Roundtable discussion: Driving clinical quality with operational efficiency, pt 1

Two mandates are driving U.S. healthcare policy: improving quality and reducing costs. At vRad, leadership has embraced these concepts and integrated them into its corporate mission, driven in part by the strong relationship between Chief Medical Officer Benjamin Strong, MD, and Chief Information Officer, Shannon Werb.

ImagingBiz spoke with both professionals recently to discuss how they collaborate to drive operational efficiency while ensuring high clinical quality in radiology. The interview was so fruitful that we will feature only the first half of it in this issue and the second in a subsequent issue of Medical Imaging Review.  Part I focuses on the efficiency side of the equation, and Part II will drill down into specific clinical quality initiatives.

Let’s start with the “e” word—“efficiency.” Why do physicians historically consider it such a dirty word?

Strong: There is no doubt they do—it’s based on a fairly reasonable assumption. When someone says ‘efficiency’, they usually mean hurrying a task, or doing it faster in any case. Most doctors correlate that sort of external pressure with doing a poor clinical job—less patient interaction and less time to consider the implications of test results or physical exam findings. It’s easy to understand the reaction since efficiency has been foisted not only on radiologists, but also on many other clinical specialties.

But what’s interesting is that with radiology that correlation falls apart. To us, efficiency means eliminating unnecessary non-clinical tasks our doctors would typically perform. By eliminating the non-essential time segments in the workflow, we enable our doctors to do what they do best—be radiologists and interpret diagnostic images. vRad does not shorten the actual time radiologists spend interpreting an image or thinking about it, actively. In fact, we allow them to make better use of that time: their ability to focus on the actual medical task at hand is greatly enhanced because we have eliminated distractions that are essentially non-medical.

When we apply efficiency rules, we eliminate mouse clicks, we eliminate the frustrations and delays associated with acquiring additional patient information or prior studies. We also eliminate unnecessary dictation of objective study information into a given report.

Shannon does efficiency carry baggage in IT?

Werb: Typically, technology personnel look at efficiency—or creating efficiency—in association with a reduction in workforce. Oftentimes, we focus on automating redundant tasks, as indicated clinically. We also can do that across various parts of the business, putting in technology where human beings are present or making the process—the workflow that people are leveraging—more efficient, which in the end can result in needing less people. 

We work really hard at keeping the technology personnel focused on the upside of what we are trying to create here. I believe efficiency drives better quality, as Ben indicated, by reducing the distractions of the physician, taking out the identification of the objective information that we can automatically pre-populate, so they are focused in the areas they should be—and maximizing the time their eyes are actually on the images they are interpreting.

Likewise, it’s enabled a business like ours to grow. We hired north of a hundred physicians last year. We would have had to bring on more of them if we were not focused on creating greater efficiency in the platform and driving better quality. We would have needed more physicians and more support personnel. 

So, if there is baggage associated with efficiency, it’s typically around reducing workforce; however, we have successfully grown the business, added physicians and made them more efficient. So for vRad, efficiency is less about reducing workforce and more about making our workforce more productive and valued clinically, thanks in part to technology.

Is there a contradiction here with improving both quality and efficiency, or is there a relationship between the two?

Strong: It’s more about the appropriate application of efficiencies. For example, when they dictate a report, most radiologists, have to say the name of the procedure, the anatomic region that was scanned, whether or not it had intravenous or oral or rectal contrast, whether there were reformats, reconstructions, what the prior study available for comparison is and what it stated.  All these are purely objective information, and hence unrelated to the clinical diagnosis a radiologist must make.  In other words, they are inherent in the study and do not require a radiologist to interpret.  As a radiologist, I know it feels like a Sisyphean endeavor to dictate this information over and over for every study.

So what has technology allowed us to do?  Shannon’s team has eliminated mouse clicks and dictation time by assembling all of the study information necessary, and auto-populating the reports.  That means we are not cutting into the actual amount of time that they are interpreting images. Instead, we are giving them a great deal of time back that they otherwise would have spent doing repetitive and non-clinical administrative tasks.

If you go at efficiency with that philosophy, the two are not contradictory. There can be an increase in quality along with an improvement in efficiency.

Werb: I absolutely agree, the two go hand-in-hand; they are not contradicting each other.

What about your relationship? What is your collaboration process, and how do you work together?

Strong: We have a standard professional relationship in that we have regular meetings throughout the week that involve software engineers, IT personnel, myself and my medical directors from the clinical side, so that we stay updated on the progress of various projects.

Beyond that, in this age of digital communication and the means we have to stay constantly in touch, we certainly go far beyond an 8-to-5 arrangement. The texting, the Skyping, the cell phone calls never really stop. In fact, we speak most weekends, and we have some of our most productive discussions on Shannon’s drives home after work.

Werb: We prioritize communication with each other because we are both tied toward the execution of a common vision. The only thing I would add is that a regular cadence is extremely important, the regular meetings that we have. 

Early on, when the two of us came together, we worked hard to make that meeting successful because initially it was not. Ben will probably recall some frustration with how that meeting was being managed and what he needed to drive the effort, the vision, forward.

We worked for a number of months on just creating relationships. It seems like such an easy and straightforward concept that you would have medical leadership (Ben and his team) and technology leadership (myself and my team) working together.  I think it's safe to say that in a lot of companies, the two groups often work in silos.   

We have worked hard to break down those walls at vRad by creating trust through ongoing collaboration. Developing a trustworthy relationship between technology leadership and clinical leadership is exceptionally important.

How did you align around what you wanted to get done? 

Strong: A reasonable person who has been engaged in this aspect of radiology practices for a long time—myself more than 10 years and Shannon more than 20—have the same basic understanding of what the ultimate goal is—integration, acquisition of patient information, efficiency in the radiologist workflow. These basic principles, when applied, cannot help but lead you to the same conclusion.

The fundamental shift that Shannon brought was the willingness to collaborate and discuss on an ongoing basis and to execute on plans in a structured corporate fashion, with the establishment of timelines, the assignment of responsibilities and the accountability for meeting goals.

Werb: I am a big believer in collaboration and working towards consensus, getting people involved, building teams, trying to break down walls, all of that. Accountability is key. The positive aspect of accountability for technology people is involvement: They want to be involved and collaborate; they want to share their ideas and feel like they are enabled to do so.  

I did walk through Ben’s door, initially, with a bit of trepidation. I had an opportunity to get to know Ben prior to arriving at vRad, so I realized I was working with a technically savvy radiologist. From the get-go, I appreciated that we could communicate in ways that allow us to be more efficient with discussions.

At the same time, he told me on that very first day, “When I have an unrealistic expectation, you need to tell me so.” That is probably the thing that’s hardest for people to do to the chief medical officer of the practice, because they feel like they are letting him down. Just creating that open communication and dialogue has been important to our success.

IT has played a vital role in driving radiologist efficiency today, and I have heard people say, “I think we’ve hit the wall, we can’t go any further.” What are your thoughts on that? Are there more gains to be made?

Werb: There definitely are more gains to be made, and it happens in a non-traditional approach to thinking about efficiency. Firstly, we typically think about efficiency, clinically, in the aggregate. Instead, we need to look at efficiency and quality tied together on an individual physician basis.

To that point, Ben and I are focused on looking at clinical quality and efficiency on an individual basis across our radiologist population. We’re using vRad’s embedded quality program to help us understand the relationship between the two from an individual perspective. 

When we make technology innovation available that we believe will drive efficiency and increase quality, we have begun to study which radiologists react and respond to it. Ben expected that radiologists who have some of the best quality and greatest efficiency would get the greatest benefit from the innovation. I actually expected the opposite, but proved Ben right through some of the latest data.

We need to start looking at it from an individual perspective and not from an industry or an aggregate perspective. You can’t just say all radiologists and all technology are created equal.

Likewise, I think you also have to recognize that the radiology industry, with regard to efficiency and quality, is changing. Teleradiology and the service we have historically provided in the middle of the night—as a preliminary interpretation service for the emergency room—now includes a 24x7 subspecialized final interpretation offering. We are now an integral part of the group that’s on site. 

Some of our radiologists work onsite and others virtually in order to create optimal staffing models for our hospital, referring physician partners and, most importantly, our patients. It is critical that the quality and availability of care be the same at 2AM as it is at 2PM.

The capability that vRad brings to the table drives a totally different equation around efficiency and quality on a 24x7 perspective. That’s really the future of where we are heading with radiology. It's reinventing the radiology service line, so teleradiology and on-site coverage are blurred to the point where you don’t even see the difference. That is what technology does for us—it enables us to create that workflow and that efficiency.

Strong: I would just add that I still see a lot of room for efficiency gains. Simple things such as eliminating a single mouse click, optimizing the radiologist workflow, these sorts of alterations can always be made.

There is always more to be wrung from the radiologist workflow, and no matter how small, it seems we find enormous benefits. Not only does it reduce frustrations—fewer pops-ups and warnings and fewer incomplete cases and more streamlined communications—it also contributes to the radiologist’s overall morale and mood.  

On top of that, if you save one or two seconds per case, it's a seemingly insignificant thing.  But you have to understand that we have 350 radiologists reading on average probably 14,000 studies a day, and if you start adding up the seconds from each eliminated unnecessary step, it increases our interpretive capacity by a large percentage. In this simple example, we could save eight hours over the course of just one day.

Editor’s Note: Part II of this interview focuses on quality improvement activities and specific quality initiatives and will be featured in the next issue of Medical Imaging Review.