Peter Bak, PhD

Having discarded many of its content-based ventures, the Internet market is finally maturing, with real applications and business solutions that improve efficiency, reduce costs, and drive business. Radiology is no exception; in fact, those in the business of radiology must look to the Internet if they are to succeed. Practices are experiencing increasingly fierce competition not only from the radiology sector, but from specialists who are, themselves, investing in imaging technology. To secure future examination volume, practices need to invest in technology that makes life easier and adds value for the referring physicians that they serve. The World Wide Web, radiology information system (RIS) investments, and communications applications such as email, instant messaging, and paging all create a stronger radiologist-referring-physician relationship that constitutes a competitive edge.

Radiology talent shortages are forcing practices to invest in technology that helps them to maximize their personnel resources, but technology will become even more critically important as part of a practice’s recruiting strategy. Physicians emerging from residency will have experienced primarily soft-copy viewing, and they will be looking for career opportunities that offer this same convenience. To this generation, which places tremendous emphasis on lifestyle quality, ubiquitous World Wide Web access and teleradiology will become must-have items.

The Health Insurance Portability and Accountability Act (HIPAA) regulations will take effect at the end of 2002. These regulations will impose sweeping changes on the way that radiology does business. The rigor of claims submissions and related transactions will drive the use of electronic patient registration, online eligibility verification, and automatic coding solutions. Security and privacy requirements, such as controlling access to information and maintaining a transaction trail, will favor the use of electronic systems. The physical location of (and lack of governance over) interested parties will demand the use of web-based solutions for information distribution.

RIS and picture archiving and communications system (PACS) applications are key to solving the problems that radiology faces. With the growing emphasis on integrating radiology services with the referring physician and patient, however, these applications must reach beyond the confines of the radiology department itself. To this end, web technology and the Internet are integral to the future of radiology. Web technology addresses the challenges of radiology.

Front-Desk Operations

Front-desk operations in a radiology department or practice are very labor intensive and, therefore, inefficient and costly. Even though the facility may have a RIS or a practice management system, order entry and procedure scheduling are still often done by phone and fax. This method of operation is not very scalable; as volume increases, costs go up, response times decrease, and more opportunity is lost. This is also inefficient for the office personnel of referring practitioners. Ultimately, the patient is inconvenienced, and his or her perception of quality is undermined.

A compelling solution to this problem is to let front-desk personnel in physicians’ offices perform patient registration, order entry, and scheduling online. If done correctly, the process is undeniably more efficient and satisfying for everybody involved.

First, it is faster, easier, and more reliable. Rather than being relayed over the phone, patient information is typed into the radiology practice’s patient-registration system through a web-browser interface. By means of preconfigured fields, multiple-choice selections, mandatory entries, and similar measures, not only is the data-entry process simplified, but the quality of information is improved, leading to a reduction in lost billings. In addition, if the patient has already visited the radiology group, then the patient’s registration information is already in the database; the physician’s front-desk staff need only search for and retrieve the registration information.

Second, an online system is more patient centered. So often, an appointment needs to be scheduled directly with the facility where the procedure is to take place. This means that the patient’s possible appointment times are limited to the time slots available at a specific clinic or center (or that the staff must call multiple facilities in order to obtain the most convenient appointment time for the patient). By virtue of being online, however, the staff can submit an order and have the system automatically present a number of alternate time slots and locations. As with many reservation systems, the online scheduler can also let the user select the best times for the patient (specifying, for example, appointments after 6 pm or before 8 am). This gives the patient greater choice.

Third, online front-desk operations are associated with a greater probability of payment. Eligibility processing and authorization are vital to being paid. Today, solutions exist that are similar to credit-card authorization: appropriate order information is submitted to a service via Internet, and that service automatically confirms eligibility, determines copayment amounts, and provides authorization (if necessary). Clearly, this eliminates ineligible appointments. This also helps prevent patients who find the copayment too high from booking appointments for services that they will not actually use.

Fourth, online systems also reduce the number of patients who fail to keep their appointments for other reasons. No-show patients can be very costly. As a result, most radiology groups and imaging centers have implemented a procedure for making reminder phone calls to patients. In addition to confirmation of the appointment, office staff confirm information for billing and gather preparatory details. Many surveys and studies of Internet use in health care show that patients are becoming more receptive to electronic communication with their health care providers. Therefore, there will continue to be a shift in communication method from the telephone to the Internet. For example, the need for reminder calls can be reduced by encouraging patients to visit a portal site for procedure screening. The patient can complete and review all necessary screening forms and information online and can send a secure email to the radiology practice.

Given these advantages, there is no question that front-office operations will go online. This is already happening, and results show that the business of radiology is the better for it.

Results Distribution

In today’s environment, most radiology results are still paper based and film based. Reports are mailed and sent by fax; films are duplicated and sent by courier. This environment has many inefficiencies and costs that are negated by moving to electronic, Internet-based distribution. Specifically,

? information is available immediately,

? information is available to any number of interested parties simultaneously,

? interested parties can gain access to information at their own convenience, and

? film-duplication and courier costs are eliminated.

Practical experience has shown that Internet-based results distribution can easily save $100,000 per year. Not only is that the case, but users of such systems have also seen increased business through improved relations with the physicians that refer patients for the bulk of procedures and through an ability to emphasize subspecialty services that generate the highest revenues.

The business case for distributing results over the Internet is proven and extremely compelling. Nonetheless, the adoption rate of systems for web-based results distribution has been slow. The reason for this is that most systems are image centered and do not consider the work flow of the referring physician. As a rule of thumb, 80% of referring physicians are primarily interested in reports. Hence, the provision of sophisticated imaging tools just gets in their way. Another factor slowing adoption has been lack of awareness. Installing a system is easy, but spreading the word about it and training physicians to use it are far more difficult propositions.

A feature of electronic results distribution is the ability to track all user activity automatically. This allows the facility to monitor who gains access to which data, and when. Similarly, through access-control mechanisms, it is easy to limit those who have access to patient results to only the interested parties. Such access control and transaction logging contribute to HIPAA privacy and security compliance.

Over time, more and more practices will distribute results over the Internet. Not only does it make economic sense, but it is improving the quality of service and is a practical method of achieving HIPAA compliance. As this occurs, awareness will increase, referring physicians will start to drive demand, and another part of the business of radiology will go online.

Distributed Reading

Radiology practices and imaging centers are consolidating to achieve greater business strength. Similarly, hospitals are increasingly outsourcing their radiology services to clinics and centers. With this comes the need to move PACS beyond facility walls and to bring multiple sites into a single system through wide-area networks.

Geographic boundaries are dissolving, with groups providing coverage thousands of miles–even continents-away. Over the next few years, this trend will probably continue, as radiology groups pursue the creative application of technology driven by radiologist talent shortages and the need for their expertise in underserved areas.

The Internet presents an economical solution for integrating facilities and radiologists into a single virtual enterprise. When systems employ browser-based (or thin-client) viewing applications and diagnostic-quality data-compression techniques such as wavelet compression, it is absolutely practical for radiologists to read studies anywhere, on almost any computer. This ability, combined with distributed PACS architectures, is allowing virtual enterprises to become reality.


Consultation between radiologist and referring physician is phone based and is often inefficient. The responsiveness of a radiologist is often hampered when information relating to the patient in question is not immediately accessible. In addition, a radiologist’s day is consumed by a never-ending case load; this invariably results in a game of phone tag with physicians. Physician frustration is the unavoidable result. Becoming closer to (and more involved with) the referring physician is the key to providing better service and greater added value. The Internet and related tools offer an opportunity to streamline communications:

If the referring physician has email or has access to results online, instant-messaging technology allows the physician to send a message to the radiologist asking for clarification. This message appears on the radiologist’s workstation. The radiologist can then finish reading the case, collect the information pertaining to the physician’s message, and either call the physician or send a response.

If both parties are using thin-client viewing applications, then it is possible to include a link (or universal resource locator) to the specific patient’s results in the message. In this way, the radiologist avoids having to search for the results; he or she simply clicks on the link to gain access to the information. Similarly, the radiologist may further annotate the images and send back a link to the modified study.

Today’s messaging tools support multimedia content. Voice clips, snapshots of images or charts, and text can be included in the message. This offers the opportunity to personalize the interaction, as well as to enhance the quality of service.

White boarding involves a utility that allows users to interact with information simultaneously. If both parties are free at the same time, but are at different locations, then they can consult with each other while viewing the same data and seeing each other’s actions. For example, the radiologist may want to point out a small lesion. Through white boarding, the referring physician can see, on his or her screen, the annotation being made by the radiologist.

Communicating face to face adds much more to the consultation than phone conversations or electronic messages can. Using videoconferencing tools, the radiologist and physician can hold a conversation while looking at each other.

The Internet has promoted the proliferation of these communication tools and has, in addition, created a mobile society and the virtual work environment. In the same way, the Internet will drive better communication between radiologists and referring physicians, thereby improving the quality of care and the business of radiology.

?In conclusion, there is no question that the Internet will become an integral part of the business of radiology. For those that embrace it now, there will certainly be early-adopter trials and tribulations. Nonetheless, the old adage that the early bird gets the worm holds true: relationships will be forged, the quality of service will improve, patient satisfaction will increase, and facilities will gain more referrals, competitive strength, and greater leverage in renewing and securing contracts. The business of radiology will go online.

Peter Bak, PhD, is vice president, Product Development, eMed Technologies, Lexington, Mass.