, Publishing Cheryl Proval VP, Administration Mary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. December 2010, Vol 3, No 6 Š 2010 imagingBiz. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 406, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

46 6 Radiology Business Journal | December 2010 |

AdView A Pollyanna Interlude As we travel down this apocalyptic road, let’s take an optimism break


hose who know me even a little would never peg me as a Pollyanna, heroine of the 1913 novel of the same name by Eleanor H. Porter (1868–1920): a cheerful bundle of optimism with the gift of finding sunshine in even the darkest day. Even by those closest to me, I am perceived as critical, skeptical, and too particular to be positive (in my defense, I come by all three traits honestly, as occupational hazards of 35 years as a journalist and editor). Now, I am ready to confess a deep, notso-dark secret: 50 years ago, as I sat on a velvet seat in a darkened movie palace, Disney’s “Pollyanna” left an imprint on my as-yet-unhardened heart. Today—right now—I am letting her loose, for if ever there was a need for optimism, it is at this moment in radiology’s long winter night. Call it my year-end gift to those of you who have endured a year of scolding, bossy editorials urging you to heed the cries of the wolf at our door. Instead of writing about the atrocities contained in the 2011 final Medicare Physician Fee Schedule (MPFS)—specifically, the shortcomings of the Physician Practice Information Survey and the multipleprocedure payment reduction—as we move into the final month of the first decade of the 21st century, I offer you 10 reasons to be optimistic about the future of radiology. First, change breeds opportunity. While complacency will get your lunch (and maybe more) eaten, creativity offers the best hope for thriving. Whatever you do, don’t bury your head in the sand; instead, free your right brain and develop some coping skills for life in this age of uncertainty. Take a vacation. Imagine the future. Private-equity money has a keen interest in health care. Second, team care trumps rugged individualism in health care. No matter which direction the politicians take health-

care reform, we can thank the legislation for getting health-care providers aligned around team care. This puts patients where they belong in the health-care equation: at the center. Third, the growth forecast predicts sunny skies, with a few thunderheads on the horizon. There are concerns about how utilization management will affect volumes, but forecasts from respected health-care consultancies like The Advisory Board Company (Washington, DC) call for moderate growth in high-tech imaging, moving through the decade. Growth is good. Fourth, functional/molecular imaging is a vast, untapped frontier. Don’t let the glowing-mouse images turn you off: The imaging of biological processes poses some very tantalizing possibilities for the future of the specialty. While you have some jingle in your pocket, look for opportunities to invest in the future of radiology. Fifth, prepare for low-dose CT lungcancer screening. Just when it was lying, besmirched, in the gutter of popular consciousness, multidetector CT got a public-relations boost with the November news that the National Lung Screening Trial had been halted due to clear evidence that low-dose CT lung-cancer screening can save the lives of smokers and former smokers. Results will be published soon; start thinking about your strategy now. Sixth, fee-for-service payment is under review. Let’s face it: CMS has thrown the RBRVS system out of the window when it comes to pricing radiology services, and once it turns its sights toward the newest growth specialties, they will feel the sting, too (perhaps a new payment system would restore some semblance of equity). Because this is an exercise in optimism, we must count our blessings: Radiology continues to be an exciting, challenging, and rewarding specialty/business/domain in which to labor. Seventh, outpatient imaging is not a business for sissies, but here, also, there

8 Radiology Business Journal | December 2010 |

is reason to be hopeful. Insurers want a low-cost option, and patients want easy access to outpatient studies. These are two very good reasons that private insurers may break with Medicare and maintain fair pricing. Eighth, bridges are better than fences. As radiology engages in seeking new forms of care delivery, now is the time for building bridges, not erecting fences (check out what health-care futurist Jeff C. Goldsmith, PhD, has to say on this subject, beginning on page 54). While they are more complex, bridges are far more interesting structures than fences. Ninth, the proliferation of accreditation requirements favors radiology. As it stands, by 2012, providers of CT, MRI, and nuclear medicine will have to be accredited for reimbursement under the MPFS. California also will require providers of CT and radiography to be accredited by 2013. This is welcome, if potentially costly, news for all high-quality providers of outpatient imaging services. Tenth, while the carrot of pay for performance will soon turn into a stick, pay for performance opens the door to another idea whose time is overdue: pay for technology performance. Should a procedure performed on state-of-the-art technology be reimbursed at the same rate as one performed using a legacy machine? We think not. The essential truth is that radiology rocks the health-care house. The specialty has the best tools, the most functional IT, the greatest people, and the brightest physicians. There’s good reason to bet on this horse. Bring it on, 2011.

Cheryl Proval, Editor

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The Bottom Line

Facing the Revolution Radiology has experienced no less than a revolution, and it has reset the balance of power in the hospital– radiologist relationship


t can certainly be said that the past four years have not been the best of times for radiology practice managers. Since the enactment of the DRA, practices with significant imaging-center investments have seen margins slashed, year after year, with no end in sight. Hospital-based practices have watched as a number of practices around the country have experienced the sudden loss of long-standing, exclusive hospitalcoverage relationships. Now, with the Patient Protection and Affordable Care Act posing a number of known and unknown threats, it is imperative for radiology managers to understand that our industry is confronting not merely routine evolutionary changes, but truly revolutionary changes. Exactly what does this mean for radiology practice executives? We must understand that the ordinary measures that we have used, throughout our careers, to deal with ordinary challenges are not sufficient to get us through the extraordinary circumstances we now face. The simple, common-sense solutions that have served us well in our careers might be perfectly suitable for the evolutionary times, but they will be woefully inadequate in dealing with the tectonic shifts underway in health care. In the past, for example, outpatient imaging center operators faced occasional reimbursement cuts or had margins squeezed by the costs of keeping pace with expensive new technologies. Management would respond by instituting cost cuts and/or efficiency measures; developing new, effective marketing initiatives; or working with advisors to find creative, lower-cost financing vehicles. These actions, along with double-digit volume growth, were usually adequate to keep the bottom line healthy. As many operators are unfortunately discovering, however, these steps are no longer enough. The survival of outpatient imaging

by lynn elliott, MBA

operations will depend upon whether management can find solutions to the challenges of revolutionary change. Increased procedural volume is, of course, an answer—but finding that volume is not going to be easy. Utilization-control programs and radiology benefits managers have finally been effective in controlling the growth in radiology utilization. Appropriateness-criteria systems currently finding their way into the industry are likely to provide additional assistance in controlling utilization. Operators will have to find a way to increase volume in existing centers in ways that might not be appealing, such as closing marginal centers and consolidating volume in more efficient centers. Such options could present problems of their own, as referring physicians might be unhappy with the loss of a local presence; competitors might take advantage of the situation and take away market share.

Hospital Relationships Hospital systems, with their reimbursement advantages, might be another avenue for radiology operators seeking relief from dwindling margins. While hospitals have generally been reluctant to enter joint ventures with physicians for services already provided by the hospital, there seems to be some movement toward a more cooperative environment in some parts of the country. Radiology practices can bring to the table existing centers, along with the expertise needed to manage them effectively. Hospital systems offer higher reimbursement levels and the ability to raise capital. With these synergies in play, radiology managers should seriously consider seeking jointventure opportunities with hospitals. For hospital-based practices, the sudden, unexpected loss of a long-standing hospital-coverage relationship imposes a dire financial impact upon the practice. The very existence of the radiology group might be threatened, as a number of recent high-

10 Radiology Business Journal | December 2010 |

profile cases have shown. An encouraging aspect of this new threat, however, is that the group has some measure of control over its hospital relationships—and, therefore, the opportunity to avoid the threat entirely. It is important for every radiology group to understand that advances in PACS technology, which have so radically improved the efficiency of the radiologist, have also shifted the balance of power in the hospital–radiologist relationship. Hospitals have more options for acquiring professional radiology services, and they are becoming increasingly willing to turn to those options when they feel that their existing radiology provider is not meeting their needs. Radiology managers should honestly assess the status of the relationships with their hospitals. Strategies should be devised and steps should be taken to ensure that the group is perceived by the hospital as a value-added provider within the system. Failing to nurture the hospital relationship (or putting off conciliatory negotiations until the last minute) can be disastrous. Once hospitals have begun to look seriously at alternatives, it might be too late to salvage the relationship. Rebuilding troubled hospital relationships and shoring up good ones will almost certainly involve some elements of compromise on the part of the radiology practice—compromise that wasn’t necessary, in the past. Revolutions all have one thing in common: They always leave winners and losers in their wake. It is the role of radiology business managers to step up and lead their practices in taking extraordinary measures to ensure that their practices will be among the winners. Lynn Elliot, MBA, is CEO of Radiology Associates of Tarrant County (RATC), a 72-member practice, and is CEO of ASI, a consulting and management affiliate of RATC that provides management and consulting services to outpatient imaging centers. Both companies are based in Fort Worth, Texas.





{priors} reimbursement

The Good-news, Bad-news Economic Scenario


he list of entities with imaging in their crosshairs goes on and on, but when it comes to eroding reimbursement and enhancing oversight, the current primary culprits are CMS and Congress, according to Maurine Spillman-Dennis, MBA, MPH, director of economics and government relations for the ACR®. In the “ACR Economic Update” presented on September 28 at the 2010 RBMA Fall Educational Conference in Austin, Texas, Spillman-Dennis and her colleague, Judith Burleson, MHSA, ACR director of metrics, outline some of the current challenges and opportunities facing the profession. Although the former outnumber the latter, the news isn’t all bad. The Spillman-Dennis portion of the presentation focuses on recent and upcoming changes in imaging reimbursement—and how the ACR is working to combat them, where possible. She begins with a look at the 2011 proposed (now final) Medicare Physician Fee Schedule (MPFS), which reduces the physician-payment conversion factor by 6.1% in 2011, adding to the 21.2% scheduled reduction that was delayed by Congress, over the summer, until November 30. Spillman-Dennis adds that it’s still difficult to tell whether action will be taken at that time; if Congress fails to delay the cuts or create a permanent change in the formula for the sustainable growth rate (SGR), imaging could be looking at reimbursement cuts on top of reimbursement cuts. The ACR also is concerned that the 2011 MPFS might undervalue certain imaging-procedure codes. “One of the big misperceptions out there is that imaging services are overpriced,” SpillmanDennis explains. “That puts codes under the microscope—we have to justify maintaining their current value.” She

notes that the DHHS secretary is likely to zero in on codes with the fastest growth, codes that pertain to new technologies or services, codes that tend to correspond with low RVUs, and codes not reviewed since the early 1990s. She adds, however, that the DHHS secretary also has the license to review any other codes, as the DHHS deems that review appropriate. “Basically, this is the whole fee schedule,” she concludes. “The days of review every five years are done.” The Patient Protection and Affordable Care Act (PPACA) mandated changing the equipment-utilization rate (for diagnostic equipment priced at over $1 million) to 75%; in the 2011 proposed MPFS, CMS issued a few clarifications of this change. First, the rate will also affect CT angiography (CTA) and MR angiography; second, the 75% rate will supersede the original CMS plan to increase the rate to 90%. The 2011 MPFS also proposes expanding the multiple-procedure reduction from 25% to 50% for the technical component of CT, MRI, and ultrasound—even if the body parts imaged are noncontiguous. The change applies to 11 families of codes, and CMS proposes adding cardiac CT and coronary CTA to these. In an ACR analysis of the potential impact of these changes, neuroradiologists and providers of portable radiography actually stand to benefit, while general radiology could suffer a 12% overall payment reduction, and IDTFs could see an even more onerous 20% reduction in reimbursement. When the ACR met with CMS to discuss the multiple-procedure reduction, the agency seemed to suggest that while the change might not be fair, Congress was just as likely to implement it down the line, Spillman-Dennis says. “We talked to them about how we’re in the process of bundling ourselves,” she adds. “The back and forth was cordial, and they

12 Radiology Business Journal | December 2010 |

seemed to get it, but who knows?” Many CMS calculations are based on the Physician Practice Information Survey, an update of the AMA’s Socioeconomic Monitoring System. The ACR paid around $75,000 to participate in this year’s survey, and the results weren’t promising: “We got hosed,” SpillmanDennis says. According to the survey, radiologists’ practice expenses will decline by 33% next year, and that figure is what CMS will use in its allowances regarding practice expenses. The ACR’s stance is that the survey wasn’t an accurate representation of radiology because its 56 respondents were primarily hospital-based radiologists— without any practice expenses whatsoever. “We complained about the transparency and lack of access to data, and we asked them to delay implementation,” Spillman-Dennis says. In the face of these complaints, CMS agreed to transition in the new practice-expense calculation over four years. “Still,” Spillman-Dennis says, “it’s a hit.” Congress Takes a Bite When it comes to Congress, the other key agitator against imaging, the news isn’t much better. “We were the only physician specialty targeted for reductions in the health-care legislation,” Spillman-Dennis says. “There were proposals that would have had an even worse impact, but since 2008, congressional staff members have been looking for $3 billion from imaging to support other initiatives.” As Spillman-Dennis sees it, the PPACA’s real hit to imaging was its missing provisions: no SGR fix and no tort reform. “The latest on the SGR is that Congress might not even extend it until the first of the year,” she adds. The PPACA also established the Independent Payment Advisory Board (IPAB)—otherwise known as the


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Medicare Payment Advisory Commission (MedPAC) on steroids, in health-policy circles. To differentiate IPAB from MedPAC, members of Congress did not build any oversight into the committee. “Their proposal is to extend the solvency of Medicare, improve quality of care, and reduce national health expenditures. That last part is what they’re really going to be focused on,” Spillman-Dennis says. The ACR is responding by proffering support for credible members for the board, in the hope of getting IPAB to focus on areas other than imaging. Spillman-Dennis notes that a key PPACA mandate affecting imaging is set to kick in soon. Beginning on January 1, 2011, a new disclosure requirement will be added to the in-office ancillary-services exception. It requires referring physicians to give patients options for additional imaging centers (other than the one that they recommend). Spillman-Dennis says that the in-office exception, however, is here to stay: “No one seems to be able to close that loophole,” she adds. Burleson’s portion of the discussion, which focused on recent efforts to link payment and quality, was slightly more optimistic. The PPACA establishes a national strategy for quality improvement, requiring CMS and the DHHS to develop priorities for quality initiatives through a transparent, collaborative process. The statute mandates that CMS review any quality measures that it establishes every few years. It must use an outside entity— in this case, Burleson says, probably the National Quality Forum—as a consultant, prior to making new rules. “One of the major criticisms of the legislation is that it didn’t go far enough to control future costs,” she says. “That being said, the CMS Center for Innovation was created to work through some of the new, innovative payment and delivery arrangements, and funding was included to test these new models.” These could include patient-centered models, accountable-care organizations, or shared-savings programs (with bundled payments based on episodes of care). The PPACA mandates the transition of the hospital-based value-purchasing program to a performance-based program; in 2013, quality measures

will be introduced into the program, and in 2014, efficiency measures will be factored in as well. Though the efficiency measures have yet to be defined, Burleson notes, “Traditionally, efficiency measures are related to imaging.” In 2013, CMS also will begin implementing the valuebased payment modifier, which it will extend to specialty areas in 2015. A 1.5% Physician Quality Reporting Initiative (PQRI) bonus will gradually shrink until 2015, when payment reductions for failing to report quality data are scheduled to begin. CMS is required to provide timely interim feedback reports on PQRI data, as well as an appeals process; participation in the PQRI, coupled with participation in a medical board’s maintenance-of-certification program, will result in an additional bonus for physicians through 2014. Some changes to the PQRI also might be in the offing. The MPFS 2011 rule proposes reducing the sample size for reporting to 50% and adding a new radiology measure: use of a reminder system for mammograms. The Hospital Outpatient Prospective Payment System 2011 proposed rule would add four imaging-related measures to the existing four, and in 2012, CMS proposes adding an imaging measure involving door-to-

interpretation time for imaging of the head. “The current specs only include CT, but it’s likely they will also include MRI,” Burleson notes. CMS is also proposing to add 12 American Recovery and Reinvestment Act meaningful-use measures to the PQRI. Concerning meaningful use, Burleson observes that “probably 90% of radiologists would be eligible for the incentive program.” This represents a shift from what many in the imaging community originally anticipated, predicting that meaningful use would be likely to refer to the use of electronic medical records (EMRs). Burleson explains that the recently published meaningful-use definition leaves an unexpected back door open for radiology and other specialties. Providers must state that they are using EMR technology that has been certified by the Office of the National Coordinator for Health Information Technology, but there are both complete EMR systems and modular programs available. A PACS or RIS might have components that “can be certified as able to do certain things—fulfill certain requirements. Potentially, radiologists are eligible for the incentives,” Burleson says. —Cat Vasko

practice management

Implementing Next-generation Radiologist Workflow By Jon Copeland


ealth-care payment models are shifting, with providers taking on risk in the form of accountable-care organizations, bundled payments, impositions such as radiology benefit managers, and other strategies. At the same time, the Joint Commission has increased its requirements for proof of quality. There are increased regulations and controls, as well as pressure to increase production by radiologists. In many cases, lack of an enabling IT infrastructure is the limiting factor in meeting these demands. Even before the growth of these environmental factors, Inland Imaging, Spokane, Washington, needed an

14 Radiology Business Journal | December 2010 |

i m p r o v e d IT workflow infrastructure, independent of multiple PACS, RIS, hospital information systems (HIS), Jon Copeland and other systems. We had already implemented PACS, and more than 1,300 modality systems (in over 30 organizations, across four states) were connected. We were completely filmless, and we used voice-recognition software. We had a single PACS database in our own imaging centers and connectivity with


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the RIS of six vendors. The systems we purchased almost 10 years ago had scaled very well as our group grew from 12 to more than 65 radiologists. Nonetheless, we still wanted to improve workflow, quality, efficiency, and the acquisition of meaningful data for analysis. We struggled to balance workloads across the group—primarily due to the lack of visibility of workflow through our entire enterprise and our inability to allocate work easily and dynamically as demand and capacity varied across locations. We had only gross estimates of the day and night demands on workflow,

and we had no accurate work RVU reporting due to data being fragmented across multiple systems. A Workflow Tool We had brainstormed about an intelligent dispatching and quality system, with our own single, aggregated, independent source of quality and production data. This intelligent dispatching system would enable us to identify exam backlogs instantly and allocate work in real time. While developing this new system, we added condition and status features

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that were usually not tracked, and we provided a Web-based form that radiologic technologists and others could use to submit updates. Prior to this, if turnaround for an emergencydepartment report took too long, for example, we could not identify whether that was because the order went in late, transport was too slow, the technologist had difficulties with the patient, or another event slowed the process. Today’s RIS, HIS, and PACS do not track all of these elements. At best, they track only a few steps in the entire process, which can be fragmented across multiple systems. At Inland Imaging, we needed a system with intelligence beyond that of any single PACS or RIS, in addition to the ability to query foreign PACS for prior studies. In 2006, we began to develop this system, and by October 2008, our new radiology workflow tool was functional. Four developers worked for more than two years to build this system. We can track work RVUs, and we have developed our own algorithm for daily equivalency of work performed. The system uses Microsoft® .NET components and resides on a single, independent server integrated via our own interface engine. For the work algorithm, accurate RVU and body-part identification across our enterprise required our cross-reference map of 14,000 different exam codes received in orders from foreign systems. We also added credit for tumor-board participation and other valuable services performed by radiologists that might not be considered in a work RVU formula. We have a highly streamlined (yet data-rich) workflow system that functions in multispecialty clinics, rural hospitals, major tertiary-care hospitals, and our own imaging centers. Everyone uses the same workflow system and common, subspecialized worklists for technologists, radiologist assistants, dispatchers, and radiologists. A three-tiered worklist allows specific work assignment to an individual radiologist, to a shared subspecialty worklist, or to a catch-all worklist for general-radiography exams. Load Balancing Since the 2008 implementation of the radiology-workflow tool, we have seen a 14%


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improvement in radiologist productivity. Our ability to balance workloads quickly across the system has dramatically reduced variation in the work performed by radiologists. Before implementation, we had more than 50% daily variation in work in some subspecialties. Variation is now less than 10%. Some radiologists obviously read more quickly than others, but the variation is no longer due to inability to monitor and control workflow. The workflow system (and the people monitoring it) can spot and move waiting work to a radiologist who has the correct credentials—and enough time available. We provide our own 24/7 coverage service, with a lot of variation in shifts. Our system includes a scheduling and credentialing component that knows everything about our radiologists, including their subspecialties and what shifts they can work in which cities. The system has enhanced exam-routing rules (beyond what PACS offers). We also have dispatchers who make this happen. We believe that rules and automation can take you only so far, in a complex workflow environment like ours, so we have two dispatchers who watch over worklists and take action, as needed, to keep things flowing seamlessly. This

technology and our dispatchers enable us to move work to the correct subspecialist who has available capacity. In addition to eliminating the waste and improving productivity, we have added quality-tracking functions. Our report-turnaround times have improved significantly due to our abilities to balance workloads and identify exams by urgency category (routine, urgent, emergency, or stroke). We are now doing peer review based on ACR® standards within the workflow system. We perform both retrospective and prospective peer review. Retrospective reviews are completed by radiologists while they are looking at a prior exam. With a couple of clicks, radiologists get a drop-down screen with the ACR categories; they can then indicate whether they agree or disagree with the previous interpretation. Prospective reviews are allocated, by the system and dispatchers, to each radiologist, throughout the day. We have added an exam-quality function that the radiologist can use to rate an exam and provide feedback on a technologist’s performance, exam quality, exam protocols, and more. The hospital managers use this feedback as a documented training tool for technologists.

We also built a call-tracking system for reports and an urgent-findings worklist. Radiologists can make these calls themselves and, with a click, record these events. The system can also send these events to a radiologist assistant to perform. The system provides reports for all of these activities, and the hospital staff has the ability to generate its own quality-tracking reports. This can be especially helpful when the Joint Commission visits. In one of our hospitals, where we have a certified stroke program, the Joint Commission did not even ask to interview our neuroradiologist because critical-findings reporting for the stroke program was so complete. There is no doubt that the rules of radiology are changing—and will continue to change. It is critical to provide added value, as a radiology group, in addition to having accurate data to measure productivity and quality. Improving workflow has become a very serious issue. Our radiologists have benefited from a balanced workday and from increased productivity, and they no longer waste time on administrative issues. Jon Copeland is CEO of Inland Imaging Business Associates, Spokane, Washington.

clinical research

Imaging in Clinical Trials: Endpoints, Biomarkers, and Methods By amit mehta, md This article is the second in a series of three providing a background and primer to radiologists and imaging professionals interested in clinical trials. It offers background on regulatory approval and on the use of surrogate endpoints and imaging biomarkers, as well as touching on the administration of medical imaging in clinical trials. edical imaging has become a significant tool in the development of clinicaltrial protocols. Diagnostic imaging enables sponsors to obtain a rapid diagnosis by using truly quantitative assessment, as well as qualitative assessment. Paramount to understanding


the utility of medical imaging in clinical trials is an understanding of biomarkers as imaging endpoints. The definitions of these key elements Amit Mehta, MD of trial mechanics were developed and distributed by the Biomarkers Definition Working Group of the National Institutes of Health (NIH).1 The key determination point in a clinical trial is called a clinical endpoint.  A clinical endpoint specifically refers to a characteristic or variable such as a sign, symptom, laboratory abnormality,

18 Radiology Business Journal | December 2010 |

or disease that represents one of the targets of the trial. It often represents how an enrolled patient feels, functions, or survives. The results of a clinical trial most often try to represent the number of patients who reach the clinical endpoint during the study, in comparison with the total number of patients who are enrolled. When patients enrolled in the trial reach the clinical endpoint, they are often excluded from other facets of the trial, so the definition and determination of the endpoint are critical. For example, a clinical trial testing the ability of a drug to prevent deepvein thrombosis could use leg pain as the clinical endpoint. A person enrolled

in the trial who develops this symptom would be categorized as having met the clinical endpoint. The use of classic clinical endpoints, however, often can lead to lengthy trials—and, based on design, nonspecific correlation with the true effect of the therapy that is being evaluated. Therefore, clinical-trial methodology experts and researchers began to investigate alternative techniques to assist them in improving the elapsed time, quality, and statistical power of clinical trials This investigation led to the development of surrogate endpoints.

group sizes to obtain quicker results while maintaining the necessary statistical power.4

Imaging Biomarkers Specific to radiology, imaging biomarkers are a subtype of biomarker that enhances the methodology of a clinical trial. An imaging biomarker specifically uses a characteristic that is objectively measured using an imaging technique; this indirectly serves to represent the pharmacological response to the therapy being administered. The benefit of using medical imaging (correctly interpreted) is the ability to reveal subtle changes that demonstrate Choosing Surrogates the effectiveness of therapy—and that are To substitute for a clinical endpoint, often missed by the more usual subjective a surrogate endpoint or surrogate methods. In addition, trial data are less marker is used. In the majority of tainted by subjectivity, as imaging findings instances, surrogate endpoints have been are subject to blinding and are evaluated shown to decrease the length of trials, as without contact with the patient. there is more rapid assessment of whether The largest growth area for radiology a drug has clinical benefits. using biomarkers for surrogate endpoints An endpoint that is simply correlated has clearly been in oncology. In multiple with a clinical endpoint that is being trials of therapeutic agents for cancer, studied might not always be a suitable sponsors have used a decrease in tumor surrogate, as the surrogate is expected to size, seen using various imaging modalities predict the benefit (or lack thereof) that (including CT and MRI), as the surrogate the treatment has on the clinical endpoint.1 endpoint in evaluating the response of The NIH has defined two specific criteria solid tumors.5 Other growing areas include in relation to surrogate endpoints. the application of surrogate endpoints in First, a surrogate endpoint is, research involving the central nervous specifically, a biomarker intended to system and the musculoskeletal system. substitute for a clinical endpoint.2,3  For example, in the evaluation of Second, a biomarker is a characteristic treatments for Alzheimer disease, classic that is objectively measured and evaluated endpoints have been based on clinical as an indicator of normal biological criteria and neuropathology. Due to the processes, pathogenic processes, or natural course of the disease, it can take pharmacologic response to a therapeutic large amounts of time to see the effects of intervention.1 therapeutic agents. Over the course of the early 1990s, the FDA began approving trials that used a test or result that measured and evaluated a biological process, pathogenic process, or pharmacologic response to a treatment or drug rather than requiring a classic clinical endpoint. An example of a biomarker is prostate-specific antigen (PSA), used in evaluating the response to therapy for prostate cancer. A trial can be designed to use a decrease in PSA (the biomarker) as a surrogate endpoint for response to therapy.  With the use of biomarkers and Figure. Functional MRI demonstrates a surrogate endpoints over the past decade, change in blood flow related to neuronal researchers have been able to use smaller activity in a specific area of the brain.

Since the advent of biomarkers, imaging biomarkers, and surrogate endpoints, researchers have been using genetic markers, such as apolipoprotein E4; cerebrospinal-fluid markers, such as beta-amyloid and tau protein; and imaging biomarkers, such as hippocampus/ entorhinal-cortex volumes and structural connectivity, evaluated using diffusion tensor imaging and functional MRI (see figure).6 Trial Methodology Involvement in clinical trials represents an opportunity for growth for a highquality imaging center or group. While typically, an imaging contract-research organization (CRO) handles the specific protocol design and implementation for sponsors, there is an opportunity for imaging centers to participate. A typical imaging based trial involves three components: the protocol, the imaging sites, and the imaging CRO. Protocol: An imaging protocol is designed that pertains to (and details) the imaging biomarker being used to study the outcome of a therapy. This protocol defines an outline that standardizes the method in which the imaging is performed, as well as the format in which images are stored, transmitted, and reviewed. Imaging sites: Typically, an imaging CRO will seek imaging centers or groups to assume responsibility for acquiring the images. The imaging site is responsible for scheduling patients, ensuring that the protocol is followed, and using the predefined techniques for transmission of the images to the imaging CRO. It is imperative for the imaging site to provide high-quality images and for it to be able to follow the protocol, as incorrectly acquired data are discarded from the trial. In small trials—where a single patient can alter the statistical power of the methodology—it is crucial for there to be no mistakes. Imaging CRO: Once the images have been collected, it is the responsibility of the imaging CRO to ensure that the data are evaluated using the methodology outlined initially by the protocol. Typically, images are reviewed in a blinded fashion by radiologists from the imaging CRO. There can be as few as two reviewers (with a | December 2010 | Radiology Business Journal 19


third adjudicating reviewer), or there can be multiple reviewers at multiple sites. As the provision of medical imaging evolves, in the new era of decreasing reimbursement, many imaging centers are seeking alternative revenue streams. If an imaging center or group provides high-quality, reproducible imaging that can support complex protocols and has radiologists who can both implement and test these protocols, clinical-trial imaging can be a good avenue for diversifying revenue streams. Amit Mehta, MD, FRCP, is a radiologist with South Texas Radiology Group, San Antonio,

and consulting radiologist and therapeutic lead for a contract-research organization; References 1. Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther. 2001;69(3):89-95. 2. De Gruttola VG, Clax P, DeMets DL, et al. Considerations in the evaluation of surrogate endpoints in clinical trials. Summary of a National Institutes of Health workshop. Control Clin Trials. 2001;22(5):485-502.

3. Cohn JN. Introduction to surrogate markers. Circulation. 2004;109(25 Suppl 1):IV20-21. 4. Hajnal JV, Hawkes DJ, Hill DL, eds. Medical Image Registration. Boca Raton, FL: CRC Press; 2001. 5. Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. J Natl Cancer Inst. 2000;92(3):205-216. 6. Hampel H, Bürger K, Teipel SJ, Bokde AL, Zetterberg H, Blennow K. Core candidate neurochemical and imaging biomarkers of Alzheimer’s disease. Alzheimers Dement. 2008;4(1):38-48.


Shortage of Radiation Oncologists Predicted


n article by Smith et al,1 published recently in the Journal of Clinical Oncology, forecasts an impending shortage of radiation oncologists, suggesting that the number of residents in training from 2014 through 2019 must double to meet demand. The authors modeled demand through 2020 (see table) by multiplying current utilization rates for radiation therapy—based on the US National Cancer Institute’s Surveillance Epidemiology and End Results database for the years 2003 through 2005—by population projections from the US Census Bureau. The projected supply of radiation therapists was derived from the current number of radiation oncologists and active residents. The authors project that demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Sociodemographic forces are behind the anticipated increase in demand: Between 2010 and 2020, the number of US residents who are 65 or older (a demographic group with higher cancer rates) is expected to increase from 40 million to 55 million. A similar increase in the number of people belonging to those ethnic minorities that exhibit higher cancer-incidence rates also is expected to inflate the number of patients requiring radiation therapy from 470,000 in 2010 to 575,000 in 2020. The breast, prostate, lung, oral cavity and pharynx, colorectum, and esophagus are the disease sites projected to be most commonly treated with radiation in 2010 and 2020. The sites predicted to show the greatest growth in radiation treatment are the prostate, stomach, liver, lung, and pancreas. The number of minority members treated with radiation therapy is projected to increase by 45%.

The authors note that several questions should be addressed before steps are taken to increase the supply of radiation oncologists dramatically: How much of the increased demand can the current supply of radiation oncologists accommodate? How will changes in practice patterns, such as hypofractionated therapy, affect throughput? What impact will the increased planning burdens of newer technology have on the number of patients a radiation oncologist can treat? Can the increased use

of physician assistants and/or advanced practice registered nurses extend the supply of radiation oncologists? —Staff Reference 1. Smith BD, Haffty BG, Wilson LD, Smith GL, Patel AN, Buchholz TA. The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? J Clin Oncol. Published online ahead of print October 18, 2010. doi:10.1200/JCO.2010.31.2520.

Table. Projected Number of Patients Receiving Radiation Therapy in 2010 and 2020 Tumor Site



Increase in Demand (%)

Total...................................................470,000........................... 575,000...........................22 Breast (invasive)................................103,000............................ 119,000...........................15 Prostate..............................................91,000............................ 123,000...........................35 Lung....................................................77,000..............................96,000............................25 Oral cavity and pharynx.....................21,000..............................25,000............................18 Breast (in situ)....................................20,000.............................23,000............................15 Colorectum.........................................19,000.............................23,000............................22 Esophagus..........................................19,000.............................23,000............................22 Thyroid...............................................15,000.............................. 16,000............................10 Central nervous system......................12,000.............................. 14,000............................16 Non-Hodgkin lymphoma.................... 11,000.............................. 13,000............................18 Uterus................................................. 11,000.............................. 13,000............................22 Larynx..................................................9,300.............................. 12,000........................... 24 Cervix..................................................7,000............................... 8,100.............................16 Pancreas..............................................6,000............................... 7,500.............................25 Stomach..............................................5,300...............................6,800.............................27 Myeloma..............................................4,700...............................5,600.............................25 Bladder................................................3,200...............................3,900............................ 24 Hodgkin lymphoma.............................3,200............................... 3,300............................. 6 Testis...................................................3,000...............................3,000..............................2 Kidney.................................................2,500............................... 3,100.............................21 Melanoma...........................................1,500................................ 1,800.............................17 Leukemia.............................................1,400................................ 1,600............................. 11 Liver...................................................... 920................................. 1,200............................ 26 Ovary.................................................... 380.................................. 440...............................16 All other sites.....................................24,000.............................29,000............................19 Adapted with permission from the Journal of Clinical Oncology.1

20 Radiology Business Journal | December 2010 |



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Medical Imaging Business Performance

Technology | Strategic Acquisition

Strategic Technology Acquisition

in the Era of Accountable Care

Radiology leaders must adopt a new rigor in technology assessment as they adapt to new payment models and reimbursement realities, yet prepare for the future By Brian C. Maher, MPH


ith the passage of the Patient Protection and Affordable Care Act (PPACA), the health-care community is preparing for a tidal shift in how all providers are expected to perform. Hospitals and physicians increasingly will be held more accountable for ensuring that the key pillars of health-care reform are satisfied: improving the quality and accessibility of health-care services while lowering costs. Among many other market factors, new payment mechanisms and regulations established by the PPACA place providers of advanced diagnostic-imaging services squarely in the crosshairs, as lawmakers have repeatedly pointed fingers at the radiology community as a major contributor to the rising costs of health care (especially over the past decade). Members of the radiology community must now accept a wholly new operating environment to come, and must adopt new strategies not only to prosper, but also merely to survive. The greatest efforts to curb the rising costs and utilization of imaging services have been aimed where it hurts most: our wallets. Since the passage of the DRA, new regulations have chipped away at technical-component reimbursement, and they also have made mechanisms to ensure more appropriate utilization of advanced imaging services commonplace, primarily via radiology benefit managers and precertification programs.

Many of these regulatory and market forces have resulted (and continue to result) in a softening of annual growth rates for outpatient Brian C. Maher, MPH imaging services. In previous years, advanced modalities such as CT, MRI, and PET grew at double-digit rates, but the outpatientmarket projections of The Advisory Board Company (Washington, DC) suggest much slower—albeit positive— growth rates for these modalities: 3% to 5% annually. Slower growth rates, coupled with lower reimbursement rates expected in the future, portend decreased profitability for outpatient imaging services (and ultimately, reduced access to capital to fund new technological and strategic investments). Looking to the future, radiology providers will need to be ever vigilant and to place additional scrutiny on how limited capital dollars are allocated, each year, toward new imaging-technology investments. In short, the cost of getting it wrong will be significantly greater than in years past. Reform’s Impact Key to the effectiveness of healthcare reform is the establishment of new payment models designed to transform the manner in which providers are

22 Radiology Business Journal | December 2010 |

reimbursed, rewarding the quality (rather than the quantity) of care. These new models—including bundled payments, episode-of-care payments, and sharedsavings programs, among many other provisions of the PPACA that directly target radiology utilization and reimbursement (Table 1)—will have a profound impact on funding appropriations for capital equipment and on the rationale behind acquiring premium, versus workhorse, technology. Perhaps the most groundbreaking of the new accountable-care payment models and regulations affecting future imaging-technology decisions is the shared-savings model. Set forth as a voluntary Medicare program in 2012, accountable-care organizations (ACOs) represent a collection of providers financially and/or legally aligned in such a manner as to permit the sharing of savings that result from besting a predetermined spending benchmark for a given patient population. ACOs will require improved coordination among providers, with added incentives to minimize unnecessary services in order to meet certain cost thresholds. According to The Advisory Board Company’s Imaging Performance Partnership research, radiology will be greatly affected by accountable-care models on several fronts. These will include: • greater involvement of radiologists, as consultants and educators, in

determining appropriate treatment strategies and educating physicians on order appropriateness; • downward pressure on traditional demand drivers, with ordering physicians taking on greater responsibility for keeping costs low and ensuring order appropriateness; • increased relevance of outpatient imaging centers, due to lower costs and greater access; and • emphasis on the need for lower-cost, capacity-enhancing technology, as opposed to premium equipment for only niche applications and/or patient populations. Right now, it is challenging to determine exactly how greatly imaging demand—and ultimately, profits—will be affected by accountable-care models. Nonetheless, radiology providers should immediately explore, with greater attention, mechanisms to lower costs while maintaining highquality services and efficient operations.

One way to help rein in the cost of care is to ensure that the most appropriate imaging technology is deployed in the correct setting. Premium equipment might find a role in the hospital environment, where it will support the growth of other clinical service lines, but lower-cost, workhorse technology will still benefit the vast majority of patients in the outpatient setting. To determine the appropriate level and siting of imaging technology, providers must pay particular attention both to modality volume (by procedure and patient type) and to the distribution of volume among equipment and sites. It is important to note that, based on research conducted by The Advisory Board Company, the overwhelming majority of advanced-imaging volume is represented by routine applications (Table 2), reinforcing both the importance and the sustainability of using standard-of-care technology for many years to come.

New Imperatives With vendors showcasing new innovations in imaging technology at the RSNA® 2010 96th Scientific Assembly and Annual Meeting in Chicago, Illinois, it is increasingly difficult for providers to determine which technologies are necessary, versus those that might be considered nice to have. Given the downward pressures of new payment models and other regulations affecting future access to capital, hospitals and imaging centers will need to be judicious in determining the most appropriate technology, both now and in the future. Imaging providers will need to ensure that future technology purchases align accordingly with the need to improve quality and access while managing costs better. Improving quality of care: There is no refuting the value and importance of advanced diagnostic-imaging services in health care today. New innovations seek

Table 1. Potential Impact of Reform and Regulation

Market Phenomenon

Driving Agency


Facilities Affected

Degree of Impact

RVU adjustments based on CMS 2010–2013 (four-year Nonhospitals the Physician Practice phase-in period) Information Survey Equipment-utilization factor Congress 2011 Nonhospitals increase (to 75%) Facility accreditation




Multiple-procedure CMS 2010 Nonhospitals payment reduction Self-referral sunshine provision


Cost-based patient steerage

Private payors Early-adoption phase Hospitals and radiology benefit managers

Targeted preauthorization (examples: cardiac and emergency imaging)

Private payors Early-adoption phase and radiology benefit managers

Increased patient obligations Private payors (higher deductibles and copayments)


Physicians’ Offices

All; hospitals bear emergency- imaging burden

15% of commercial Hospitals lives on high- deductible plans | December 2010 | Radiology Business Journal 23

Technology | Strategic Acquisition

to provide better means of noninvasive screening, diagnosis, and monitoring for myriad diseases and conditions. Nonetheless, the quality of diagnosticimaging services is closely scrutinized, as quality relates to both effectiveness and appropriateness. Now, chief among new challenges in imaging quality is measuring the long-term effects of medical exposure to ionizing radiation. Increased cancer risks have been ascribed to CT and fluoroscopic procedures, and this has not gone unnoticed, due to negative press reports and a handful of sentinel events across the country. This attention, however, has led to marked improvements in awareness within and outside the radiology community, with members of industry, regulators, and clinicians all focusing on reducing radiation dose for applicable exams. There is no shortage of novel dose-management techniques, from prospective ECG gating modes to iterative reconstruction algorithms, and more improvements are anticipated for the future. While it’s unclear to what extent federal, state, or other regulations will affect radiation-dose management and associated technologies, acquiring technology with

low-dose capability now represents a significant step in providing high-quality— and safe—imaging services. Imaging technologies that seek to reduce unnecessary downstream interventions will also satisfy new quality imperatives. Hybrid PET/CT imaging is now fundamental to cancer treatment planning, based on its demonstrated ability to change the management of cancer patients to a more appropriate course of therapy. Similarly, breast tomosynthesis— though not yet commercially available— might reduce unnecessary downstream tests, given early results suggesting that it could produce lower recall rates and greater diagnostic confidence than traditional 2D digital mammography can. With each new innovation in technology, we will hope to see a direct correlation with improved safety and clinical outcomes. Improving access to care: Due to the passage of the PPACA, millions of newly covered lives will enter the health-care marketplace (most after 2014), and imaging providers will need to become more efficient to accommodate the anticipated moderate increase in volume. Technology that enables providers to handle greater throughput and that allows more exams

to be performed (without considerable staffing or operational changes) will have a greater role, moving forward. For this and many other reasons, digital mammography is now considered requisite technology for institutions offering breast-health services. Providers using digital mammography can better accommodate more patients daily, owing to the significant reductions in exam time (often cited as 50% or more, compared with film mammography), allowing both more expedient imaging and greater perunit capacity. Another imaging technology likely to have a significant impact on accessibility is wide-bore or high-field open MRI. Equipped with standard-of-care imaging capabilities, these systems allow a more accommodating patient experience, reducing anxiety and claustrophobic reactions that degrade optimal scanning conditions. For many organizations, widebore and open MRI scanners have reduced the need for time- and resource-consuming sedation, allowing more patients to be imaged by decreasing reliance on anesthesia delivery and by promoting better management of MRI schedules. Wide-bore and open MRI scanners also permit bariatric patients to be imaged more comfortably, meeting an immediate

Table 2. Procedure Mix for Advanced Modalities: 2009, 2014, and 2019

Modality Procedure

Portion of Total Volume (2009)

Portion of Total Volume (2014)

Portion of Total Volume (2019)

Abdominal/pelvic CT




Head/neck/brain CT




Chest CT








Spine MRI




Bone/joint MRI




Brain MRI








Cardiology nuclear imaging




Bone nuclear imaging




Gastrointestinal nuclear imaging










Nuclear Medicine

24 Radiology Business Journal | December 2010 |

market need. Though debate remains today regarding the ability of highfield vertical open scanners to serve as workhorse units, there is little doubt that more accommodating MRI scanners— either open or wide-bore, but more likely to be the latter—are becoming the industry (and market) standard. Bending the cost curve: The diagnosticimaging industry has often been singled out as a major contributor to the escalating costs of health-care services. Imaging providers, however, can play an integral role in managing costs by ensuring that the most appropriate technology is used in the most appropriate setting. To that end, it is important to understand the incremental benefits afforded by technological innovations, relative to added costs. Though vendors have recognized the economic hardships of hospitals and imaging centers, offering price reductions on selected equipment classes, premium imaging systems still command premium prices. Despite the significant cost differential between premium systems and their standard-of-care counterparts, the incremental benefits of premium technology are commonly limited to advanced applications and/or niche populations (Figure 1, page 26). Moving forward, imaging providers will have greater options within modalities, but they must still be pragmatic when weighing premium versus workhorse technology. Emerging as a trend, across all imaging modalities, is the need for greater automation in imaging protocols. From start to finish, considerable opportunities exist to improve efficiency and reduce variability (which can lead to increased costs or alternatively, less revenuegenerating scanner time). Providers can expect more productivityenhancing features, especially in new MRI and ultrasound systems. Because many of these will be made available only with premium technology, however, there is still a price tag attached. In addition, administrators must not neglect the importance of training and of process efficiencies in determining whether a need for costly productivity-enhancing features exists. Looking to the future: Though standard-of-care functionality will still

be highly desired for many years to come, radiology also must prepare for the dawn of personalized medicine, in which genomic information will be used to make individual, tailored care decisions based on a person’s genetic characteristics. Diagnostic imaging will increasingly be involved in aspects of translational medicine, helping scientists to identify genomic and proteomic biomarkers for cardiovascular diseases, cancer, neurodegenerative conditions, and many

e l e v a t i n g

other clinical processes. Leading the way will be the molecular-imaging modalities of hybrid PET/CT, SPECT/CT, and (in the next several years) PET/MRI. While these modalities, and the accompanying targeted radiotracers that they will require, might not be widely adopted into clinical practice for many more years, imaging specialists must still consider the untapped potential of these modalities to contribute to new scientific and clinical discoveries in the personalized-medicine field.

t h e

o u t c o m e (866) 323-7227


Technology | Strategic Acquisition

$2 million– $2.5 million

$1.3 million– $1.6 million $750,000– $900,000 $450,000– $500,000

16-slice CT

64-slice CT

Progressive CT

Premium CT

Figure 1. The incremental benefits of premium technology are commonly limited to advanced applications and/or niche populations, despite significant cost differentials; source: The Advisory Board Company.

Figure 2. A practical approach to prioritizing planned acquisitions can improve return on investment for imaging technology; source: The Advisory Board Company.

Adding Rigor As the radiology community embarks on a new era of health-care delivery, having regimented processes to evaluate new imaging technologies and assess their respective impact on different clinical services will be imperative. These processes should solicit the perspectives of many key stakeholders, both within and outside the radiology department, and should be well grounded in robust data to support the business case for the technology in question. Paying particular attention to the needs of ordering physicians will be more

important. For example, if little interest exists among neurologists, orthopedic surgeons, or oncologists for a 3T MRI system to support their respective needs, now and into the future, then deciding to acquire a 3T scanner might not be prudent at this time. While it is still important to recognize advanced imaging services as a revenuegenerating opportunity, accountablecare models emphasize imaging’s role as an ancillary service—and as a result, new imaging-technology needs must be matched with the overall strategic needs of the organization.

26 Radiology Business Journal | December 2010 |

Research from The Advisory Board Company indicates that institutions are mobilizing efforts to match technologies with discrete service-line growth opportunities and overall vision for the organization, with some setting limits on the level of technology for tertiarycare centers, community hospitals, and outpatient imaging centers. For a smaller institution to acquire premium equipment, such as a 320-slice CT scanner or a 3T MRI system, a very compelling and databacked business case must be made. To accomplish this, it will be imperative for radiology administrators to evaluate current and projected inventory needs continually and to develop methods for assigning priorities to both replacement technologies and those that are new to the institution. Regularly collecting information on the level and functional status of technology; on utilization statistics for discrete pieces of imaging equipment, relative to maximum capacity levels; and on market-growth forecasts is a requirement for determining when it is necessary to purchase incremental units. Further, staying abreast of the latest technology developments and innovation will improve future decision making. A comprehensive imaging-technology evaluation can be burdensome for the radiology administrator. A considerable return on this investment exists, however, because such an evaluation helps eliminate shortsighted purchases, identify strategies for optimal equipment use, avoid temporal spikes in capital-budget needs, and identify bulk-purchasing opportunities (Figure 2). As radiology reaches a crossroads in the new era of accountable care, both challenges and opportunities will exist in planning for new diagnostic-imaging technologies. Developing regimented technology-evaluation processes and ensuring that due diligence is undertaken for each investment will ensure that the right technologies are deployed, at the right place, and at the right time. Brian C. Maher, MPH, is a consultant with The Advisory Board Company (Washington, DC), a health-care research and consulting company.

The Third Annual Ranking of

The 50 Largest Private Radiology Practices

Ranked by number of radiologists and including number of employees, studies, and imaging centers

Sponsored by


By Chris


Founder & Chief Technology Officer Intelerad Medical Systems

YOUR VISION. YOUR SUCCESS. we have a few answers. One example: our InteleConnect™ thin-client portal delivers mobile-friendly and media rich results right into referrers’ mobile devices, including iPads. Its customizable interface is a sure way to develop brand awareness, increasing physician and patient loyalty.

The stories are amazing and they keep coming. Remotely connecting rural hospitals to the best specialists in town around the clock. Delivering results to referring physicians in shorter-than-ever turnaround times. Taking quality of care to its highest possible level.

Breathe. Let your IT infrastructure do its job

This is how you are transforming radiology. This year again, a good number of our customers belong to the 50 Largest Private Radiology Practices in North America. We're sincerely thankful for your ongoing trust and grateful you share your vision with us. So where does that vision take the industry?

Accelerate. The time to take the lead is now For radiology practices to thrive, it's critically important they expand geographically and broaden service offerings while becoming more efficient. Those are the conclusions of our recent Radiology in Motion survey, done in collaboration with Radiology Business Journal. Along those lines, our goal is simple: to help our customers step down hard on the gas pedal.

Recent case studies focusing on Central Louisiana Imaging Inc., Radiology Imaging Consultants, SC and Diversified Radiology of Colorado, P.C. clearly demonstrate we do this effectively. With InteleOne™, these companies quickly overcame the inefficiencies of operating multiple PACS, HIS, RIS and EMRs. Features like our new multi-method reporting workflow now enable radiologists to choose voice recognition, dictation or report templates on-the-fly, with native 64-bit multiple platform support.

Stand Out. Differentiate your offering Another survey highlight: the need for differentiation in a very crowded market place. The question, of course, is how – and

Radiology practices set the bar high for their IT teams and infrastructures. Fortunately, developing and supporting solutions for large businesses in complex, distributed environments is what we live and breathe. Our experience is based on hundreds of installations, every one proactively monitored and backed by our industry-leading customer service and support. We strive to provide our customers with peace of mind so they can focus on growing their business. Congratulations to this year’s 50 Largest Private Radiology Practices. We admire your vision and welcome the challenge of helping you achieve it. Sincerely,

Chris Henri

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COVER | The 50 Largest Radiology Practices

The 50 Largest Radiology Practices Our third annual survey reveals that overall, the nation’s 50 largest radiology practices continue to increase in size, and imaging-center ownership is consolidating among the very largest By Cheryl Proval Introduction A year ago, I would not have predicted the results that follow in the third annual survey. In last year’s introduction, I mentioned that there was a fair amount of merger activity going on; I would have predicted that the big would become bigger. Nine groups in the top 50 did increase their radiologist counts by five or more, with Charlotte Radiology increasing by 15. The surprise comes in terms of the number of groups that decreased in size. Fourteen groups have become smaller. This appears to be due to increased efficiencies—and also to hospitals’ employment of radiologists. The world of radiology is unpredictable now. The recent announcement of the merger of two large teleradiology companies creates some interesting dynamics in the marketplace. Combined, the two organizations employ 325 radiologists, but they are excluded from the survey because it is limited to private-practice radiology groups. The new, postmerger entity has the capital and the infrastructure to continue to grow, and I would guess that it will. The private groups do not have the capital (and many do not have the infrastructure) to handle growth. Collaborative joint ventures like Strategic Radiology may be a partial solution. Strategic Radiology (a consortium of 15 groups covered in the April/May 2010 issue of Radiology Business Journal) has about 900 radiologists. The top 15 practices in the survey this year have a combined total of 1,078 radiologists. Some of the Strategic Radiology groups did not participate in the survey; other larger groups, in Texas and elsewhere, chose not to participate, so the survey is not 100% accurate. It is fun, however, to see how groups are doing. Thank you for participating. Joseph P. White, CPA, MBA Principal, Health Care LarsonAllen LLP: CPAs, Consultants & Advisors Minneapolis, Minnesota


ome evidence of the consolidation occurring in the broader health-care market can be observed in the results of the third annual survey to rank the 50 largest radiology private practices in the United States. Cosponsored by LarsonAllen and Radiology Business Journal, the survey revealed that several practices took great leaps up the ranking, several dropped down, and some accumulated more imaging centers (though many shed them). A total of 14 practices decreased in size. Financial information submitted by the practices is confidential, so the criterion used to rank the practices was number of radiologists (FTEs, rather than individuals, were counted for all practices’ radiologists and employees). The Web-based survey, made available to readers of Radiology Business Journal and, was conducted from July 15 through September 15, 2010. This year, 72 practices participated (slightly more than last year), and the sponsors are grateful not only to those in the ranking, but also to the 22 practices that filled out the survey, but had too few radiologists to be included. The information provided by all 72 participating practices was instrumental in identifying trends affecting the practice of radiology in 2010. Participation is voluntary, so the list should not be construed as definitive. This year, however, the survey was more representative of the nation’s largest

practices, with 14 established practices appearing for the first time. This resulted in increases for both the median size of the 50 largest practices and the size of the smallest ranked practice (31 radiologists, compared with 25 last year). Because the survey was more inclusive this year, practices could retain last year’s rank only if they had added radiologists. Where two or more practices had the same number of radiologists, we assigned a rank based on their number of employees. Medians for the selected practice variables (Figures 1–4, page 33), likewise, are based solely on the input of our universe, and are not necessarily representative of the broader practice environment. Nonetheless, these 72 practices gave input that is likely to resonate with their peers and to provide useful insight into contemporary practice. The Practices at the Summit For the second year, Advanced Radiology Services PC was the largest practice in the nation (see table, page 30), with 106 radiologists. The practice continues its focus on the hospital market, with 15 hospital clients and 105 teleradiology clients in one state. It has no imaging centers. The practice interpreted 1,557,551 procedures in 2009. The second-largest practice is Charlotte Radiology, which leaped from last year’s ninth spot following a practice merger that created a practice with 80 radiologists. A leader in the outpatient-imaging arena,

About the Survey The survey to rank the 50 Largest Radiology Practices is the result of a collaboration between LarsonAllen and Radiology Business Journal. LarsonAllen is a nationwide professional services firm based in Minneapolis, Minnesota, and counted among the top 20 accounting firms. Radiology Business Journal is a next-generation bimonthly economics journal serving leaders in medical imaging.

Radiology | The 50 Largest Practices Charlotte Radiology operates 23 imaging centers and has 350 employees. It also has 12 hospital clients, and it provides teleradiology interpretation for 15 clients in two states. It interpreted a total of 1,350,000 procedures in 2009. The third-ranked practice is St Paul Radiology, with 80 radiologists (down from

85). The practice has 320 employees and 12 hospital accounts. It also owns seven imaging centers and has teleradiology clients in 15 states. It performed 1,100,000 procedures last year. The fourth-ranked practice, University Radiology Group PC, also had a large growth spurt, going from 61

to 80 radiologists. The practice has 290 employees, has four hospital contracts, and owns 10 imaging centers. Last year, it interpreted 950,000 procedures. Austin Radiological Association is ranked fifth, with 76 radiologists (down two from 2009). This practice has 626 employees, has 17 hospital clients, and

Table. The 50 Largest Private Radiology Practices for 2010 (Ranked by FTE Radiologists) 2010 Rank Group Location

CEO Lead Physician

1 Advanced Radiology Services PC Grand Rapids, MI Konstantin Loewig, MD 2 Charlotte Radiology, PA Charlotte, NC Arl Van Moore, MD 3 St Paul Radiology, PA St Paul, MN Michael Madison, MD Michael Madison, MD 4 University Radiology Group, PC East Brunswick, NJ S. Thomas Dunlap Robert E. Epstein, MD 5 Austin Radiological Association Austin, TX Doyle W. Rabe Gregory C. Karnaze, MD 6 Radiology Associates of Tarrant County Fort Worth, TX Lynn Elliott John Queralt, MD 7 Fairfax Radiological Consultants, PC Fairfax, VA William F. Allison Marshall C. Mintz, MD 8 Consulting Radiologists, Ltd Minneapolis, MN Neeraj Chepuri, MD Neeraj Chepuri, MD Christian Dewald, MD; Rodney Owen, MD 9 Southwest Diagnostic Imaging Phoenix, AZ 10 Radiology Associates of South Florida, PA Miami, FL Jack Ziffer, PhD, MD Jack Ziffer, PhD, MD 11 Riverside Radiology & Interventional Associates Columbus, OH Marcia Flaherty Mark Alfonso, MD 12 Inland Imaging Spokane, WA Steve Duvoisin, MBA Dan Murray, MD Kevin Gustafson, MD; Aaron Binstock, MD 13 Suburban Radiologic Consultants, Ltd Minneapolis, MN Jim Tierney 14 Radiology Imaging Consultants, SC Harvey, IL Jay Bronner, MD, MBA Perry M. Gilbert, MD; Jay Bronner, MD, MBA 15 Mountain Medical Physician Specialists, PC Murray, UT Clark Davis Michael Webb, MD 16 Texas Radiology Associates, LLP Plano, TX Ted S. Wen, MD 17 Diagnostic Imaging Inc Trevose, PA Bruce Lehrman, MD 18 Radiology Associates of Hollywood, PA Pembroke Pines, FL Mark Schwimmer, MD 19 Bay Imaging Consultants Medical Group Inc Walnut Creek, CA Mary Gerard Ira Finch, MD 20 Clinical Radiologists, SC Springfield, IL Thomas C. Dickerson Charles E. Neal, MD 21 Diversified Radiology of Colorado Denver, CO Chris (Kip) McMillan Steve George, MD 22 S&D Medical, LLP Bedford Hills, NY Kenneth S. Schwartz, MD 23 American Radiology Associates, PA Dallas, TX J. Mark Fulmer, MD 24 Wake Radiology Raleigh, NC Robert E. Schaaf, MD 25 Alliance Radiology, PA Overland Park, KS Rob Newth, MD 26 Radiological Associates of Sacramento Medical Group, Inc Sacramento, CA Mark H. Leibenhaut, MD 27 Foundation Radiology Group Pittsburgh, PA Tom Skelton James Backstrom, MD 28 Jefferson Radiology, PC East Hartford, CT Ethan B. Foxman, MD Ethan B. Foxman, MD 29 TRA Medical Imaging Tacoma, WA Dennis Carter Michael Dowd, MD 30 Radiology, Inc Powell, OH G. Patrick Cain, MD 31 Rhode Island Medical Imaging East Providence, RI John Cronan, MD 32 Northwest Radiology Network, PC Indianapolis, IN Vincent Mathews, MD Vincent Mathews, MD 33 Radiology Alliance, PC Nashville, TN J. Keith Radecic Webb Earthman, MD 34 Drs Harris, Birkill, Wang, Songe and Associates, PC Dearborn, MI David S. Yates, MD 35 Greensboro Radiology Greensboro, NC Worth Saunders, MHA Eric Mansell, MD 36 Huron Valley Radiology Ann Arbor, MI Patricia J. Neinas Eric C. Ferguson, MD 37 Northside Radiology Associates, PC Atlanta, GA Steven Moss, MD 38 Radiology Ltd Tucson, AZ Edward Woolsey, MD 39 Quantum Radiology Marietta, GA Alan Zuckerman, MD 40 Vista Radiology, PC Knoxville, TN Samuel Feaster, MD 41 Desert Radiologists Las Vegas, NV William P. Moore, II Robert B. Poliner, MD 42 Radiology Associates of Clearwater Clearwater, FL John Fisher, MD 43 Atlantic Medical Imaging, LLC Galloway, NJ Robert M. Glassberg, MD Robert M. Glassberg, MD 44 Radiology Associates, PA Little Rock, AR Kathleen Sitarik, MD Kathleen Sitarik, MD 45 Milwaukee Radiologists, Ltd, SC Milwaukee, WI Emil Hurst, MD Jeffrey Thomasson, MD; Thomas Applewhite, MD 46 West County Radiological Group, Inc St Louis, MO 47 Nassau Radiologic Group, PC Garden City, NY Annette Marinaccio Jay Bosworth, MD 48 X-ray Associates Hockessin, DE Kert Anzilotti, MD 49 Mid-South Imaging & Therapeutics, PA Memphis, TN Brian M. Bareito Dexter White, MD 50 Seattle Radiologists Seattle, WA Karen Leppert Michael Peters, MD 50 Professional Radiology, Inc Cincinnati, OH Robert J. Ernst, MD Robert J. Ernst, MD

owns 15 imaging centers. It interpreted 1,761,712 procedures in 2009, making this the single busiest practice in the nation. Changes for 2010 The average size of the largest 50 practices has grown steadily since we began the survey, starting with an average

of 45.4 radiologists in 2008 (median: 42.5), increasing to 48.5 in 2009 (median: 45), and increasing again to 52.7 in 2010 (median: 52). This increase could be ascribed to a trend, or it could be due simply to the fact that the survey is now more inclusive of the nation’s largest practices.

Of the 37 practices that were ranked last year, more are growing than are shrinking: 18 practices added radiologists, 14 practices lost them, and five stayed the same; the other 14 practices are new to the ranking. Several practices took great leaps in size, probably through merger or acquisition, while several others

Preliminary Final 2010 FTE 2009 FTE 2008 FTE 2010 FTE Imaging Hospital Teleradiology Teleradiology Teleradiology Lead Nonphysician Radiologists Radiologists Radiologists Employees Centers Contracts Procedures Interpretations Interpretation States

Bill Ziemke 105.7 Mark Jensen 80 Michael Martin 80 S. Thomas Dunlap 80 Doyle W. Rabe 76 Lynn Elliott 74 William F. Allison 72 67.7 Lisa Mead 67 Dennis Wiseman 65 Marcia Flaherty 64 Steve Duvoisin, MBA 63 Jim Tierney 63 Steven Newell, MBA 61 Clark Davis 60 Susan Spain 58.8 Richard Zimmerman 58 Dan Strub 58 Mary Gerard 56 Thomas C. Dickerson 56 Chris (Kip) McMillan 55 Jonathan Schwartz 55 Craig Cunningham 54 WIlliam Johnson 53 Deb Palmisano 53 Fred Gaschen, MBA 52 Tom Skelton 51 Lawrence Freni 50 Dennis Carter 50 Michael Murphy 50 Betty Simas 50 Linda WIlgus 47 J. Keith Radecic 45 Dawn E. Portelli 43 Worth Saunders, MHA 41 Patricia J. Neinas 40 Mike Kolesar 40 Chip Hardesty 39 Adam Fogle, MBA 39 Charles McRae 39 William P. Moore II 38 Patrick L. Empting 37.5 Michael J. Jenoriki 36 Jerry Linebarger 36 Russ Lein 35 Carol Hamilton, MBA, CMPE 34 Annette Marinaccio 33 Matt Dangel, MBA, CPA 32.5 Brian M. Barbeito, MBA 32 Karen Leppert 31 Joseph R. Hundepohl 31

106.2 65 85 61 78 61 72 67 – 57 63 60 65 71 – – 58 52 – – 55 – – 50 52 71 50 41 52 61 – 41.5 45 – – 30 – – 37.5 38.1 38 39 30 38 33.1 35 35 – 34 34 –

89.2 125.7 61.3 350 83 320 – 290 84 626 59 285 – 426 65 128 65 572 – 15 60 95 61 650 65 275 – 6 – 240 – 8 – 61 34.3 55 – 150 44 34 – 58 – 4 – 12 50 300 – 1 77.8 380 20 75 45 332 – 223 – 51.2 41 120 – 50 – 28 – 152 – 11 – 9 – 385 – 57 – 6 39 240 – 3.5 31 297 45 100 – 7 31 31 28 435 – 16 30 14 21 72 – 40

0 23 7 10 15 13 12 3 19 0 0 7 5 0 2 0 1 0 5 0 0 0 1 17 0 14 0 9 6 2 5 3 1 0 5 1 0 9 4 0 4 0 8 2.5 2 0 15 9 0 2 0

15 1,557,551 22,955 12 1,350,000 40,000 12 1,100,000 150,000 140,000 4 950,000 12,000 800,000 17 1,761,712 491,000 12 1,400,000 3 19 1,077,427 47,025 5 1,390,612 370,316 5 700,000 14 947,760 5,000 14 880,000 10 12 1,000,000 7 750,000 16 960,000 10 900,000 3,650 6 840,000 11 1,028,000 70,000 21 900,000 40,000 12 750,000 11 950,000 40,000 100,000 5 700,000 130,000 5 665,000 10,000 525,000 16 740,000 0 1,050,000 19 1,250,000 55,000 4 625,000 7 650,000 8 2,241,602 84,010 84,010 3 15 750,000 7 750,000 6 890,000 8 675,000 50,000 7 779,000 3 600,000 3 600,000 5 715,000 10 725,000 80,000 8 1,100,000 1,200 10,729 6 700,000 3 536,000 11 620,000 2 513,000 900 900 2 407,000 0 302,444 165,000 2 568,000 11 600,000 10,000 100,000 1 4 500,000 50,000

1 2 15 3 1 1 1 5 2 1 1 3 2 3 2 1 2 1 1 3 1 2 2 1 2 1 5 1 1 1 1 1 1 1 2 1 1 1 2 2 2 1 1 1 2 1 1 1 2 1 3

Teleradiology Clients

1 15 10 300

26 2 45 41 12 0 0 9 3 30 60 32 45 50 16 0 22 15 12 33 5 0

1 16 14 1 0 11 2 1 31 6 20

COVER | The 50 Largest Radiology Practices experienced dramatic declines of 20% or more, quite probably due to the loss of hospital contracts. The average size of practices with more than 65 radiologists has declined since 2008, when it was 81.8; in 2010, it was 78. While larger practices benefit from having greater resources to build organizational infrastructure (in the form of IT, imaging-technology investments, and skilled management), they also face the challenges of maintaining hospital contracts, governing large numbers of highly independent partners, and managing assets. It will be interesting to see whether many practices can grow beyond the 80-member mark. Consolidation in imaging is most evident in median imaging centers for each practice-size category (Figure 1). Median centers were stable (at two) for the smallest practices, declined by 50% in those having 35 to 49 radiologists, and nosedived from five to one among practices with 50 to 65 radiologists. The largest practices clearly saw a buying opportunity; their median centers doubled (from six to 12). Procedural volumes (Figure 2) increased in each of the four practicesize categories, probably in response to the continuing downward pressure on reimbursement. The two categories that experienced the greatest growth were the largest practices and those with 35 to 49 radiologists. In median procedures per radiologist, it appears that all but the groups in the smallest category succeeded in increasing volume per radiologist. The largest practices increased per-radiologist volumes from 15,384 in 2008 to 18,030 in 2009; practices with 50 to 65 radiologists, from 13,913 to 16,036; and practices with 35 to 49 radiologists, from 15,544 to 18,141. Although median procedures did increase for the smallest practices, an increase in their median practice size meant that procedural volumes per radiologist actually fell off significantly (from 16,337 in 2008 to 15,479 in 2009). This could be because some of

the smaller practices that fell off the list this year were highly productive, or it could be that the smallest practices were unable to leverage IT or support staff to help boost productivity. Shedding Employees Along With Centers The number of employees of a practice has a clear, direct relationship both to the size of the practice and to the number of imaging centers that it owns. Therefore, it is not surprising to see a relationship between trends in imaging-center ownership and practices’ employment levels. In those practice-size categories where imagingcenter ownership remained the same or increased, employment increased, but employee totals plummeted where practices shed imaging centers. In the smallest and largest categories, employment increased in 2009 (Figure 4). In the size categories in between, however, employment dropped. The number of employees dropped most precipitously where imaging-center ownership declined most: In groups of 50 to 65 radiologists, median employee counts declined from 209 to 68. Just one practice-size category experienced an increase in median hospital contracts (Figure 5): Practices with 35 to 49 radiologists had a median seven hospital contracts in 2009, compared with five in 2008, possibly accounting for this size category’s significant increase in procedural volume per radiologist. All other categories experienced declines. These were most dramatic for the smallest practice category, possibly signaling the difficulty that these practices have in meeting hospitals’ increasing demands for subspecialization. It also is a possible consequence of teleradiology companies’ incursions into the business of final interpretations—or of the trend in hospital employment of specialty physician practices.

The Productivity–Revenue Relationship Many (22) of the participating practices submitted revenue numbers, which cannot be shared. These data, however, are important because they enable us to look for patterns that might reflect practice characteristics related to size. Because the sample is so small, comments on the data are highly subjective—but where there are no data, even small amounts of information prove irresistible, so take these comments under advisement. Last year, revenue per radiologist was greatest in the smallest groups, steadily declining as the group size increased. This year, that trend was reversed, with one exception: groups with 35 to 49 radiologists had the highest median revenue per radiologist. This year, the productivity numbers also synced more closely than they did last year with revenue per radiologist. The practice-size category with the greatest productivity (35 to 49 radiologists) also had the highest revenue per radiologist. Groups of more than 65 radiologists were the second most productive and had the second-highest revenue per radiologist. Many variables can influence revenue per radiologist, including revenue-cycle management and geographic location. Two other factors that appeared to influence revenue per radiologist were technology ownership and the number of support staff. All 10 groups reporting the greatest revenue per radiologist owned two or more imaging centers, and their average number of employees was 230. The average number of employees for the groups that reported low to median revenue per radiologist was 45. While there is a clear relationship between the number of imaging centers owned and the number of employees, a higher-than-average number of employees could be due to other influences as well. It is possible that greater support from IT staff (in devising electronic solutions to practice problems) and more administrative support (producing cleaner billing/coding and

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< 35 FTE radiologists 2009


35–49 FTE radiologists


50–65 FTE radiologists



2009 2008 2009



2008 20082009

> 65 FTE radiologists 2

2009 2010






Figure 1. Median imaging centers, 2009 and 2010. 80 2009



Figure 2. Median procedures performed, 2008 and 2009. 350



300 2009



2009 2010 2009


20 10 0



2010 2009













2009 2009

100 2009










Figure 3. Median FTE radiologists per practice-size category, 2009 and 2010.

Figure 4. Median FTE employees, 2009 and 2010.

Figure 5. Median hospital contracts, 2009 and 2010.

greater collections) helped to boost perradiologist revenue. Due to a poorly worded survey question regarding teleradiology activity, we believe that we might have confused many practice respondents with our request for final and preliminary teleradiology numbers. We had hoped to quantify teleradiology activity outside the realm of hospital contracts, but so many practices today are using teleradiology in serving their hospital clients that the question was probably misunderstood by some respondents. We will make an attempt to clarify this next year, but meanwhile, we have chosen to publish the numbers that we received (however confusing). What was clear is that the nation’s largest practices appear to be leveraging their size and resources to provide their own in-house night and subspecialty coverage. Last year, 10 practices reported outsourcing night coverage or using a combination of in-house and outsourced night coverage. In 2010, only two of the

nation’s 50 largest practices reported outsourcing a portion of their night coverage.

private radiology practices? Is there a ceiling? Will more practices come closer to having 100 radiologists next year, or is that the exclusive domain of corporate teleradiology practices? As readers consider these questions (and others that might arise in reviewing the numbers), we would like to remind them that this information would not exist without the generous contributions of the participating practices’ representatives, to whom we are, once again, very grateful. As the survey grows and more practices participate, we hope to rank not just the largest 50 private radiology practices; next year, we hope to list the largest 75.

Conclusion We are seeing some consolidation of imaging centers in the hands of larger practices, which may be better equipped to deliver the management expertise and efficiencies required to succeed in the outpatient imaging market (the target of severe reimbursement cuts during the past five years). We continue to see growth in the average size of the largest practices, which increased to 52.7 from 48.5 radiologists in 2009. Median size in each of the four practice-size categories increased, over 2009 size, in three of the four categories. For the fourth group, practices with 50 to 65 radiologists, the median was 57 in 2009 and 55 in 2010. Just one practice reported having more than 80 radiologists, and three groups had 80 radiologists, raising this question: Is there an optimal size for

Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, imagingBiz, Tustin, California. The sponsors gratefully acknowledge the support and patience of Laura Tierney, manager, health care, LarsonAllen LLC, Minneapolis, Minnesota, who provided the computations for this survey.

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CMS | Decision-support Project

Medicare Imaging Demonstration Project: CMS Rolls the Dice

on Decision Support The challenges of meeting the requirements of the Medicare Imaging Demonstration Project might create some strange bedfellows By George Wiley


utomated decision-support systems to guide physicians who order advanced imaging exams for their patients have been promoted for years, but there have been few implementations. Now, CMS is launching a pilot study to see how well decision support works. It is the first test of decision-support systems applied on a national scale, and the first to look broadly at outcomes. There are problems, however. The three-year study is funded at only $10 million, a pittance for a national study. Moreover, CMS wonâ&#x20AC;&#x2122;t pay participating physicians unless they meet high compliance thresholds; this factor might put participants at financial risk. | December 2010 | Radiology Business Journal 35

CMS | Decision-support Project

If it’s successful, on the other hand, the pilot project might lead to broad implementation of decision-support systems across the health-care provider/ payor axis. That’s why a thousand eyes— some with competing agendas—are paying close attention to this test. Vendors of decision-support software have a lot to win (or lose); so, perhaps, do radiology benefit management (RBM) companies. Health insurers looking at the CMS study might select decision support as a way to hold down imaging utilization and bypass the cumbersome and expensive preauthorization processes that the RBMs employ. The deadline for applying for the Medicare Imaging Demonstration Project (MIDP) passed on September 21, 2010, but CMS still hasn’t announced the names of the successful applicants. The names (and even the number) of unsuccessful applicants might never be known. According to Linda R. Lebovic, MPH, the pilot program’s project officer for CMS, there is no timeline for the review panel that is currently assessing applicants to decide on the successful candidates. Once the successful applications have been selected, they will be forwarded to the CMS administrator for final approval, Lebovic says. “We do have the applications in,” she says. “We never share how many, made by whom, or who the review panel is. That information is proprietary. We offer participation, and when the successful applicants agree, we proceed to start implementation.”

Once the data have been collected for 18 months, CMS will turn to an evaluation team. The team will take another year to analyze and report on the data. That puts the end date for the project at around 2014, although the timeline is loose. The initial six months of the study will consist of a baseline period, during which participating physicians will use the system to order exams without ever seeing the decision-support guidelines. This will establish ordering patterns that can be used for comparison after decision support is added to the ordering system. Lebovic says that the baseline is needed so that when decision support is deployed, the MIDP’s evaluators will be able to compare ordering data with Medicare-claims data for all exams—thus determining whether decision support had a beneficial impact, in terms of changing utilization patterns, minimizing radiation exposure, and reducing costs. Often discussed is how the MIDP will feed into larger health-care projects like the CMS Innovation Center, which is funded at $10 billion, and the Office of the National Coordinator for Health Information Technology (ONCHIT). ONCHIT has developed meaningfuluse guidelines under which physicians can receive federal compensation for implementing electronic medical records (EMRs) for their patients.

Conveners The term that CMS uses to describe applicants is conveners, since they will convene the disparate elements needed for the study. In its project solicitation, CMS calls for up to six conveners to organize implementation and to roll out the decision-support tool to ordering physicians. Thereafter, the conveners will track and report the results of ordering that is augmented by decision support. CMS envisions that the conveners will enroll 2,000 to 3,500 physician participants through diversely compiled sets that will include between 500 and 650 physician practices. 36 Radiology Business Journal | December 2010 |

While the MIDP’s participants could be spurred to install EMR technology by virtue of their involvement in the decision-support demonstration project, they won’t be required to have EMR capability to participate. Because CMS wants to test decision-support systems across multiple settings, from urban to rural and from large to small, those physicians still operating in the paperand-fax world can use decision support, too. Instead of getting their decisionsupport guidance on the front end, through computerized provider order entry (CPOE) systems to which pointof-order decision support is attached, physicians without CPOE will get decision support through point-ofservice connections in which radiology providers deploy decision support and give feedback to the ordering physicians. “We tried to be flexible and have practices access decision support by phone, fax, Web, or EMR,” Lebovic says. “What we do require, electronically, is for the convener to transmit data securely to and from CMS.” Comparability In its MIDP solicitation, CMS calls for conveners, in designing and implementing decision-support arrays, to use only the relevant guidelines for imaging developed by medical societies. The MIDP study will look at ordering results for the 11 advanced imaging procedures most commonly paid for by Medicare: CT of the brain, sinus, thorax, abdomen, lumbar spine, and pelvis; MRI of the brain, lumbar spine, shoulder, and knee; and SPECT myocardial-perfusion imaging. Decision-support systems must address these 11 exams using medicalsociety appropriateness and utilization standards, whether the medical society is the ACR®, the American College of Cardiology, the Society of Nuclear Medicine, or some other relevant medical society. Only Medicare Part B fee-for-service patients will be included in the pilot project, giving the MIDP an outpatient focus. CMS pointedly does not want to get caught up in assessing one decision-

















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CMS | Decision-support Project

I don’t know if it will be apples and Buicks, but my confidence is that they will be close enough to be meaningful. —Chris Fenno, CEO, HealthBASE Corp, Solano Beach, CA

support vendor’s product versus another’s, and this is one reason that it is demanding the use of impartial medicalsociety guidelines. This has the effect, however, of dumbing down existing decision-support products, which have been developed with broader analytical and clinical protocols. Chris Fenno is CEO of HealthBASE Corp (Solano Beach, California) which describes itself as an on-demand health-care service and medical benefit management platform connecting radiology, diagnostic testing, and ancillary providers with payors, patients, physicians, and other clients. Fenno says that HealthBASE is a licensed reseller of a prominent decision-support product. HealthBASE is also a partner with the Connecticut State Medical Society’s CSMS-IPA, Inc, of New Haven, in the MIDP. The independent practice association (IPA) has applied to be a convener for the MIDP. As the system is now envisioned, ordering physicians in the CSMS-IPA network will use a secure HealthBASE portal that will seamlessly integrate the order with decision support when CMS is the payor and the study being ordered is one of the 11 on the MIDP list. Fenno says, “The next screen they will see is decision support, which will ask for the clinical indications for the type of study they want to order. For that, they will get the appropriateness output.” The decision-support product will need to be revamped, however, to meet MIDP comparability requirements. As licensed, the system delivers what Fenno calls a stew of clinical decision-support tools and algorithm data that populate all the guidelines. “The ACR criteria are central, but there’s a lot of clinical data,” Fenno notes. “We need to strip everything out of the stew and leave only the broth.”

Fenno says that the ACR is still working on the specific guidelines for the 11 procedures in the MIDP. “We can receive the database directly from the ACR and implement that ourselves,” he says, but he would much rather use a revamped form of what his decisionsupport vendor already has put together. The end result on what will be deployed is, as yet, unclear. Fenno says that he doesn’t know how other decision-support vendors are approaching the MIDP, but he guesses that comparability will be achieved across the pilot project, whoever the decisionsupport supplier is. “I don’t know if it will be apples and Buicks, but my confidence is that they will be close enough to be meaningful,” he observes. David Kurth, MPH, MA, is director for practice guidelines, technical standards, and appropriateness criteria for the ACR. He says that ACR guidelines will be used in the MIDP study in companionship with

38 Radiology Business Journal | December 2010 |

guidelines developed by other medical societies. Conveners will have leeway in which guidelines they use in the decisionsupport systems that they deploy, but all will be drawn from CMS-sanctioned appropriateness guidelines developed for the MIDP, he says. Conveners will have to document exactly which guidelines they are using for each exam, he adds. “CMS is trying to be inclusive and to adopt whatever is out there,” Kurth says. “The unfortunate part is that not all the medical societies have the breadth or width of guidance that we have. They will have to use some ACR guidelines because no other medical society offers guidance” for some of the 11 procedures. To ensure comparability, CMS, according to its solicitation, intends to run tests of each convener’s decisionsupport system and make adjustments for variances. Each decision-support assessment must convey, to the ordering physician, whether the proposed imaging test is appropriate, inconclusive/uncertain, or inappropriate. The decision-support system must also give feedback on more appropriate alternative exams. Getting Payments Under the CMS solicitation, each convener must issue a bid for the operational and administrative costs for which it expects to be reimbursed, if selected. No set amounts are detailed. The situation is different, however, for the cash incentives to be paid to physician practices that use decision-support systems under the MIDP. One requirement is that any physician practice that participates must require all of its physicians to use decision support. There are strict compliance standards that must be met; 80% of all relevant claims submitted by participating practices must have gone through decision support in the first year. In the second year, the compliance rate rises to 90%. Given the resistance levels always encountered when new technology is deployed, some think that these compliance standards will put conveners and physician practices at financial risk because the standards will be hard to meet. “That one performance measure could trigger a situation where the

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CMS | Decision-support Project

We figured, originally, that there would be far more than 50 applicants, but I’ve heard numbers as low as 12 or 13. —Nicholas Christiano Jr, CAO, Advanced Radiology Consultants, Orange, CT

If an IPA did have a capitated contract, this would be a tool to maintain cost control and provide a service for the patient. —Ken Lalime, RPh, executive director, CSMS-IPA, Inc, New Haven, CT

convener has exposure for the project, and that seems like an awfully big caveat,” Fenno says. “It’s a challenge to get practices to perform in new ways at that level—especially quickly.” If physician practices do meet the compliance standards and get reimbursement through their conveners, they still won’t become rich. The MIDP calls for each practice to receive between $1,000 and $20,000 per year, based on the volume of the 11 designated exams for which it submits claims. Practices must submit at least one exam claim every six months to qualify. Nicholas Christiano Jr is CAO for Advanced Radiology Consultants (Orange, Connecticut), a radiology group that is partnering with CSMSIPA in its application to be a convener. Christiano says that the MIDP pilot is well designed—except for its anemic financial incentives for physicians. He says, “The inducements are not enough to encourage primary-care physicians to modify their behavior. There is not enough per physician, and there is little or no inducement for the imaging people. We are spending considerable amounts of money to get our constituency online. That’s where the issues are with the demonstration project. The government should be providing more funding than what it has initially identified.” Christiano says that the paucity of funding might have discouraged some

potential conveners from applying. “We figured, originally, that there would be far more than 50 applicants, but I’ve heard numbers as low as 12 or 13,” he says. Being a Convener Despite the extraordinary breadth that CMS has allowed for convener applicants, being a convener has turned out to be a daunting prospect, for some. The ACR, for instance, did not apply, although, as a medical society, it could have. “I don’t think we have the time or the resources,” Kurth says. “We have contacts in radiology, but not with the other specialties ordering

40 Radiology Business Journal | December 2010 |

radiological procedures. We will advise other conveners, and help any way we can to make sure the appropriateness criteria are used the way they are supposed to be used.” Strategic Radiology, a recently formed national consortium of 15 practices, was rumored to be an applicant. It was not. Its chair, Arl Van Moore, MD, FACR, says, “It would take a lot of resources and insight, and I don’t see the government picking up the tab for that. None of our groups are affiliated with physician groups or hospitals where there were enough pieces to put it together.” In addition to bringing the participating physicians on board and deploying decision support, the MIDP calls on conveners to submit secure files quarterly to CMS and to tell the agency whether the decision-support system will be used for orders other than those in the pilot, and whether decision support will be retained after the study’s data have been collected. Conveners are not allowed to change the amounts that CMS pays to physicians, nor can conveners pay physicians additional amounts. The financing for MIDP might have been low, but issues other than money proved attractive to the entities that did apply to be conveners. They looked at the MIDP and saw opportunity there. CSMS-IPA Ken Lalime, RPh, is executive director of CSMS-IPA. There are already “some wonderful decision-support systems in the e-prescribing space,” Lalime says. He adds that the MIDP pilot is an opportunity to bring similar radiology-based software solutions to health care. Lalime says that CSMS-IPA, like so many health-care providers, is looking down the road at the advent of accountable-care organizations (ACOs). ACOs are now ill-defined constructs, but the idea is that they will provide and coordinate care for patients, with an emphasis on disease prevention; efficient, outcomes-driven treatment; enhanced quality; and minimized cost. The deployment of a decision-support system to streamline the delivery of imaging services fits right into the ACO





CMS | Decision-support Project

Everybody will have to modify to meet what Medicare put down. We’ll modify what we have to for them. —David Soffa, MD, FACR, senior vice president, American Imaging Management, Chicago, IL

narrative, Lalime says. CSMS-IPA wants to participate in the MIDP to learn the technology and assess its use. “If an IPA did have a capitated contract, this would be a tool to maintain cost control and provide a service for the patient,” Lalime says. CSMS-IPA currently comprises about 7,000 physician members, making it one of the largest IPAs in the country. For now, CSMS-IPA is operating on a fee-forservice basis, Lalime says, but capitated contracts might come in the future. CSMS-IPA has already pulled together a subset of about 1,200 of its member physicians to create a patient-centered practice model (PCPM) that will offer care coordination, quality control, and cost improvement to interested payors, Lalime says. If CSMS-IPA is chosen as an MIDP convener, it is through this PCPM that imaging decision support will be deployed, Lalime adds. “The demonstration says internal medicine and cardiology, so we’ll make sure we bring that forward. We’ve known for years which specialties order those 11 services, so we went out to our PCPM network and came up with 400 physicians across 100 practices. Then, we built the demonstration to tell CMS how we would put that out,” Lalime says. “Those 100 practices will have the software rolled out to them, with education on how to use it for all their Medicare orders.” The decision-support system will select and report on orders involving the 11 designated procedures, which (as Lalime notes) account for about 80% of Medicare’s advanced imaging exams. Lalime is concerned about meeting the MIDP compliance threshold. Practice dropouts from the MIDP study also are a concern. “CMS wanted to know how we would handle dropouts,” Lalime

says. “The demonstration calls for 200 physicians, and that’s why we said we would include 400. We told CMS this is not totally in the control of the convener.” The MIDP fits well as part of a healthcare convergence that includes ACOlike structures and an emphasis on IT, Lalime believes. Already, ONCHIT has released meaningful-use guidelines that could net physicians as much as $63,000 for installing EMRs, he says. He sees the MIDP study as possibly demonstrating meaningful technology to serve patients, too. “Medicare has a real cost problem. If that can be influenced with appropriateness guidelines,” he says, “that can help.” As for CSMS-IPA’s financial balance sheet for the MIDP, Lalime says, the IPA won’t make money—but it hopes to break even.

42 Radiology Business Journal | December 2010 |

RBMs as Conveners The MIDP was mandated by Congress in the 2008 Medicare Improvements for Patients and Providers Act. At the time, the demonstration project was perceived as a battleground where either decisionsupport systems or RBMs might emerge victorious. That line of thinking is changing, however. Christiano chairs the meaningful-use subcommittee of the Imaging e-Ordering Coalition (formed by the ACR, imaging providers, and interested vendors). He also is working with CSMS-IPA on its application to become a convener. Christiano says that he now takes the heretical view that decision-support systems and RBMs can exist in the same utilization-management space. He states that RBMs could quite feasibly work with decision-support developers and health-care providers on the MIDP. “The RBM would look at utilization and cost, and our provider group would look at quality—that’s the model,” he says. Christiano suggests that one reason for keeping the MIDP application process secret is that CMS is still massaging applicants into forming broader entities (involving RBMs and providers) to act as conveners and oversee decision-support testing. “I’m almost 100% sure that’s what they’re doing, since I’ve seen them do it in the past on other demonstration projects where they asked applicants to combine,” he says. Such a scenario is certainly possible. At least one RBM has applied to be an MIDP convener to test decision support—though on the surface, having an RBM back decision-support seems counterintuitive. David Soffa, MD, FACR, is senior vice president of medical affairs for American Imaging Management (AIM), Chicago, Illinois, an RBM that is a subsidiary of health-insurance giant WellPoint, Inc (Indianapolis, Indiana). AIM, Soffa says, has applied to be a convener for the MIDP. For proprietary reasons, Soffa won’t say how AIM has proposed to roll out a decision-support system, although he notes that a clinical engine that AIM uses to support its preauthorization process

CMS | Decision-support Project

Not everybody gets to win in this scenario. There aren’t enough hard truths being uttered by policymakers, but as a taxpayer, that’s exactly what I want to see. The cost of health care is not sustainable. —Nathan Goldstein, senior vice president, Gorman Health Group, Washington, DC

has elements that could be redesigned. “Everybody will have to modify to meet what Medicare put down,” he says. “We’ll modify what we have to for them.” Paul Danao, AIM’s vice president for business development, has spearheaded AIM’s bid to be a convener. He says that AIM wants to participate in the MIDP so that it can see whether decision-support systems will work when applied on a broad scale. “We haven’t seen widespread understanding of how these systems will work in more general and community settings. The most important thing to come out of this project will be the impact of decision support across practices,” Danao says. Another advantage that AIM sees in the MIDP is the integration of decision support into existing IT and EMRs. “We have 84,000 registered users of our Web portal—either physicians or staff,” Danao says. “We already do automated preauthorization. We get 10,000 imaging requests per day, and 75% of them are approved through our automated intake process. This is an opportunity to leverage the strengths of decision-support systems and RBMs.” Danao says that AIM isn’t worried that decision-support deployment will undercut the need for its RBM services. Decision-support vendors don’t understand what RBMs do, he adds. “They don’t have a lot of understanding of the health-care–payor environment— how to deal with membership and how to transmit authorization data in such a way that claims can be paid. They don’t have the functionality to provide that replacement solution, in regard to information management that goes beyond the clinical.” Danao says that ideally, AIM would

have preferred to see CMS conduct a pilot program that studied decision support in conjunction with preauthorization, as an alternative, to see how the use of both systems would work. As it is, MIDP participants are barred from using any preauthorization during the trial. AIM has reservations about the CMS plan to look at exam results as part of outcomes-data collection for MIDP claims; this, Danao says, adds a level of complexity that it might not be possible to meet. “The reports of radiologists can be difficult to analyze to determine if the ordered exam was appropriate for what the actual exam showed. There are information systems that can extract data from the radiology reports,” Soffa adds, but determining how those could be used and benchmarked is very difficult. Data-mining, however, is one of the stated capabilities of at least one of the commercial radiology decision-support systems. Danao says that participation as

44 Radiology Business Journal | December 2010 |

a convener in the MIDP would be a novel opportunity for AIM to work closely with provider organizations to understand decision support and how it could be integrated into the RBM tool kit. “We’re very supportive, and we really hope we get chosen as a convener,” Danao says. Winners and Losers Nathan Goldstein is senior vice president for strategic development for Gorman Health Group (Washington, DC), a company that helps health-care providers navigate the twists and turns of federal regulation and participate in programs like the MIDP. Goldstein has been following the MIDP on behalf of a decision-support vendor seeking a role in the demonstration. Goldstein takes a cautious view of the project. “There’s no reason to think that this demonstration means CMS is going to start mandating imaging decisionsupport systems in its programs,” he says. Nonetheless, he calls the MIDP a critical step forward for CMS in controlling imaging costs. “This is exactly the sort of process that needs to happen,” he says. “The government can’t continue to provide a blank check any longer.” Goldstein warns that when the MIDP is finished, “not everyone is going to come out a winner.” Imaging providers might have to rethink imaging volumes, he says, facing what he calls the “granular fear of slowing innovation.” He notes that CMS itself assesses the risk that it is taking when it designates conveners. “It doesn’t like to do business with companies that haven’t been around at least two or three years,” he says. “It doesn’t like companies straight out of the garage, so any potential convener has to ask, ‘What risk do we represent to CMS? How can our selection of partners help mitigate that risk?’” He repeats, “Not everybody gets to win in this scenario. There aren’t enough hard truths being uttered by policymakers, but as a taxpayer, that’s exactly what I want to see. The cost of health care is not sustainable.” George Wiley is a contributing writer for Radiology Business Journal.

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Unlocking the Business-intelligence Vaults in Radiology


n the current climate of accountability, regulation, and continual improvement, radiology managers and administrators are called upon to make timely and informed decisions that affect the quality of their departmentsâ&#x20AC;&#x2122; output (the radiology report) and the financial viability of their practices. Successful managers need a system of measurements (metrics) to reflect the performance of their units in order to achieve strategic goals. In a radiology department, this translates to the managerâ&#x20AC;&#x2122;s need for access to live data demonstrating workflow and identifying bottlenecks, in addition to the need for on-demand fiscal reports. The time it takes to build a report using traditional methods reduces both the value of the information and the time that an organization then has available to take action to correct a deficiency. The traditional report can only answer questions that are identified prior to a periodic meeting, and there is no way to answer questions that might occur during the meeting. Without reports based on accurate, current, integrated data, decisions might not be based on an accurate picture of workflow and resource utilization. For example, the chief technologist might be requesting additional manpower, but without information on how the current workforce is being used, a decision might be based on anecdotal evidence. Perhaps the number of studies performed by the department might be increasing, but reimbursement is decreasing, and the manager needs to identify the reasons for the discrepancy. During a meeting, a question might come up regarding the utilization of a 46 Radiology Business Journal | December 2010 |

The legal, regulatory, and reimbursement climate in health care makes it imperative for practice and department leaders in radiology to have access to relevant data By Janice Honeyman-Buck, PhD, FSIIM modality such as MRI, and if this question was not anticipated, a report might not be available. With on-demand reports generated by business-intelligence analytics, a report can be generated in real time. Business intelligence is loosely defined as using computer techniques and databases to identify and organize information about business processes and trends. Other terms are used in the radiology literature to define the process; these include data mining, data analytics, and using a digital dashboard. Typically, a digital dashboard refers to real-time measurements resembling the dashboard in a car that gives the driver indications of compliance (speedometer) and resource utilization (fuel, oil, and air in the tires), along with warnings of potential problems. Other business-intelligence analytics can provide static reports on the dayto-day operation of the department. The difference between these businessintelligence analytics and typical reports generated by various information systems is that business intelligence uses data from multiple sources and can generate these reports on demand. Businessintelligence tools and dashboards are described in detail in the literature or in presentations at meetings, but there is very little guidance for the manager who wants to use these tools. Identifying the Target Before setting out to find an individual solution for a business unit, the manager needs to define the problems that he or she wishes to investigate. A team approach will help identify specific targets for improvement.

Digital dashboards or businessintelligence tools in the radiology literature usually focus on one or more of these general topics: resource utilization, workflow improvement, improvement in reporting, reimbursement, and quality assurance (to include safety). Resourceutilization analytics provide reports on the productivity of staff and the utilization of imaging modalities. Workflow dashboards can give the user a real-time display of the flow of patients and procedures through the department. Radiology-interpretation dashboards tend to focus on real-time views of reportturnaround times, and reimbursement models focus on the appropriateness of studies. Ensuring the appropriateness of performed procedures can lead to improvement in reimbursement. Quality-assurance analytics are used to evaluate errors and to monitor safety measures. For example, two of the Agency for Healthcare Research and Qualityâ&#x20AC;&#x2122;s metrics deal with reducing radiation exposure, and the agency recommends recording CT dose and documenting fluoroscopic examinationsâ&#x20AC;&#x2122; duration.1,2 Although tools to measure and monitor radiation exposure are not yet widely available, these quality measures will become mandatory. Unfortunately, digital dashboards and other business-intelligence tools are not yet widely used, partly because radiology data are distributed across widely disparate system and partly because there is no plug-and-play commercial solution that will work with all systems. The institutions that report phenomenal successes with these tools either have a team of imaging-informatics professionals who have the time and resources to create

a one-off solution3-13 or have a singlevendor solution in place that applies to all the medical information systems throughout the institution. The basis for a radiology businessintelligence system or solution is the set of data that probably already exists in an institution. This dataset includes patient information, radiology orders, radiology images, and reports. In addition, the institution will be most likely to have the required infrastructure, including the networks and servers that support the enterprise. Data acquisition is triggered by specific events, such as patient registration, order entry, performance of a study, or reporting of the studyâ&#x20AC;&#x2122;s results. In addition to the basic data generated by the workflow (orders, images, and reports), each of these activities generates additional information on the timing, location, and personnel involved. If the organization is to build a businessintelligence solution, selected data must be integrated and stored in a repository for analysis. An analytics engine will mine the aggregate data in response to requests from users and will generate reports, which are then displayed through a user interface. The components of a businessintelligence system are shown in Figure 1 and include the usual sources of data for radiology applications: the hospital information system (HIS), the RIS, the PACS, and the dictation system. The trick is to get all of the required data into a single consistent format in what is shown as the business-intelligence database, so the analytics engine can formulate real-time analysis, as well as historical data reports. This is not an easy task, and it will require work on the part | December 2010 | Radiology Business Journal 47

Radiology | Business Intelligence

User interface

Analytics engine

Business-intelligence database


Hospital database

RIS database

PACS database

Dictation system

Figure 1. The components of a business-intelligence solution include sources of data for radiology applications, including the RIS, PACS, hospital information system, and dictation system.

of managers; they must identify their goals, gain cooperation among various IT sections, collaborate with vendors, and perhaps obtain outside help from consultants. A Recipe for Success The first thing that radiology managers and administrators will need to do is to

articulate the goals that they wish to achieve using their business-intelligence solution, ranking them in order of importance. The table shows some of the more common goals and which systems might contain the data required to meet those goals. This is the time for managers to engage other stakeholders in the process. Stakeholders will include the radiologists,

Table. Business-intelligence Solutions and Data Sources Business-intelligence reports Data sources Departmental real-time workflow

PACS (reporting patient status to RIS)

Resource utilization

PACS (reporting personnel, imaging location, date, and time)

Report-turnaround time

PACS and radiology reporting system


PACS, RIS, and hospital information system (HIS) for patient history, symptoms, and reason for study


Radiology reporting system for critical results

Error reporting

RIS and HIS for drug indications

Radiation exposure

PACS for CT and fluoroscopy


Billing system, HIS, and RIS

48 Radiology Business Journal | December 2010 |

IT personnel, clerks, and technologists, each of whom will have their own individual concerns and prioritiesâ&#x20AC;&#x201D; and potential conflicts. For example, an IT manager might not be willing to assign resources to the work involved in identifying sources of data and might be reluctant to approve additional information systems to support the objective. Technologists might resist an effort to quantify their work product by the number of studies performed because it could affect their performance reviews. Managers will need to use tact and all of their leadership skills to show that these tools will benefit everyone by improving departmental performance and remuneration (and possibly patient satisfaction). Two business-intelligence solutions are widely described in the literature, probably because the data required for each are readily accessible, and the applications can help a department improve its total turnaround time (from the time that a patient enters the department until the report is communicated to the referring physician). Rapid turnaround appears to result in improved perception of value on the part of the referring physician, in addition to enhanced patient satisfaction. The illustrative scenarios that follow would be appropriate for a real-time, interactive dashboard application that could help managers identify bottlenecks as they occur, or they could be implemented as static, ondemand reports. The first application is a dashboard showing departmental workflow, with the ability to drill down to evaluate the suspected problem areas. The second application is a real-time view of dictation, signing, and communication of reports. Departmental Workflow A simple description of the process of performing a radiology study can be broken down into discrete steps defined as order entry, patient arrival, patient preparation (if necessary), imaging, verification that imaging has been completed and is correct, report generation, report signing, and report communication. As the table shows, order

Radiology | Business Intelligence

entry is performed using either the HIS or RIS, patient arrival is marked in the RIS, patient preparation might be entered in the RIS (especially if the preparation includes the administration of drugs), imaging and verification will be included in the PACS, and reporting will use the dictation system. It is probable that some imaging steps (such as study completion) will be reported to the RIS. If managers wish to view a dashboard that shows exactly how their resources are being used, the integrator engine will need to know (from the RIS) which studies are scheduled. Then, the integrator will need to receive status reports on each patient as the study is performed, and it must be able to show, at any moment, where the patient is located. The integrator engine will pull study information from the PACS indicating which specific imaging system was used, which technologist was responsible for the study, the time that the study was started, and the end of the study (indicated by verification). Unfortunately, in many institutions, the PACS and the RIS are not tightly coupled, so the integrator will need to match the information from both systems, synchronize the timing of events, and store the information for the analytics engine. Many methods have been suggested for doing exactly this job, and if an institution has the resources needed to create a custom application, those methods from the literature can be used. After the data have been successfully integrated into the business-intelligence database, an analytics engine can query the database and present the user with the information in myriad formats. If managers wish, for example, to see three CT units and their current throughput, they can be presented with a table showing the throughput over a user-selected time frame, the average length of time spent performing a study, and the queue of studies waiting to be performed. Managers can drill down to see where each patient is in the workflow and can highlight areas where the average waiting time or average imaging time is greater than expected. In addition to tables, businessintelligence dashboards and tools offer a number of other options for data

visualization,14 including 2D graphs, 3D cubes, and tree maps.15 To illustrate a potential use of the tree map for radiology, Figure 2 is a fictional example of how a map might look for a department with three CT units, three ultrasound units, two MRI units, and six DR rooms. In each case, the size of a box indicates how many examinations are being performed on a unit (in comparison with other, similar units), and the grayscale indicates how quickly the examinations are being performed. Lighter grays indicate that studies are moving through the particular modality quickly, and darker grays indicate that studies are taking longer. The tree map is a constantly changing picture of the department’s throughput, with the blocks or leaves changing as workflow in the department changes. The black arrow is pointing to a DR room providing relatively fast throughput and also doing most of the DR examinations. The white arrow is pointing to the underperforming CT unit. In many cases, a tree map is interactive, and the user can click on a rectangle for more information—such as the location of the equipment, the personnel working with it, and the patients whose exams have been completed, along with numerical data on the average length of time needed CT




Figure 2. Use of a tree map provides visualization of activity in a department with three CT systems, three ultrasound units, two MRI scanners, and six DR units. The sizes of the boxes represent the quantity of studies performed and the shades of the boxes represent the speed with which they are accomplished.

50 Radiology Business Journal | December 2010 |

for a study and the distribution of the performed studies. While it is tempting to require a tree map in a solution, multidimensional cube visualization of data, simple graphs, and tables could impart the same information. Radiology Reporting After studies have been completed, radiologists report their findings through dictation, usually using a speechrecognition system or a transcriptionist. The final step in the reporting cycle is the signing of the report by the radiologist, indicating that the report is complete and correct. Delays in the dictation and signing of reports can result in reduced turnaround time for a study (and this, in turn, can delay the patient’s treatment). In today’s more competitive environment, rapid turnaround can give a department an edge with referring physicians. A signal that a study has been completed is sent to a dictation system to alert the radiologist that a study is ready to be interpreted. The total turnaround time for the report is the time between completion of the study and the beginning of dictation, added to the duration of dictation and to the time elapsed between the end of dictation and the signing of the report. If a speech-dictation system is used, dictation duration and time between dictation and signature are automatically recorded as events occur. The completion of the study should be recorded in the RIS, triggered by an interface with the PACS. A business-intelligence dashboard can be created that shows each radiologist and his or her average total turnaround time, time from dictation to signing, and total volume of reports. In some cases, radiologists will not truly appreciate the power of these tools because they are understandably proud of their work; they could feel threatened by this type of analytics, which seems to value quantity over quality. Quality Metrics Khorasani10 has described some suggested measures of quality as performing the right procedure, using

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the right protocol, and imaging the right side of the right patient. To perform the right procedure, a referring physician might require assistance in an automated computerized provider order entry system that will guide the ordering of the appropriate procedure. Carefully documented, consistent imaging protocols will help ensure that the correct protocol is used to perform the procedure. It is the responsibility of the technologist to image the correct side of the right patient (after verifying the patientâ&#x20AC;&#x2122;s identity). Business-intelligence methods can be used to mine the data from these systems to see whether ordering physicians are ordering appropriate procedures and to ensure that the procedures were acquired using consistent protocols. Errors can be detected by examining the databases and reports for repeat procedures or for procedures performed on the wrong patients. Radiology departments have been challenged to reduce the radiation dose delivered to patients and to collect data for each patient showing cumulative dose, especially during CT and fluoroscopic examinations. At this time, many imaging modalities and PACS do not record and store this information, but systems are being developed that will extract these data from the modality or PACS and store the data in the RIS or HIS. Commercial Solutions If an institution does not have the in-house expertise needed to create business-intelligence analytics, and it does not wish to employ an outside entity to create a one-off solution, there are commercial solutions available to consider. The advantage of a commercial solution is that the vendor will probably continue to support and enhance the product, and it will continue to evolve over time. The disadvantage is that an institution will have to settle for a more generic solution, designed to meet the needs of a larger group of customers. If managers want to find the best commercial solution for their departments, they should identify the expected results and then issue a request for proposal to potential vendors. If the department and

hospital have a single-source solution for the HIS, RIS, and PACS, that vendor will be the one most likely to provide the businessintelligence analytics needed by managers. Since vendors still have not implemented the types of systems described in the research-anddevelopment literature, customers will have to put pressure on them to supply these systems. If enough radiology managers and radiologists demand business-intelligence solutions from their vendors, the vendors will respond. The RSNAÂŽ 2010 96th Scientific Assembly and Annual Meeting in Chicago, Illinois, and the annual meeting of the Society for Imaging Informatics in Medicine (to be held in Washington, DC, in June 2011) are both appropriate venues for starting the dialogue between vendors and their customers who need business-intelligence solutions. Janice Honeyman-Buck, PhD, FSIIM, is an imaging-informatics consultant and is editor-in-chief of Journal of Digital Imaging, the official journal of the Society for Imaging Informatics in Medicine; References 1. Agency for Healthcare Research and Quality. Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time. http://www. aspx?id=14305&search=fluoroscopy+ time. Published February 2009. Accessed November 4, 2010. 2. Agency for Healthcare Research and Quality. Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices or manual techniques for appropriate moderation of exposure. http://www.qualitymeasures. =computed+tomography. Published February 2009. Accessed November 4, 2010. 3. Chen R, Mongkolwat P, Channin DS. RadMonitor: radiology operations data mining in real time. J Digit Imaging. 2008;21(3):257-268.

52 Radiology Business Journal | December 2010 |

4. Gregg WB, Randolph M, Brown DH, Lyles T, Smith S, Dâ&#x20AC;&#x2122;Agostino H. Using PACS audit data for process improvement. J Digit Imaging. Published online ahead of print February 9, 2010. doi:10.1007/ s10278-009-9272-y. 5. Nagy PG, Warnock MJ, Daly M, Toland C, Meenan CD, Mezrich RS. Informatics in radiology: automated Web-based graphical dashboard for radiology operational business intelligence. Radiographics. 2009;29(7):1897-1906. 6. Nagy PG, Daly M, Warnock M, Ehlers KC, Rehm J. PACSPulse: a Webbased DICOM network traffic monitor and analysis tool. Radiographics. 2003:23(3):795-801. 7. Nash M, Pestrue J, Geier P, Sharp K, Helder A, McAlearney AS. Leveraging information technology to drive improvement in patient satisfaction. J Healthc Qual. 2010;32(5):30-40. 8. Andriole KP, Prevedello LM, Dufault A, et al. Augmenting the impact of technology adoption with financial incentive to improve radiology report signature times. J Am Coll Radiol. 2010;7(3):198-204. 9. Khorasani R. Setting up a dashboard for your practice. J Am Coll Radiol. 2008;5(4):600. 10. Khorasani R. Can metrics obtained from your IT databases help start your practice dashboard? J Am Coll Radiol. 2008;5(6):772-774. 11. Prevedello LM, Andriole KP, Khorasani R. Business intelligence tools and performance improvement in your practice. J Am Coll Radiol. 2008;5(12):1210-1211. 12. Khorasani R. Objective quality metrics and personal dashboards for quality improvement. J Am Coll Radiol. 2009;6(8):549-550. 13. Glaser J, Stone J. Effective use of business intelligence. Healthc Financ Manage. 2008:62(2):68-72. 14. McCandless D. The beauty of data visualization [video]. TED: Ideas Worth Spreading. david_mccandless_the_beauty_of_data_ visualization.html. Accessed November 4, 2010. 15. Map of the market. SmartMoney. Accessed November 4, 2010.

Ferdinand Barth (1842â&#x20AC;&#x201C;1892)

Interview | Jeff C. Goldsmith, PhD

54 Radiology Business Journal | December 2010 |

The Sorcerer’s Apprentice: A Conversation With Jeff C. Goldsmith, PhD In a new book on medical imaging, the dysfunctional payment system, unproductive turf battles, the fusing of diagnostics and therapy, and the future of the profession are all on the table By Cheryl Proval


hat happens when you cross a futurist and a radiologist? In October 2010, Oxford University Press published The Sorcerer’s Apprentice: How Medical Imaging Is Changing Health Care, by Bruce J. Hillman, MD, the effective father of the ACR® Imaging Network, and Jeff C. Goldsmith, PhD, a health-care futurist known for his contrarian views. The two met at the University of Virginia, where Hillman is the Theodore E. Keats professor of radiology and professor of public health sciences and Goldsmith is associate professor of public health sciences. Goldsmith is also the president of Health Futures, Inc, a consultancy based in Charlottesville, Virginia. The pair has turned out an engaging, thoughtful, and compelling book that is equal parts science, history, and healthpolicy analysis; it is a must-read book for anyone who practices, uses, or pays for medical imaging. Radiology Business Journal sat down with Goldsmith to discuss some of the ideas explored in the book and their implications for the specialty.

RBJ: What is the story behind the book? How did a futurist and a radiologist come to collaborate? Goldsmith: I’ve been interested in this profession and technology for years because the rest of medicine seemed to me almost to be standing still, compared with radiology and imaging. There are so many other parts of medicine where technology has not developed as rapidly as people expected, but this area has consistently exceeded expectations. I also thought it was an incredible success story that no one has told, as such. Here’s a profession that has done a remarkable job of leveraging technology in a digital world—and it became, as a consequence, one of the most successful knowledge disciplines. It was a story worth telling from a management standpoint. When I was getting serious about the research on the book, I went to talk to Bruce and asked if anyone had told this story. He said, “Not really—and by the way, I’ve been thinking about doing something like this. Why don’t we work together?” | December 2010 | Radiology Business Journal 55

Interview | Jeff C. Goldsmith, PhD

There’s a sort of instrument lag in the policy world; the people driving the bus think we are fighting double-digit rates of growth in high-tech imaging. In reality, imaging volume is growing in the low single digits or not growing at all. —Jeff C. Goldsmith, PhD, president, Health Futures Inc, Charlottesville, VA

Both of us were thinking along the lines of trying to explain, to lay readers and to the policy and business community, how this technology works, how it is used (and perhaps misused), and how society could get its arms around it. We hit upon the metaphor of the sorcerer’s apprentice to explain how hard it is to control a complex technology, and that mixture of fascination and fear people have toward it. It was a great metaphor for describing how disruptive imaging has been. RBJ: In your discussion of our dysfunctional health-care payment system, you make the case that the use of other people’s money for

health care creates a suspension of normal economic forces. In your words, the invisible hand of the market is not enough to solve these systemic problems. Could you give our readers a sense of what you recommend in your final chapter? Goldsmith: Third-party payment introduces this problem of moral hazard: If you are not directly responsible for the cost of a service, then you have to put an enormous amount of trust in the people you rely on to perform that service, to make sure that it is needed and is performed in a responsible way. As we went around the country, we kept hearing—and not just from the usual

56 Radiology Business Journal | December 2010 |

suspects, like health insurers—that there was a great deal of unnecessary imaging. Moral hazard (and how you manage it) was one of the themes in the book because our political and healthinsurance systems haven’t gotten their arms around the moral-hazard problem. We talk about how to get to the point where appropriate use of technology is the norm, is rewarded by the payment system, and is recognized by patients and the technology’s users. Radiologists have been ahead of the curve when confronted with policy challenges. They did it with digital standards. They did it again with relativevalue payment approaches. Through the ACR, radiology has been very aggressive in developing appropriateness guidelines backed by applied clinical research. The expansion and use of that information in guiding payment policy, both public and private, are going to become crucial in the next seven to 10 years. RBJ: You write that since initiating the sustainable growth rate (SGR) in 1997, Congress has let it stand just once, effectively creating a $300 billion pothole in Medicare, with imaging accounting for more than the average share of that debt. What impact has this had on radiology’s standing in the medical community, and what are its implications for the development of new imaging technologies? Goldsmith: Many physicians don’t understand the SGR—the fact that Congress placed an arbitrary economic cap on growth in Part B Medicare physician payment 13 years ago. The fact that imaging costs were growing much more rapidly than other Part B costs also was not widely understood in the physician community (even though physicians were doing the ordering). It inflamed policymakers, however. As early as 2000, there were warnings (and an increasingly strident voice from the Medicare Payment Advisory Commission and its staff) that something needed to be done. Imaging payment reductions have come thick and fast this past four years, without a lot of assessment of the effects on reducing volumes and cost. Medicare’s imaging expense went down 13% in the first full year after the DRA (2007). The

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Interview | Jeff C. Goldsmith, PhD

molecular imaging, but is going to affect the course of the broader biotechnology industry. In the book, we quote a scientist as saying that, in the future, every disease is going to be a rare disease. Diagnosis will not merely be physiological; diagnosis will occur in a specific genetic context for specific individuals. We need a different payment model for these things. In this book, we grope for new payment models that encourage not only personalized diagnosis, but technology that enables you to diagnose and resolve a clinical problem in a single session. In diagnostic therapy (theranostics), there may be diagnostic molecules that can be modified and used to kill a pathogen or cancerous lesion. We need to move to a payment model that encourages diagnosis and treatment to take place in the same setting.

DRA actually had a much more profound effect on cardiology and orthopedics than it has had on radiologists because radiologists are better integrated into hospital imaging activity. The policy community doesn’t understand that imaging is now deep into a recession quite unlike anything seen in the past 30 years. In late 2008, Health Affairs published an issue that highlighted the so-called imaging boom. People working in this field realized that the discipline and technology had already gone under the front wheels of the bus by 2008, and by the end of this healthreform cycle, they now have gone under the back wheels. The deep recession also has hurt elective-imaging volume. There’s a sort of instrument lag in the policy world; the people driving the bus think we are fighting double-digit rates of growth in high-tech imaging. In reality, imaging volume is growing in the low single digits or not growing at all. In some markets and systems, we’re seeing full-blown volume declines approaching double digits in the major high-technology modalities. There’s also something like a 30% fall in imaging-equipment sales (since their peak

in the middle of the decade) in the wake of the DRA; I’m concerned that the past four years may have done fundamental damage to the economic foundation of the technology. There is a delicate balance between containing growth in imaging spending and extinguishing the researchand-development investment in imaging technology. If you continue the trends of the past four years, you create an environment where the big-ticket investment that’s required to build out the technology— particularly molecular imaging—just isn’t going to be there. One of the major contributions we hope to make is to give people a better understanding of the relationships among payment policy, utilization, and technology investment. RBJ: You discuss an interesting—and disturbing—economic catch-22 that threatens the future of personalized medicine: the “daily reclassification of diseases into ever smaller markets of more accurately defined diseases.” What can be done to promote investment in therapies for effectively smaller markets? Goldsmith: This problem not only is going to slow the development of

58 Radiology Business Journal | December 2010 |

RBJ: In the last chapter, you say that subspecialization can foster more effective team medicine. What roadblocks will radiology have to navigate to become part of the team? Goldsmith: The discipline has been so successful that it really hasn’t had to collaborate, and it has viewed disciplines that might find radiologist-developed technologies useful as competitors. Bitter turf struggles with cardiology and orthopedic surgery have taken place largely out of the view of the patient. If patients understood that there was actually controversy about whether a specific discipline was qualified to image them, it would raise anxieties—and questions such as, “Why aren’t you guys working together?” I understand why people aren’t working together, but I also think that radiology has clung, perhaps a decade too long, to this idea of a generalist practice model. If they are going to be successful, particularly in an era of molecular medicine, radiologists either are going to subspecialize (which will take decades) or are going to acknowledge that the radiologist’s training is not so broad that it encompasses things like applied genetics. These are things that radiologists learn in the basic-science phase, very early in their education, but don’t necessarily come back and apply, in a clinical context, in

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Interview | Jeff C. Goldsmith, PhD

We are moving toward an era of team-based medicine, and the radiologist has a tremendous amount of power to bring to that team (and in many cases, will be in the best position to convene and organize the team). later phases of their training. With molecular imaging, you have a rapid convergence of molecular pathology and radiology—and the potential for a collision, Project1:Layout 1 4/14/10 and 10:41yet AManother Page 1

turf struggle. I see the alternative potential for mutually reinforcing strengths. Why can’t pathologists and radiologists work together to create centers for molecular diagnosis and therapy? It’s about making

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60 Radiology Business Journal | December 2010 |

the pie bigger. The whole medical profession is sufficiently weakened by economic and political forces that it is not really prudent to launch a new set of turf struggles right now. That would be really counterproductive in the policy world. RBJ: In the 1797 Goethe poem “Der Zauberlehrling” (on which Disney’s “The Sorcerer’s Apprentice” is based), the sorcerer cleans up the mess created by the apprentice, with the admonishment that powerful spirits should only be called by the master himself. Have radiologists been vocal enough about the dangers of imaging moving into the hands of others? Goldsmith: They’ve been vocal about it, but in a way that might be perceived as parochial and self-serving. It’s not enough to say that others are not adequately trained to use these tools. Radiologists do, in fact, have a far greater depth of awareness of the effect of the technology on their patients, and also of the subtleties of diagnosis, than any other clinical discipline has. The overarching question is this: What is the best way for patients to get the best care? If I am offered a choice between a discipline that understands the physiology of a particular organ system (like the heart or digestive system) better than anyone else and a discipline that understands the diagnostic technology that might address that organ system—or the choice of a multidisciplinary center of excellence where those disciplines work together to answer a complex clinical problem—where am I going to go? Moreover, what is the payor going to perceive as the configuration of knowledge that produces the best value for the patient? Eventually, payors will get around to cutting the patient in on some of the savings that result from having a definitive diagnosis from a team of caregivers. We are moving toward an era of teambased medicine, and the radiologist has a tremendous amount of power to bring to that team (and, in many cases, will be in the best position to convene and organize the team). My argument is that you can define your discipline as having control over all of these modalities and tools, or you can define your role as solving a






Interview | Jeff C. Goldsmith, PhD

clinical problem. When you define it in that way, you end up drawing the circle of potential participants a lot wider—and making the pie bigger, as a result. RBJ: You clearly understand all of the problems and threats facing radiology, yet you are very optimistic about its future. Why? Goldsmith: Lewis Thomas, MD, (1913–1993), the New England Journal of Medicine’s famous essayist/biologist, talked about how expensive halfway technologies (those that treat the symptoms of a disorder, but neither AHC CMS Mandate ad 11-1_Layout 1 11/2/10 prevent nor cure it) were in the 1950s.

An example of that was the iron lung: You couldn’t cure polio, so you ended up with patients in iron lungs for the rest of their lives. Another halfway technology was coronary-artery bypass graft surgery. Imaging technology may be, at this point in its evolution, a two-thirds (not halfway) diagnostic technology. Imaging doesn’t always answer the question of what is wrong with the patient; instead, it can raise expensive questions for follow-up work. From technology and medicolegal standpoints, it is urgent to go the rest of the way. The sooner we can 1:59 PM Page 1 get the technology to the point where an

ame is Hello, My N

e t a d n a M CMS Meet me with one application, one survey, one cost. Regardless of number of sites or modalities, meet the Advanced Diagnostic Imaging mandate with one application, one survey, one cost. Learn why the Joint Commission staff and comprehensive survey process compares to no other accreditor. Visit:

imaging exam is truly definitive, the more solid the ground on which the profession will be standing. Elegant images are not enough. We need elegant functional characterization and definitive prognosis. It is urgent for this field to change both its business models and its policy positions to address some of the concerns that are coming out of Washington. There’s still not the sense of urgency that needs to be there about addressing the issue of the appropriate use of this technology. That’s my biggest concern. If you are as successful as radiology has been in this political climate, it’s actually a handicap. You can’t afford to be defensive about it, but you also can’t continue to behave as if fighting to defend your turf is the appropriate response to the present climate. Ironically, because of its extraordinary success, wealth, and strength, the profession is actually in a weak political position. There’s not a lot of sympathy for radiologists in Washington right now. RBJ: What’s the most important thing for radiologists to know about how they should move in this world? Goldsmith: Radiologists’ colleagues accurately perceive them to be the best at business among physicians. Why not use those skills—and the ability to adapt to uncertainty—to organize new business models, new subdisciplines, and new economic relationships, as well as to participate aggressively in the experimentation that will go on as a result of the Patient Protection and Affordable Care Act? Radiologists can use the perception that they are effective organizers to their advantage. This is a profession of experimenters, tinkerers, and people who are willing to take risks, try things, and see how they work out; it’s that adaptive skill that’s the real asset of the discipline. I’ve never seen more uncertainty in medicine than right now. That presents radiology with a great opportunity to exploit what I think is a tremendous evolutionary advantage. Cheryl Proval is editor of Radiology Business Journal and vice president, publishing, for imagingBiz, Tustin, California.

62 Radiology Business Journal | December 2010 |

Editorial contEnt that mattErs



For Leaders In Medical Imaging Services










Case Study | Building a Stroke Network

Saving Brain:

Nowhere is radiology’s role in the team approach to health care more critical than it is in stroke response By Erin Burke


n Los Angeles County, a 4,752– square-mile urban–suburban sprawl that is home to an estimated 10 million people, no one knows exactly how many acute strokes occur each year or how well they are managed. Nationwide, stroke is the number-three cause of death; stroke-related medical costs in 2010 are estimated at $73.7 billion.1 Since the debut of the Los Angeles Stroke Center System in November 2009, however, the county has been poised not only to know exactly how many acute stroke patients it is delivering to hospitals, but how quickly and efficiently they are being treated. Most important, patients are more likely to get the care that they need. Radiology, of course, has a key role to play. Fernando Vinuela, MD, says, “We deal with a stroke as soon as possible because

64 Radiology Business Journal | December 2010 |

for each minute, a person loses 2 million brain cells.” Vinuela is professor of radiology, interventional neuroradiology division, at the Ronald Reagan University of California–Los Angeles (UCLA) Medical Center. UCLA Medical Center is one of 20 hospitals in Los Angeles County that have earned certification as primary stroke centers from the Joint Commission. This designation enables hospitals to apply to Los Angeles County’s Emergency Medical Services (EMS) Agency for inclusion in the Los Angeles Stroke Center System, which initially included only nine hospitals. Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine and director of the UCLA Stroke Center, says, “The American Heart Association (AHA) has been a driver in this process. It helped design a process to bring all stakeholders to the table.”

Building the LA Stroke Network

Saver has played an integral role in the development of the stroke system in Los Angeles County and was the recipient of an award from the AHA for his continuing volunteer work for the organization. UCLA Medical Center created a prehospital stroke-screening scale, and UCLA Medical Center’s physicians used it to train the county’s paramedics to identify strokes. This ensures that a stroke patient will be taken to the nearest stroke center (instead of to the nearest emergency department). Bill Koenig, MD, is medical director of the Los Angeles County EMS Agency, which enrolls hospitals in the stroke system and is in the process of building a database to monitor the benefits of the system. No one in the EMS Agency knows exactly how many emergency vehicles are deployed by the county and by the 88 cities (and many incorporated

areas) that constitute the most populous county in the United States. In fiscal year 2008–2009, more than half a million people were transported to county emergency departments. An estimated 2,000 to 3,000 of those patients were having strokes. “The care of the patient is a continuum that starts in the field,” Koenig says. The benefit of having more hospitals in the stroke system is that EMS personnel don’t have as far to travel when transporting a stroke patient. The stroke system began with a onetier network of primary stroke centers, but it is evolving into a two-tier system that will include comprehensive stroke centers, Saver says. Primary stroke centers are the first-choice locations for diagnosing a stroke, and they are able to deliver recombinant tissue plasminogen activator (tPA) intravenously.

If the stroke-care team at a primary stroke center decides that a patient requires endovascular delivery of tPA or needs neurosurgery, however, the patient is transferred to a comprehensive stroke center. Comprehensive stroke centers offer vascular surgery and neurosurgery, and ideally, each would support five to 10 primary stroke centers. In 2005, the Brain Attack Coalition2 recommended key capabilities that comprehensive stroke centers should have. These include the presence of health-care personnel with specific expertise in neurosurgery and vascular neurology; advanced neurologicalimaging capabilities, including MRI and various types of cerebral angiography; microsurgical and endovascular techniques, including clipping and coiling for intracranial aneurysms, carotid endarterectomy, and intra- | December 2010 | Radiology Business Journal 65

Case Study | Building a Stroke Network

The care of the patient is a continuum that starts in the field. —Bill Koenig, MD, medical director, Los Angeles County EMS Agency

arterial thrombolytic therapy; and other infrastructure and programmatic elements, such as an ICU and a stroke registry. Meeting Requirements Of US hospitals, 1,200 are certified by the Joint Commission as primary stroke centers, Saver says. He estimates that the cost of running a stroke program can range anywhere from $8,000 to $150,000, depending on a hospital’s existing staff and technology. “The core thing that is needed is a nurse specialist who will anchor the program and enter data into the database, and that requires time,” Saver says. The money spent to run the program could be recouped, however, in shorter lengths of stay for stroke patients who have been successfully treated and in higher reimbursement, he notes. Debra Flaherty, director of neuroscience and rehabilitation at the 411-bed Northridge Hospital Medical Center, reports that the facility incurred startup costs that included time spent on the Joint Commission’s survey and the addition of two personnel: a stroke coordinator and a department specialist who enters data and creates spreadsheets, allowing the stroke coordinator to spend more time with patients. Programmaintenance costs stem from the need for ongoing education for nursing and ancillary staff. Providence Little Company of Mary Medical Center San Pedro hired a strokeprogram manager, as well as a consultant to educate nurses and physicians on best practices, according to Karen Frederick, director of rehabilitation, respiratory therapy, and neurodiagnostics. In addition, the hospital paid for the stroke-program manager to visit a Providence hospital in Oregon to study

its existing stroke-program protocol. Although stroke certification and participation in the stroke system did not require that the department’s CT program be accredited by the ACR®, the radiology department paid for fees related to CT accreditation. The cost–profit ratio hasn’t yet been measured by the hospital, but the value of the program is apparent to Frederick: “The profit is in the improved quality of care,” she says. Implementing stroke programs would be easier if these projects were eligible for government funding, but hospitals shouldn’t expect funding from the state of California. There have been various bills under consideration that would fund stroke programs, but they were not passed, Saver says, because of economic conditions. He adds that for many organizations, implementing a primary stroke center would have either a neutral or a positive impact on the hospital’s bottom line. Radiology’s Role Radiology plays a key role in a hospital’s response to stroke, but even radiology departments that are part of an established stroke program require adaptive changes for stroke certification. Barry D. Pressman, MD, chair of the department of imaging at the S. Mark Taper Foundation Imaging Center and Department, says that Cedars–Sinai®

66 Radiology Business Journal | December 2010 |

Medical Center’s program had been in place for about seven years before the institution became a certified stroke center. Nonetheless, the radiologic technologists still had to undergo retraining to ensure that scans would be performed in a more timely manner. Radiologists worked with the technologists, primarily to teach them how to choose patients’ target arteries and veins more quickly in the course of procedures. Technologists are now able to turn around CT scans in 10 minutes, Pressman says. Training is ongoing, and if radiologists see an error, they immediately work with the technologist to ensure that it is corrected. Pressman concedes that the technologists have a more difficult job than radiologists. “Nothing is more important than the training of the technologists in getting this process to work,” he says. Cedars–Sinai Medical Center also introduced a 64-slice CT scanner in the emergency department to minimize patient-transport time and to enable technologists to perform CT angiography and CT perfusion studies for stroke patients in the emergency department. In accordance with the Joint Commission’s policy, the hospital took steps to ensure that each radiologic technologist has the ability to perform scans efficiently and effectively and that a technologist is available around the clock. Providence Little Company of Mary Medical Center San Pedro not only retrained radiologic technologists, but cross-trained others in the department to perform CT scans to ensure that the hospital met Joint Commission coverage requirements, Sandra Edson, RT, director of imaging and cardiovascular services, reports. Technologists with advanced technical skills and an interest in professional growth were chosen for


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Case Study | Building a Stroke Network

Nothing is more important than the training of the technologists in getting this process to work. —Barry D. Pressman, MD

cross-training (which was supervised by Though Northridge Hospital Medical radiologists), she says. The department Center currently is a primary stroke also provided education on stroke center, Flaherty says that the organization protocols for the imaging staff. plans to implement interventional“The additional training basically radiology services in about six months to involved making sure they were familiar a year. This will require new equipment. with the signs and symptoms of a stroke The addition of interventional radiology and the limited timeframe we have to alone will not qualify the hospital to be perform the study and have it read,” a comprehensive stroke center, but it is Edson says. For primary stroke centers a step in that direction. Until Northridge that do not provide the interventions Hospital Medical Center achieves found at a comprehensive stroke center, that status, the hospital has a transfer turnaround time for brain scans is even agreement with UCLA Medical Center. Providence Little Company of Mary more critical because the patient might 1269_Rad_Sprd_RBJ_BOT.qxd:Layout 1 1 5/7/10 PMPM Page 1 1 1269_Rad_Sprd_RBJ_BOT.qxd:Layout 5/7/10 3:06 3:06 Page Medical Center San Pedro also is a need to be transferred.

primary stroke center. Members of the four-radiologist practice that covers the hospital have advanced training in neuroradiology and interventional radiology; although three of them have experience in catheter-directed thrombolysis, they do not expect to perform that procedure at the hospital. Measuring Success A linchpin of the stroke program is a commitment to recording data, preferably concurrently with care, at specified care milestones. Data to be collected include the date and time that the patient was last known to be well, that prearrival notification was received, that the patient arrived, that the stroke team was notified, that the stroke team reached the patient’s bedside, that CT/MRI studies (including scout-image acquisition) were performed, that tPA was ordered, and that tPA was administered intravenously. Other figures recorded include the time elapsed before tPA administration (with a goal of an hour


or less), before CT/MRI scanning (with a goal of 25 or fewer minutes), and before stroke-team notification (with a goal of 15 or fewer minutes). “That step is a new procedure for our department. Our triage procedures have not changed,” Edson says. “In the radiology department, we now track exactly when the patient arrives in our department and when he or she leaves, and that number is part of the overall tracking process.” Koenig reports that Los Angeles County is currently building a database that will include additional metrics and enable hospitals to benchmark their performance against that of other facilities in the stroke system. “The Joint Commission data are not all that we want; we want some additional data fields that involve paramedic care and the paramedic patient,” Koenig says. “That is an overlay we are putting on the stroke system.” In total, the county will be tracking about 25 data points, some of which will

be automatically provided by the Get With the Guidelines database. “We are currently working with the AHA to integrate our database with their database, so that only one group of data has to be entered by stroke hospitals,” Koenig explains. “The Joint Commission, in general, doesn’t look at the system aspects. It is primarily interested in hospital-by-hospital information. We are interested in the big picture: How long is it taking paramedics to get stroke patients there? How fast are the patients treated once they get to the hospital? From a systems standpoint, the Joint Commission doesn’t put all of that together.” From the county’s perspective, Koenig says, the success of the program will be assessed based on triage errors (whether these involve underestimation or overestimation of the severity of the patient’s problem); aggregate neurological outcomes, based on data collected by the individual hospitals for the Joint Commission; and response times at the

facilities—such as time elapsed before the performance of CT exams. Practice Demands UCLA Medical Center and Cedars– Sinai Medical Center are well-endowed, luminary sites with established stroke programs and large radiology practices equipped to provide 24/7 coverage. The demands on a four-person practice would be expected to be somewhat greater. Nonetheless, David Feldman, MD, medical director of the radiology department at Providence Little Company of Mary Medical Center San Pedro, reports that the burden on the practice has not increased since the stroke program debuted, and the practice has not had to change its staffing model. “The stroke program is still relatively new, but our practice is not expecting a significant increase in volume as a result of being part of the stroke network,” he says. “Like the vast majority of radiology groups in the United States, we use

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Case Study | Building a Stroke Network

We are the center of patient management—the centerpiece of treatment. —Fernando Vinuela, MD

limited night coverage via teleradiology service. Our radiologists are on call every night and frequently consult. This did not change with the new stroke program. There was no need to change our staffing model to accommodate the stroke program.” According to Edson, the volume of stroke patients that the hospital receives has remained steady, thus far, at 10 to 15 stroke patients a month. “Our medical center was the first in the Los Angeles South Bay region to receive accreditation as a stroke center, but it was several months before ambulances were required to divert stroke patients to stroke centers,” she notes. “By that time, the other two main medical centers in our region had also attained their own accreditation, so

we can’t say that being part of the network has increased our volumes at all.” She continues, “That, however, was not our motive. Our motive in pursuing accreditation was to ensure we were providing the highest level of care possible to our patients.” Feldman agrees that the benefits of participating in the stroke system come from the satisfaction of living up to high care standards. “A major benefit of the stroke program is verifying that we are providing the absolute best patient care possible,” he says. “Our practice benefits from being part of this network because it meets our demands to provide the best medical service that we can.” He adds, “Our protocols and best practices are freely available for the

Achieving Certification


rimary stroke center certification by the Joint Commission is based broadly on three components: standards, guidelines, and performance measures. Under the umbrella of components are 11 criteria that must be met for certification, according to M.J. Hampel, MPH, MBA, senior associate director of the Joint Commission’s DiseaseSpecific Care Certification Program. To become a certified by the Joint Commission as a primary stroke center, hospitals must: • have a designated medical director; • provide proof that the stroke program is supported by the organization’s administration; • collaborate with providers of emergency medical services; • have a neurosurgeon available onsite or maintain a transfer agreement with a hospital that has an on-site neurosurgeon;

• be able to perform a cranial CT scan or brain MRI scan on acute stroke patients within 25 minutes of an order written by the emergency-department physician, read the scan within 20 minutes of its completion, and be capable of performing such scans at all times; • have all laboratory work completed and reported within 45 minutes of the order; • be prepared to offer therapy using recombinant tissue plasminogen activator (tPA) if the patient is a candidate for it; • ensure that the emergency-department staff has 24-hour access to consultation regarding the administration of tPA; • conduct initial and ongoing education for the staff; • perform at least one public-education activity per year; and • keep a stroke log that tracks the team’s response times and monitors service trends. —E. Burke

70 Radiology Business Journal | December 2010 |

asking. The stroke program has been well received by the local physicians and community, and we are enthusiastic about being part of this program, which standardizes service excellence and increases the chances of an excellent outcome. It’s exciting to be such an important part of that process.” Preliminary Diagnosis When Los Angeles County paramedics identify a stroke patient, they notify the nearest primary stroke center. When the receiving hospital receives that call, the stroke team immediately prepares for the patient’s arrival. At Cedars–Sinai Medical Center, the call-to-action term is code brain, which immediately mobilizes the stroke team (including the imaging and neurology departments). Upon the patient’s arrival, the emergency-department physician evaluates the patient and determines when he or she was last known to be well. If the onset of the stroke was less than 3–3.5 hours earlier, the patient is a candidate for intravenous tPA therapy; if the stroke’s onset was between 6.5 hours and 8 hours earlier, the patient is a candidate for endovascular treatment, Pressman says. Starting when the emergency department calls code brain, the radiology department has less than 45 minutes to perform and read a diagnostic brain scan—usually including a CT angiogram of the neck and brain and a brain perfusion study—to determine whether the patient is actually having a stroke, and if so, whether the stroke is ischemic or hemorrhagic. If the stroke is ischemic, the angiogram will be used to determine whether there is a blocked major vessel, Pressman says. Radiologists must also determine whether strokelike symptoms are being caused by another problem, such as a subdural hematoma, a tumor, drug use, or a cardiac disorder.

Many hospitals perform CT studies for stroke diagnosis because they are quickly completed. If it is determined that the patient is having an ischemic stroke, IV tPA can be administered or endovascular clot dissolution or removal can be performed. If a hemorrhagic stroke is occurring, a CT angiogram might be performed to determine the source of the hemorrhage, Pressman says. CT exams are the diagnostic modality of choice at Providence Little Company of Mary Medical Center San Pedro. “CT brain scans are the most commonly used procedure,” Edson says. “They can be completed fast and provide images that can detect an abnormality.” There are still variations in the way that stroke programs function, even though they all must meet the same Joint Commission criteria. Each organization has created a unique system best suited for its stroke team and for the hospital. For example, UCLA Medical Center uses MRI exams for diagnosis in stroke patients, although CT scans are used for patients with pacemakers, Vinuela says.

Frederick adds, “The protocol has to fit the stroke program, the demographic, and the hospital.” The Feedback Loop One undisputed benefit of participating in a stroke program is the availability of data on every step of care, from arrival to treatment. This gives providers feedback that can be benchmarked against national numbers. Providence Little Company of Mary Medical Center San Pedro already has made changes to the best practices that it implemented just over a year ago, adjusting physicians’ stroke order sets (protocols), revisiting the symptoms of ischemic and hemorrhagic strokes, and providing more bedside information to caregivers and patients, Frederick says. The organization also created nurse champions: ICU and telemetry nurses who help drive best practices and assess the components of good stroke care while the patient is still in the hospital. The stroke team’s efforts have improved its rate of providing what it defines as defect-free

care from 62% to 93% over the course of a year, according to Frederick. The data collection required by the Joint Commission helps stroke teams gauge everything from response time to the quality of patient care and education. It also provides them with invaluable information that reveals both strengths and weaknesses in their protocols and performance. M.J. Hampel, MPH, MBA, senior associate director of the Joint Commission’s Disease-Specific Care Certification Program, says, “There are three components necessary to have a successful program: standards, guidelines, and performance measures.” Hospitals commonly make the mistake of focusing only on one of these components, which is when issues arise. Hampel recommends collecting data concurrently because this provides the organization with more opportunity to identify concerns that someone along the chain of care might have missed. Flaherty says that Northridge Hospital Medical Center collects as

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Case Study | Building a Stroke Network

much concurrent data as possible, but it collects information retrospectively as well. This is analyzed and used to make ongoing improvements in the operational flow, including the turnaround time for radiology. An improvement that will be implemented in the future is telephone contact with stroke patients to determine whether they have additional needs after leaving the hospital. Data collected by radiology departments are used for the betterment of stroke teams and contribute to the data that are provided to the Joint Commission, but these data are also used by the departments themselves. At Cedars– Sinai Medical Center, the information is discussed at weekly vascular meetings. Pressman says, “We constantly review what we are doing.” UCLA Medical Center’s radiology team also works collaboratively to review all of the stroke-program data. Vinuela says, “We are the center of patient management—the centerpiece of treatment.” Many hospitals in the stroke program would agree that both earning certification as primary stroke centers and joining the Los Angeles Stroke Center System have created new avenues for improvement. Certification and the system, Pressman says, have “brought a uniformity to the way patients are treated and brought speed and accuracy to the process. The data show there is an increase in positive results. The bottom line is improved patient care.” Until its database is up and running, the county is measuring success by the number of hospitals that participate in

the stroke system. Koenig is proud of the fact that the initial nine-hospital stroke system has grown to include 19 (26%) of the county’s 72 acute-care hospitals. The system’s goal is 80% participation. “We’re really excited about it,” Koenig says. “One of our concerns is the use of resources in the system to take patients great distances to stroke centers. If you make the paramedics drive 30 miles, it’s a lot more resource intensive than if they drive five miles. The more stroke centers there are, the less likely it is that the paramedics will have to be taken out of their service area to transport the patient.” Meanwhile, Koenig says, radiology coverage has improved in the stroke system. “Radiology has to provide a stat reading on the CT exams and that, in some places, wasn’t always the case,” Koenig says. “You had the emergency physicians reading the CT exams. Because of the importance of reading a CT exam to the administration of thrombolytics, the model now is to have radiology involved. I think the emergency physician welcomes that.” Erin Burke is a contributing writer for Radiology Business Journal. References 1. American Heart Association. Executive summary: heart disease and stroke statistics—2010 update. Circulation. 2010;121:948-954. 2. Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36(7):1597-1616.

Resources The Los Angeles Stroke Center System (information about becoming a certified primary stroke center in Los Angeles County): The American Heart Association’s Get With the Guidelines Stroke Toolbox: www. GetWithTheGuidelinesStrokeHomePage/Get-With-The-Guidelines-StrokeToolbox_UCM_308030_Article.jsp The Los Angeles Prehospital Stroke Screen: scales/lapss.html Stroke information for health professionals from the Internet Stroke Center at Washington University: 72 Radiology Business Journal | December 2010 |

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A Corner Turned With our offer of a next-generation economics journal and your enthusiastic acceptance, we can promise more of a good thing in 2011 By Curtis Kauffman-Pickelle


t is rather amazing, for those of us here at imagingBiz who hopefully envisioned this day, that it has arrived much sooner (and with much more definition) than we anticipated when we crafted the concept for Radiology Business Journal a few short years ago. The fact that we are bringing you a 76-page publication—in an era when many other publications are cutting staff, are printing fewer pages (on inferior paper), and are generally anemic in their editorial matter—is a testament to the degree to which our commitment to the profession has bucked a trend toward skimping on quality. For us, high-quality content has been the impetus for what is now, quite obviously, a valuable source of credible information for the profession. We humbly thank you for your positive reception. We are very gratified that you have embraced this journal and that you find it timely, credible, and meaningful in running your practice, center, or hospital. You have told us how important you find the articles and that you pass them along to colleagues. It is our goal to find the most compelling authors to write about the topics that contribute to your education about the economics and business elements of the fast-paced world of medical imaging. Because we actively participate in the profession ourselves, the articles that we develop reflect the issues, trends, interests, and concerns that are playing out, in real time, all across the country. That is an unusual combination for a media organization and one that continues to set us apart from the ordinary and mundane.

Year Four As we end our third year of publishing this important journal and enter what is, perhaps, the most exciting and interesting time in the history of the medical-imaging profession, we are extremely excited about

the ideas and topics that we plan to bring you throughout 2011 (and beyond). The editorial staff has developed an outline of a wide variety of articles that we will be publishing next year, along with an equally impressive list of authors and case studies that will bring to life, through words and illustrations, the dynamic stories that will inspire and help guide us through another year of change and complexity. Quite literally, this would not be possible at all were it not for the generous support of our growing list of sponsors and advertisers. Through their active participation as underwriters, we are able to invest the resources necessary to attend the appropriate conferences, to interview the thought leaders, to attract the highestcaliber writers, to print on better paper, to include original artwork and graphics, and to use the other expensive elements required to produce a top-level publication. We extend our thanks to all of those advertisers who signed up early on, as well as to those that have come on board with us this year. Based on our early commitments, 2011 looks likely to be an even better year, allowing us to continue to add great content, for your customers and our readers, in each of the planned six issues. I started my publishing career in college, as a staff writer for the university’s magazine, in 1973. My passion for the creation of superb journalism has only grown since that time, increasing each year as I have continued to learn about interesting people, issues, topics, and trends. The opportunity to encounter them, experience them, and synthesize them, in a way that allows me to use my communications skills, has been a true gift—and so, 37 years on, is publishing yet another wonderful issue of an important publication. Never lose the passion for what you do.

Curtis Kauffman-Pickelle is publisher of and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry.

74 Radiology Business Journal | December 2010 |

As we end our third year of publishing this important journal and enter what is, perhaps, the most exciting time in the history of the medical-imaging profession, we are extremely excited about the ideas and topics that we plan to bring you throughout 2011 (and beyond).

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Radiology Business Journal December 2010  

Welcome to Radiology Business Journal, a bi-monthly print journal published by ImagingBiz. This next-generation economics journal is publish...