Improving Workflow in Free-Standing Imaging Centers

There are many levels of workflow in free-standing imaging centers - all focused on maximizing time for patients and referring physicians. They all share the Holy Grail of perfecting efficiency to ensure monetary success. And proactive campaigns that constantly examine and perfect every step of the workflow - from the time the appointment is scheduled to the time the report reaches the referring physician - are the best way to secure success.

Imaging equipment is a huge capital expenditure for any healthcare provider, whether it's a large medical center, mid-sized hospital or free-standing imaging center. For the latter, the only imaging assets that make sense are those that enable the center to maximize patient volume and streamline operations and workflow. At the same time, managing this volume requires a level of operations and workflow that runs at optimal speed - timely scheduling of exams, quick patient throughput and fast report turnaround time.

"There are really three [components] to workflow," says Shane Forman, president of 3d Health Inc. in Chicago, a business advisory company to radiology groups, imaging centers, hospitals, and multi-specialty group practices. "First, there is workflow within the center, which is the efficiency of moving patients through. Second, there is customer service-related workflow, and that is workflow surrounding the patient experience and making sure that you maximize that patient experience. Finally, there is a whole separate workflow that is about maximizing the referring physician experience."

In terms of in-house workflow, Forman explains that there needs to be an understanding of how much time each exam takes as to not create a backlog. This will directly impact how long patients wait from the time they enter the building to the time the exam is actually performed by the technologist. In terms of increasing patient experience, "this really starts when the patient calls to book the appointment," poses Foreman. "Everything that the center does should revolve around the patient experience, such as appointments, parking and the check-in process. We are starting to see some centers begin to offer patients multiple ways to fill out paperwork, such as online, fax or email [forms]."

The final component to Foreman's model is maximizing referring patient workflow. "To compete in most markets, you need to offer same day/next day scheduling and two-hour stat reads for referring physicians and results within 24-hours."

According to Dave Frazee, president of Frazee Nuclear in Cleveland, Ohio, a nuclear medicine/PET consulting group that conducts productivity operations reviews, if there is a backlog and the physician cannot schedule an appointment, he or she will stop using the facility. Expectations are usually met if the facility can get a patient scheduled within five to seven days. "After the referring physician calls a number of times and it's always a two-week backlog, that physician will stop calling your facility and send patients else where," challenges Frazee. "And it's often the case that the facility does not know about the problem because they don't have good communication with the referring physician."

Improving the backlog requires looking at a couple years worth of data. "We look for problems in scheduling that may only be seasonal or chronic," poses Frazee. "If it is chronic, then why? Sometimes it may be a staff shortage or they need to add another piece of equipment to facilitate or reduce the backlog of wait time for scheduling." Frazee also recommends sending out surveys to both the referring physicians and their office staff to learn more about the severity of the backlog.


Staff and physicians in imaging centers must work together and hit all the right notes to ensure referring physicians get the report with the diagnosis. Digital dictation, voice recognition systems, data and image management systems and information systems all help to improve workflow and consolidate volume. Implementing newer technologies requires strategic planning and team involvement to develop training programs, set goals and realize exactly how the new equipment will impact every facet of the facility.

"You will obtain 30 to 40 percent efficiency in terms of personnel with picture archiving and communications systems and radiology information systems," says Jeff Landman, MD, partner of New Light Imaging, the management company for Cools Spring Imaging in Franklin, Tenn., and Hillsboro Imaging Center in Nashville. Landman has been involved with the construction and management of outpatient imaging centers since 1990 and believes the biggest driver for success is better patient care.

"When you can move to digital systems where you can dictate into the RIS or into some digital transcription system, you get your report in a file that can be signed and sent out electronically," continues Landman. "Referring physicians want to know two things when they send a patient to an imaging center: can you do it now and can you send a report quickly? If you can do it now, you have systems that are going to allow you to do it more efficiently and quickly. And you are going to have systems that allow you to generate a report much quicker and get the information back to the referring physician."

Within three months, Epic Imaging in Portland, Ore., will be entirely electronic, except for bone mineral densitometry, after the implementation of CR in the x-ray room and voice recognition for transcription. The practice includes two multi-modality imaging centers and two satellite x-ray offices and sees approximately 450 patients daily.

"When I arrived in 1997, we had a front desk where patients were checked in manually on paper," says Bill Dunlap, center manager for Epic Imaging. "They also performed scheduling at the front desk and took calls for medical records. I started a new department for medical records and a department for scheduling and I added several patient registration booths. Now we have about 15 schedulers, 15 patient registration personnel, and 20 medical records workers."

Next, the facility implemented a RIS and digital dictation. With the addition of PACS, Dunlap says he immediately noticed that the center and the radiologists were more productive. Epic Imaging also purchased a web distribution product so that referring physicians can pull up their images and reports using the internet. For the most part, referring physicians' offices call the center to make an appointment. "We don't allow them to enter our program, but they can leave a note online and we will call the patient to schedule the appointment," says Dunlap.

Dunlap attributes business growth and workflow improvements to having people who know how to utilize the technology appropriately. "You also need an IT person who understands the industry technology and understands the needs of internal and external customers," says Dunlap.


The blossoming of the internet, coupled with an abundant marketplace of high- tech systems permits imaging centers to replace analog workflow methodologies with digital processes. "I think that imaging centers are trying to figure out how they can leverage internet technology to offer patients and referring physicians better, more efficient service," poses 3d Health's Foreman.

Such is the case for Doshi Diagnostic Imaging Services that spends $17,000 monthly on servicing and supporting its high-speed wide area network (WAN), which includes one DS3 line and 24 T1 lines that can handle 30 gigabytes of data daily. "We have improved efficiency using newer technology," says Hemant Maru, director of operations. "Also, our radiologists and referring physicians are very happy with the turnaround time [average is eight hours]." The PACS has increased efficiency 30 to 40 percent, notes Maru, with 15 full-time radiologists who read on average 350,000 studies a year.

In 1998, Doshi Diagnostic consisted of five locations. Today the network connects nine centers, with the 10th one in construction. In addition to the WAN, Maru also attributes the improved workflow to computed radiography. The centers are equipped with multiple Eastman Kodak DirectView 400 Plus and 900 CR systems. "We do more than 120,000 patients a year on fluoroscopy and x-ray and they are all there on the archive," says Maru. "Anytime we want to pull any of these studies, it is very easy to look at them without the hassle of the jacket. CR has been a great modality for us."

The centers also utilize digital dictation for preliminary reports, which are instantly transmitted to a company in India where they are typed and sent back to the radiologist for approval. "Once the radiologist electronically signs the report, the RIS then knows to automatically fax the report to the referring physician," explains Maru. "Our average, turnaround time is eight hours. The report also is sent to a central printing location where a hardcopy is printed and sent out in the mail."


To boost workflow, consulting companies provide a wide range of services for free-standing imaging centers, such as marketplace analysis, advice on equipment purchases and examination of departmental operations. Greeley X-ray Medical Group (GXG) in Greeley, Colo., hired AGI Healthcare Group located in San Ramon, Calif. "Before we started this project, the group did not have an administrator and really did not have the experience base to bring out a free-standing imaging center," notes Scott Beethe, practice administrator at GXG. AGI developed a proforma for the group, which was used as a model to springboard a multi-modality imaging center opening this spring. It will consolidate GXG's two smaller locations.

The building was purchased with a local orthopedic group that plans on building a surgery center. In addition to a RIS and NovaRAD Corp.'s NovaPACS, the center will house a 3-tesla MRI scanner, CT, nuclear medicine, ultrasound, x-ray, bone densitometry, fluoroscopy, and mammography.

"We felt that RIS and PACS were very vital to providing a service that includes short turnaround time of reports and the ability for doctors to see the reports online," says Beethe. "Our No. 1 thing that will differentiate us from the hospital is service and getting patients in quickly."

Providing high-speed web access for the referring physicians to review images remotely, GXG purchased web-viewing software through Dictaphone Corp. called Clinical Data exchange (CDx) that can be attached to the PACS. To ensure workflow in the digital environment, GXG has hired a manager of information technology services and hired an off-site IT consulting group.


MRI Center Inc. in Torrance, Calif., is a single-modality imaging center that images, on average, 27 patients daily. "Everything we do is same-day turnaround and that's due to integrating new technologies," says Brian Salmon, clinical director of the facility.

The center integrated MedWeb's image report and teleradiology system with MediDox Corp.'s MediDox for Radiology, a template-based voice dictation system. Together, the systems enhance report turnaround time and eliminate transcription expenses. "We are able to export images off the MedWeb into the MediDox so we can insert images onto reports and our report turnaround time is 12 hours within the exam being performed," explains Salmon. "Physicians can verify their own documents and our 45 to 50 referring physicians can log onto the system and look at the images as well as upload the reports."

While the systems have improved workflow, the final piece to the puzzle is excellent service. "One of the most important components of workflow is having a great team that works together," says Salmon. "That is going to be the basis of your workflow and decide patient throughout."

The Benefits of Improved Workflow

For the most part, people don't hear about imaging centers through the grapevine. Patients usually go to an imaging center that is referred by his or her physician. Thus, referring physicians are critically important to an imaging center's fiscal health. Imaging centers must reach out to their referring physician community and let them know about their services, modalities and when changes are made.

"By improving the operations at a facility, things run more efficiently and the desired outcome is improved patient and physician satisfaction," says Dave Frazee, president of Frazee Nuclear. "The happier the referring physician is, the greater the loyalty and the more persuasive that doctor becomes in encouraging patients to use a specific facility."

Over the years, Frazee says he has learned that referring physicians generally want three things to occur when referring a patient: the patient has a pleasant, stress free and professional experience; the exam is scheduled easily and performed in a timely manner; and the results are accurate, definitive and communicated expediently.

Patricia Riskind, CEO of 3d Health Inc., says that if the diagnostic imaging center has a strong relationship with their referring physicians, they may want to create a little brochure about their facility that sits in the waiting room of the doctor's office.

Riskind also was involved in 3d Stat, 3d Health's patient satisfaction survey that involved four imaging centers in the Chicago area. Over three months, the group collected data from approximately 500 patients. According to Riskind, some of the highlights include: patients choose imaging centers themselves; their decisions are influenced by location, technology and reputation; once a patient has had an imaging procedure, satisfaction is determined primarily by "consumer" issues; and a significant number of patients have repeat imaging procedures in a given year.

Does advertising play a role in the selection of healthcare facilities? Solucient LLC conducted a 2003 Health View Plus survey (see chart) on patients who had an imaging procedure performed in the past 12 months - 58 percent said they heard about the healthcare facility on television, 51 percent read an advertisement in

a magazine and 9 percent heard about the facility on the internet. While the internet may not be the best advertising medium, it is important in the age of computers to have a web site for patients to browse and learn more about the facility and services.


Fueling Better Workflow

The Level Scheduling Tool, developed by the access group at Massachusetts General Hospitals (MGH), informs operation managers and directors daily what the target goal is for patient volume per modality at the main campus (Brigham & Women's Hospital) and MGH's two free-standing imaging centers in Chelsea and Waltham. Shown below are daily targets for CT at the three sites based on 365 days.


Managing Patient Volume

Establishing two local free-standing imaging centers in Chelsea and Waltham, Boston‚s Massachusetts General Hospital (MGH) pushed its outpatient image volume to off-site clinics and focus more on inpatient exams at the main campus. The imaging centers have eliminated radiology as a bottleneck for the hospital. Positive results include improved patient turnaround and increased outpatient capacity.

With the onset of the diagnostic imaging centers, MGH took its integrated performance management (IPM) system (that looks at specific clinical, financial and operational benchmarks and how they relate to each other) a step further and created the access group (TAG) to figure out a way to manage and influence patient flow from the time of scheduling based on availability and where [facilities] were in respect to their volume targets. The group created a scheduling report called the Level Scheduling Tool [see above] that is sent out every day in an email from the scheduling department to all operation managers and directors.

"In terms of financials, we look at variable unit costs, such as cost per exam and cost per relative value unit as well as revenue," explains Ron Doncaster, director of MGH's off campus imaging group and senior manager of the Radiology Consulting Group. "We monitor volume and measurement milestones so that we can manage the trip through our system right to the final report. Some of these milestones are time of scheduling, time of arrival, exam begin, exam complete, patient depart, preliminary report and final report."