Winthrop University Hospital houses a collaborative cardiovascular imaging program that employs financial incentives to encourage cooperation between radiologists and cardiologists. Here, Orlando Ortiz, MD, MBA (left), is the chairman of radiology and Kevin Marzo, MD (right) is the chairman of cardiology, review patient images together.

Conventional wisdom (and experience) tells us that radiologists and cardiologists don't like to play in the same sandbox. The relationship between the specialties has long been characterized by turf wars, competition and political wrangling. Yet, a new collaborative model is beginning to emerge across the radiology/cardiology spectrum—cardiovascular imaging, vascular medicine and cardiac cath labs. Indeed, external factors, including healthcare reform, reimbursement cuts and increasing health imaging scrutiny, may accelerate the development of partnerships and blur traditional boundaries between specialties and departments.

The benefits of collaboration are indisputable, according to the handful of brave pioneers who have developed strong collaborative programs. "Having a collaborative approach is more likely to lead to better outcomes, more appropriate utilization and streamlined testing—so that multiple tests are avoided when a single test can provide the answer," offers Peter L. Zwerner, MD, co-director of the Medical University of South Carolina Chest Pain Center in Charleston. The cumulative advantages include less radiation, less expense and less risk. Barry Katzen, MD, medical director of Baptist Cardiac & Vascular Institute in Miami, agrees, noting, "We're able to produce much more cost-efficient, high quality care."

At Brigham and Women's Hospital in Boston, the Carl J. and Ruth Shapiro Cardiovascular Center houses all non-invasive cardiovascular imaging technology and expertise in one location and under one organizational aegis. Its director, Marcelo F. Di Carli, MD, hopes to provide more definitive answers about the value of collaboration with a recently designed clinical trial that compares downstream testing and costs for the collaborative and traditional cardiovascular imaging models.

Collaboration advocates refer to the federal tea leaves as an indicator of what's around the corner. Discussing accountable care organizations (ACOs), vertical integration, patient-centered medical home and global capitation, Zwerner notes, "These are all buzzwords for 'play well in the sandbox or else.' We need to figure this out, or it will get legislated."

Collaboration, however, is much easier said than done. Few organizations have met with success, partially because the approach represents a monumental shift in practice models and requires physicians to shed their egos and share the wealth.

The writing on the wall

Baptist Cardiac & Vascular Institute formed in 1987 with a few fundamental principles. "We treat the circulatory system as a single organ—the pump and the pipes. This principle is integrated in care delivery and how physicians work together," explains Katzen. The institute's founders aimed to minimize turf battles and prove that a collaborative approach could benefit everyone across the enterprise. "Hidden in that statement is the fact that everyone does not always win equally," confides Katzen.

The MultiSpecialty Occupational Health Group (MSOHG) represents a more recent exemplar of multidisciplinary collaboration. Formed in 2005, the committee is comprised of physicians representing all major cardiac, radiologic and electrophysiological societies and aims to optimize the interventional laboratory. "Ultimately, the distinction between interventional radiology and interventional cardiology will disappear," predicts Lloyd W. Klein MD, professor of medicine at Rush Medical College and director of Clinical Cardiology Associates, both in Chicago.

Klein envisions the development of a vascular medicine team, with current approaches to peripheral vascular disease and carotid stenting performed by neuroradiologists serving as leading indicators of the new model.

Teamwork is at the heart of collaboration. Di Carli refers to the Brigham's cardiovascular imaging program as the imaging specialist-guided, patient-centric approach. "The new vision starts with the patient and the clinical questions presented by the referring physician. We take it from there and determine the best testing pathway, irrespective of how finances flow," he explains.   

Take for example the 58-year-old male who reports to the ER with atypical angina and some risk factors. In the conventional model, he's referred for treadmill testing. If the result is non-diagnostic, the patient returns to the ER for plan B, which may be release home or an imaging study. In contrast, Di Carli's team focuses on the best and most effective approach for arriving at a definitive diagnosis, which can help expedite a safe and efficient management decision. "It isn't necessarily more expensive [partly because an accurate and fast answer helps guide the correct patient management strategy], while often reducing length of stay in the ER and downstream costs from further testing or ER visits."

Di Carli believes that employing the imaging specialist as a consultant upfront can stymie the conventional convoluted diagnostic process, in which an initial inappropriate test produces nondiagnostic information that leads to additional testing or misdiagnosis that isn't discovered until catheterization confirms normal coronary arteries. "Cardiovascular imaging is still very much an art that requires an understanding of the clinical question and the strengths and limits of imaging technology and the ability to pick freely from modalities without bias," he asserts.

The model benefits both patients and hospitals. Winthrop University Hospital in Mineola, N.Y., formalized a collaborative comprehensive cardiovascular imaging program two years ago. "Before this, patients were travelling to different institutions for cardiac CT and MRI. Studies weren't directly accessible to our cardiologists," recalls Orlando Ortiz, MD, MBA, chairman of radiology. Now, cardiologists and radiologists work together to obtain the highest quality study based on the patient's history and presentation.

Self interest is likely to drive collaboration. "There's power in a common enemy. And the common enemy is the new healthcare horizon. Integrated delivery systems and regulatory changes will demand cooperation that doesn't currently exist. People who understand that and get ahead of it will be in a much better place than those who scramble or lobby for their own individual needs," predicts Zwerner.

Getting from A to B (or Z)

There's no pro forma for a successful transition to collaborative medicine. The process may be more akin to marriage counseling or international diplomacy than traditional healthcare project management.

"The will has to come before the way," asserts Zwerner, who identifies mutual respect and acknowledgement of each specialty's unique skills as essential prerequisites. Radiologists who require a quick refresher should remember that cardiologists bring knowledge of cardiac anatomy and physiology and a clinical perspective and semantic to the table, and they control which imaging modalities are utilized. On the flip side, radiologists are adept with imaging physics and technology, they are well-acquainted with image acquisition and tomographic viewing, and they provide broader knowledge of non-cardiac structures.

Di Carli points out, "Cardiovascular imaging is a subspecialized field. Radiology or cardiology training is the starting point. Subspecialty training in cardiovascular imaging is necessary regardless of background." Brigham and Women's Hospital and Winthrop University Hospital accept radiologists and cardiologists into their cardiovascular imaging educational programs, setting the stage for a multidisciplinary future.

Even old dogs (or doctors), however, can learn new tricks like collaboration. Katzen recalls the advent of coronary CT angiography. The practice's radiologists recognized that it would be a disruptive technology. Rather than trying to control access, they developed training programs for cardiologists. Ultimately, it turned out that the volume did not justify cardiologists' participation, but by engaging them, radiologists may have circumvented a turf war.

In some cases, physicians subjugate their individual interests for the better of the practice. At Baptist Cardiac & Vascular Institute, interventional radiologists and vascular surgeons, but not cardiologists, are involved in peripheral interventional procedures. "Because the peripheral intervention program is a center of excellence, we demand that the people who do those procedures do them full time," shares Katzen. The approach may be less collaborative than ideal, but it allows the practice to be a leader in the area.

Indeed, credentialing strikes at the heart of collaboration. Zwerner advocates for basing procedures on competencies and credentialing. "Develop minimal capabilities. Then the whole issue of whether you are a radiologist or cardiologist starts melting."

When Winthrop University Hospital recruited an advanced cardiac imaging subspecialist into its cardiology department two years ago, he was credentialed in both radiology and cardiology, which helps establish fertile soil for cross-pollination such as multidisciplinary grand rounds attended by physicians from both disciplines. Equally important, the cardiologist is financially credentialed with the radiology billing company, so he can bill for imaging studies, explains Ortiz.

Brigham and Women's Hospital's approach is to recruit imaging specialists with dual appointments in cardiology and radiology, thereby eliminating concerns about balancing revenue between departments, says Di Carli.  

The philosophy is playing out in organizations across the country. At Edward Heart Hospital, in Naperville, Ill., interventional radiologists, cardiologists and surgeons jointly developed procedures and credentialing criteria for interventional suites. Physicians who meet the criteria can perform in the suite, regardless of specialty, explains Yvette Saba, administrative director, cardiovascular, emergency and women & children's services. The process primarily relates to peripheral vascular procedures.  The hospital is embracing the challenge head-on to avert future battles. "We are going to put together a quality committee that will include radiologists, cardiologists and surgeons to review cases and set up quality indicators," explains Saba.

Baptist Cardiac & Vascular Institute employs a quantitative standard to its centers of excellence, which may limit physicians' options. For example, if the institution performs 50 carotid stent procedures a year and credentialing requires a minimum of 25 procedures, only two physicians can perform the procedure. One alternative that may seem more palatable to physicians' wallets, five physicians who perform 10 procedures annually, is more akin to a center of adequacy, opines Katzen. "There are hard decisions," he admits.

Following the dollars

Collaborative practice blurs the distinctions between specialties. In the ideal scenario, says Klein, the patient is referred to a program not a physician.  The current fee-for-service (FFS) structure represents a hefty obstacle because more cases mean more dollars in the individual physician's pocket.

However, the current economic woes afflicting cardiology practices could bode well for collaboration between radiologists and cardiologists. As cardiologists seek haven in hospital employment, savvy administrators can forge new models because competition between specialists is clearly not in the hospital's best interests. "When the hospital is globally capitated, it does not benefit the hospital when each specialty is incentivized to do more," explains Zwerner. Hospitals that can reduce unnecessary testing can save millions.

According to Klein, the opportunity to coordinate and collaborate is higher when warring factions are sheltered beneath the hospital umbrella because the hospital can create an economic model in which physicians benefit from cooperative efforts that enhance quality and utilization and focus on streamlined care rather than maximum utilization or procedures. Di Carli admits that traditional metrics for success—volume and RVUs—remain important in collaborative programs, but stresses that hospital administration view the metrics comprehensively rather than in departmental silos.

Visionary administration, in fact, is key to success. According to Kevin Marzo, MD, chairman of cardiology at Winthrop University Hospital, the hospital encourages collaboration by eliminating financial competition for dollars. The hospital has forged alliances with multiple cardiology groups and created financial incentives for different disciplines that make it in their best interest to cooperate, explains Marzo.

The inverse is true as well. Klein cautions that it's possible to replicate the downsides of the FFS structure in the employment model if compensation rewards volume and competition.

As the transition to collaborative models moves beyond the will and into the way, an attorney is in order. Multiple, workable models—including equity sharing and block leasing—exist. "This is where the rubber hits the road. Physicians need very transparent policies about who reads what part of the study, who's responsible when and how equipment and staff are supervised," notes Zwerner.

An infrastructure evolution?

Existing infrastructure is designed for siloed care, with specialists segregated by department. The setup doesn't encourage communication or collaboration.

At Winthrop University Hospital, the radiology and cardiology departments are adjacent. "We're talking to each other all of the time. It makes for a healthy relationship," offers Marzo.

Baptist Cardiac & Vascular Institute took anti-segregation a step farther and employed architecture to express philosophy. Its invasive rooms are located in a central "gallery" with alternating vascular and cardiac rooms. "It forces physicians to work side by side. If an interventional radiologist is doing a case and there's a cardiac problem, he can call for help. Because of this, we see better outcomes and fewer failures," asserts Katzen. He likens the practice's vascular environment to a fishbowl; glass walls separate various rooms, reinforcing the notions of transparency and interdisciplinary learning that are central to the collaborative model.  

"Geographic integration makes it all work much more easily," adds Di Carli. The center combines everything in one space; patients are greeted into a program; and imaging specialists and modalities are all co-mingled to bolster communication and collaboration. Nevertheless, function does not follow form. That is, a hospital cannot build a collaborative center and expect radiologists and cardiologists to come to it. They need to establish a program and then focus on the physical configuration.  

Successful collaborative programs between radiology and cardiology are few and far between, but the model is gaining steam, fueled primarily by healthcare reform. It isn't an easy transition; experienced collaborators agree that both the Middle East peace process and mud wrestling may be easier battles to wage. But ending the battles is necessary and promises to benefit patients, providers and the bottom line.