As one of the nation's largest private practice radiology organizations, Southwest Diagnostic Imaging (SDI) provides comprehensive diagnostic imaging services to the entire Phoenix metropolitan area. Comprised of three radiology practices – Valley Radiologists, Scottsdale Medical Imaging, and EVDI Medical Imaging – SDI annually interprets more than 2.6 million exams across 35 full-service imaging centers and 12 regional hospitals, including Banner Health, HonorHealth and IASIS Healthcare.
Like many evolving healthcare institutions, SDI struggled to reconcile and exchange patient data and imaging files from multiple systems and locations. For years, radiologists spent much of their day writing addendums into patient records, because information at the point of care was missing or incomplete. At times, radiologists could not access patient studies from hospitals just 150 yards away.
To give their providers a consolidated view of any given individual, and enable greater clinical and operational efficiency, SDI’s leaders partnered with the Monrovia, Calif.-based NextGate, implementing the company’s enterprise master patient index capability to achieve real-time, cross-platform patient identification. The EMPI allows for seamless health information exchange and a longitudinal view of a patient’s medical and imaging history.
Moving ahead with this initiative has led to a number of advances. Among them, SDI leaders have been able to streamline physician workflow and productivity; automate real-time patient matching and duplicate record detection and resolution, thereby reducing the administrative waste involved in having to pursue manual patient lookup and identification; improve practicing radiologists’ confidence in data quality and accuracy. The organization’s leaders estimate that they have averted over 100,000 patient-record duplications since implementation of the solution. Indeed, they report, in the process of implementing the solution they found one individual who was associated with 50 different patient records, with 50 separate account numbers.
Recently, two of SDI’s leaders, Travis Haskins and Brian Frohna, M.D., spoke with Healthcare Informatics Editor-in-Chief Mark Hagland. Haskins is the organization’s CIO, and has been with the organization since 2000, while Dr. Frohna has been a practicing radiologist for 24 years, and is the group’s chief technology officer. Below are excerpts from that interview.
Please share with us a sense of the scope of the challenges you faced, and of this initiative.
Travis Hoskins: We have about 4.5 million patient lives we’re managing in our system, and the streamlining of managing patient demographic and other related patient information, saves us time, as opposed to having six or seven disparate systems to independently manage. As we continue to build the system out, a process that used to involving merging five or six different systems’ information to merge into a patient, has become just one system to merge.
When did you begin this initiative?
Travis Haskins: A little over three years ago, we identified that our systems were aging; this was part of a much broader system overhaul for most of our applications. So we embarked on better managing patient lives, implementing a better RIS [radiology information system] system, which went live just a few weeks ago, and on automating systems that used to be handled manually by individuals. There’s a lot of ingestion of outside forms and images; we’ve bene working on automatic order generation. We’re working on the ability to automatically receive a patient into the system and link an order to a RIS; these are all processes that used to be done manually.
What kind of governance process have you established around this multi-pronged initiative?
Brian Frohna, M.D.: A couple of years ago, three organizations got together to form this umbrella organization, SDI, for several reasons, one of which was to streamline and unify processes under one umbrella organization, even as the two physician practices remained operationally separate. Eventually, we brought a third and a fourth organization in, and we realized we had patients who had interacted with each organization separately, sometimes with demographics that matched, such as the same name, address and phone number, and those records were relatively easy to match; but we also found that there was a large number of patients whose demographics didn’t match identically, so that’s what required manual processes to de-duplicate. So, bringing in [vendor] helped make that easier. On top of that, our organization, Southwest Diagnostic Imaging, does billing for the hospitals as well. We have a number of contracts with hospitals here in the valley.
And we needed to get the patient a common medical record number, the EMPI number, so that everyone could be aware of them across inpatient and outpatient, all the transitions of care. And creating this makes that process more efficient, and also makes us aware of prior outside studies. And as most radiologists know, having awareness of a prior chest x-ray or CT scan makes us that much smarter.
Do you know the volume of petabytes of data stored in your systems?
Haskins: Currently, we have approximately 500 terabytes of data.
You’re talking about 4.5 million patients across the valley, correct, and stored in a unified database, then?
Frohna: Just to make it clear, the radiology market and practice are still a very, very fragmented entity. Even within our current practice model, we have four different PACS [picture archiving and communications systems] systems that we need to be aware of; we internally control three of those four, and the hospitals control their own. And we’ve just transitioned to a common RIS among two of the three entities, while the third still controls its own. So we’re still dealing with different imaging informatics systems, to some extent. But as long as you have multiple, independent information systems that need to talk with each other and cooperate with each other, you’re going to need a product like this, as you expand.
Looking at the Phoenix metro area, there are organizations with any of the widely available commercial PACS systems. And the reality is that you’ve just got to accept that you’re not going to bring all those disparate systems into a single vendor environment overnight, or possibly even over the next five to 10 years. Everyone will make their own judgments on what the best information systems are on a cost/value basis. And people may be six years into a 10-year contract with a vendor. There are any number of reasons why the environment is as heterogeneous as it is, and that’s not going to change overnight. So at a base level, you want to make all systems aware of all other systems. And that’s what the NextGate solution does, it allows the various PACS and RIS systems to function in a more integrated fashion.
Speaking as a practicing radiologist, you and your colleagues are finding yourselves compelled towards being more efficient than ever, correct?
Frohna: There’s no question that that’s the case. We’re following trendlines in inpatient and outpatient volume, and trends in payment. And we’ve anywhere from single-digit to double-digit volume increases year over year, for over a decade. And we’ve been able to actually manage that increase in volume with relatively small increases in radiologist hiring. So we’ve seen our radiologists’ productivity increase tremendously. Ten years ago, it was at 70 RVUs per shift on a 9-hour shift, while currently, it’s in the low 90s—a 20-plus percent increase. I myself am in the 140s per day.
The key to achieving that productivity increase has been multifactorial. It includes everything from having templates being populated as much as possible in your dictation solution. So out of the 20-some partners in my practice, apart from two radiologists I know of, everyone uses pre-populated templates. And for me, if I’m looking at a normal chest x-ray, in the PACS, I have to do nothing more than hit the ‘sign’ button, to sign it.
So the big thing is not only pre-populating templates, but also creating payment protocols inside your system. And in the past few years, we’ve been inundated with requests for addenda—say for a late import of a study we should have known about, but that the doctors weren’t aware of—that kind of thing. And with this vendor solution, we’re now becoming aware of prior studies done at our affiliate organizations that we weren’t aware of previously, so we cut down on the number of addendums. And so from a radiologist workflow, we’ve noticed a real win with [vendor]. From an everyday perspective, getting rid of the addendums is huge.
Mr. Haskins, what are the key operational imperatives from your standpoint as CIO?
Haskins: For me, it’s been advancing the technology in the organization. We can’t get better, using tools that are 15 years old. And what we look for in new tools is the ability to customize systems, and systems that have APIs. And we’re able to automate processes that historically, radiology has thrown human capital at. We have several file rooms full of files, ingesting and distributing information. And with the system we’ve put in place, we’re looking at automating those processes. As Dr. Frohna mentioned, it’s about getting the right information to the practicing radiologist, the first time, as they’re in their workflow. By doing that, you’re improving patient care. And most of our results are provided the same day.
How will all this evolve forward in the next couple of years?
Haskins: I think for the next couple of years—we’ve laid a lot of foundations—our next steps are to build a lot of applications on top of those foundations, that will improve patient care and patient lives, things like patient portals, things, like that.
Frohna: One of the things we’ve put into play through Travis’s team is putting into place a patient portal that allows patients to schedule their visits, as opposed to going through a scheduler at a physician’s office, especially for routine events. And having a solution that recognizes a patient as a new patient to our system, or recognizes a patient who’s already been seen at one of our internal or affiliate organizations, and being able to put that information in there, that to me is the Holy Grail—having systems in place from the point of scheduling to the point of care. And that needs to happen regardless of whether we merge all of our RIS systems or all of our PACS systems or not, because there will always be patients coming in here from Tucson or Albuquerque or Las Vegas.
Are you optimistic in terms of getting beyond the hamster-wheel phase of improving efficiency?
Frohna: Yes, I’m really optimistic. I’ve been a big proponent of radiologist efficiency and how to make us work smarter. When you work smarter, you can work faster. A lot of people think working faster means reading ten studies when I used to read five. But you should consider instead, doing things differently. Yes, once everybody is maximally efficient and has their workflow maximally optimized, then you can talk about the hamster wheel. But in my opinion, we’re nowhere near to optimizing workflow, reducing the number of clicks, of drag-and-drops, and so on. And I say, OK, in your workflow, I can help you eliminate 10 clicks per study, right here and right now, and if you’re going to read 100 studies, that’s 1,000 clicks I can help you eliminate. Most people don’t realize how minor efficiencies in each study result in major inefficiencies overall. It’s not about running faster on the hamster wheel. How about if we read each study more efficiently, without adding to our workday?
How many diagnostic imaging studies are performed every year in the organization altogether?
Haskins: Our inpatient numbers are nearly 900,000 outpatient exams that we create and perform and another 1.4 million for local hospitals, per year.
Is there anything you’d like to add to this?
Frohna: Just that partnering with this vendor has been an important building block for practices that are undergoing regional consolidation with otherwise-unconnected entities. And it’s really important to be made aware in the moment of previous studies. When we’re talking about the turnaround on reports—our average has been between 2 and 4 hours—when you can eliminate addendums, that helps tremendously.
Haskins: Radiology is a technology-driven specialty. And our organization embraces technology, and the doctors are highly supportive of our IT department. Across the U.S. healthcare system, many physicians look upon IT as a necessary evil, rather than something that can change clinical practice for the better. And when I came here, we had operational leaders who had a desire to do online patient scheduling. So we developed a real-time online patient scheduling portal, which actually allows them to pick their times.
That’s something that primary care groups have done for years, but it’s much harder to achieve in radiology. And that’s also where this vendor solution comes into play. And our leadership supported this; being that type of organization that takes the risk, and is willing to invest in technology, drives a lot of our success. And our implementation has allowed us to improve our processes, and help them improve things for their next customer. This organization has always supported information technology; and that’s always been a part of our success.
