Practices invest in billing and scheduling software to improve accuracy and workflow

From the moment a patient schedules an appointment to the time the practice bills for the examination, radiology practices depend on tried and true workflow systems to successfully complete the process. Setting up a workflow that routes the right information to the correct party can take weeks of trial and error, so it’s no wonder that once an imaging center settles into a routine, staff are often reluctant to reevaluate their processes.

However, a number of factors make this reevaluation more attractive to radiologists. In the wake of the cuts from the Deficit Reduction Act of 2005 (DRA), most practices are seeking ways to streamline workflow without sacrificing quality services. At the same time, practice management software—which originally emerged as one-size-fits-all solutions—is evolving to address the needs of individual specialties. With the ability to integrate scheduling and billing software specifically tailored to radiology, practices are finding that this technology not only streamlines workflow but also increases accuracy, cash flow, and patient satisfaction.

Streamlining Systems

Since purchasing integrated scheduling and billing software from CPU Medical Management Systems, San Diego, in 2002, Fred Vernacchia, MD, medical director at San Luis Diagnostic Center, San Luis Obispo, Calif, said that the practice has cut its accounts receivable days in half to 30 days. He attributed this to electronic billing as well as to a dramatic increase in accuracy that comes from an integrated system. “You don’t end up doing an MR of the shoulder with contrast and billing it as an MR of the shoulder without contrast,” he said, “because what gets scheduled through the system is what gets billed.”

Reducing errors is directly tied to eliminating manual data entry wherever possible. “You put the information in once, and it gets populated throughout the system,” said Rae-Lynn Bidon, accounts receivable manager at Medical Imaging Northwest, Seattle, which uses an integrated scheduling and billing system from Sage Software, Pensacola, Fla. “Everyone can access the same information. If they’re in the RIS, the billing system, or the scheduling system, they might be looking at different modules of the software, but they’re all looking at the same information.”

When the system was implemented in 2004, one of the goals for Medical Imaging Northwest was to achieve centralized billing and scheduling so that all of its locations could store their information in one place. “When we opened up additional imaging centers, the workflow stayed the same,” Bidon said. This ensured uniform processes, which makes going from one imaging center to another very easy for patients and radiologists.

An unanticipated benefit of transitioning to this software system was increased positive feedback from patients. “Because of flow tracking, the patients no longer get lost in the dressing rooms because we didn’t know that we’d already checked them in,” Bidon noted. “They don’t sit out in the lobby waiting because we didn’t realize they were there. We track our customer service responses, and they’re much more positive now.”

Because software programs keep track of who enters the data, mechanisms are in place to trace mistakes back to their source and correct them immediately. Dakota Radiology, Rapid City, SD—which uses the billing system from Imagine Software, Charlotte, NC—gives its 13 radiologists monthly feedback detailing how many of that month’s reports were not able to be coded immediately upon receipt and why. “It used to total in the hundreds each month, and in the past 12 months, it’s been less than 30 reports per month,” said Tom Kushman, practice administrator at Dakota Radiology. “The system enables us to give real-time feedback to people so that they can improve the process.”

Improved accuracy also means that the systems can handle a greater influx of data without practices having to hire more staff. In the past 5 years, San Luis Diagnostic has increased the average number of studies performed per month from 1,450 to 3,200—and added only one full-time collector. “We’re still getting all of the day’s bills done with only one biller,” Vernacchia said.

Adding new staff positions is very costly, and when Dean Doucette became business manager for Catawba Radiological Associates, Hickory, NC, in 2002, he sought alternative solutions to meet the demands of the growing practice. “I realized that with our volumes increasing, the answer was to add more staff, which to me was not an answer,” he said. “So, I wanted to see if technology could settle the problem.”

After researching several software options, Doucette chose Imagine Software, which was developed specifically for a radiology practice in nearby Charlotte. Doucette was particularly impressed with the easy retrieval of records as well as the report-generating capabilities, which offered him instantaneous feedback on any aspect of the practice. Almost immediately, Catawba Radiological saw a 20% jump in monthly cash flow. “Our efficiency just went through the roof without having to add staff,” he said. “We added more physicians, but we have not added staff.”

Currently, radiology practices can pick and choose which types of software to implement. Some, like Catawba Radiological, might incorporate a vendor’s proprietary billing system but skip the same vendor’s scheduling system. Ultimately, however, all practices investing in software are moving toward the same goal—one centralized, fully integrated system with RIS/PACS as well.

Negotiating Workflow

When integrating billing and scheduling software, the entire practice team needs to agree to a new standardized workflow. Because these systems are centralized, everyone needs to follow the same procedures, and this can take some adjustment. Most vendors offer on-site training for weeks at a time to help staff get up to speed, but practices also must be proactive about continuously fine-tuning the workflow.

Practices that are researching software options should look into at least five different vendors. Once they narrow the field to two or three, they should attend as many on-site demos as possible to get a feel for how other practices have structured their workflow, what they like, and what they don’t like. Consider the goals for your practice, your staff’s training needs, and how the vendor will support the product.

When it comes to standardizing workflow, Bidon recommended observing as many on-site clients as possible as well as getting the vendor’s input about how to best use the software and what changes to your current process will be needed. Then, staff members must set goals and negotiate new standards.

“One of the things that’s hard for people to realize is that when you change the way you do something, it directly impacts others,” she said. “So, that was a learning curve for us. We no longer had total control over managing our departments the way we wanted; we had to think about other departments as well.”

This led to compromises between departments so that the practice could meet its ultimate goals. For example, to ensure that examinations were billed on the same day that they were performed, radiologic technologists had to scan in patient information like MR worksheets immediately, rather than scanning them in at their convenience sometimes days after the examination was performed. “Even though it was a little harder on their workflow, the techs actually had to scan the information at the time of service,” Bidon said. “We’re billing our exams the same day, where before, we were 7 days out.” The result is increased cash flow for the practice, reduced accounts receivable days, and more accurate billing.

Making significant changes like this can be difficult for staff members, and it is important for practices to offer them as much support, feedback, and team-building opportunities as possible. When Dakota Radiology decided that all examinations had to be coded and billed by the end of the following business day, the staff needed to be taught how to make this happen. “They had to believe that they could get everything off of their desk by the end of the day,” Kushman said. “And we had to give them the tools to enable them to do that and give them real-time feedback on how improvements could be made.” This meant showing staff members how to best use the software, and how deviating from the process could negatively affect other departments down the line.

Looking Ahead

Practice management software for radiology is still evolving, and those who are using the systems already look forward to seeing better integration with their processes. For example, Vernacchia hopes to see vendors continue to improve report-generation capabilities, and he is particularly interested in software updates that address regulatory changes in radiology. “Mammography tracking needs to be kept current with the requirements placed on us as radiologists from the regulatory agencies,” he said. “It will allow you to perform internal audits on your performance and help you provide information for the pay-for-performance initiative by Medicare/Medicaid.”

Radiology practices also look forward to the possibility of making patient records available over the Web to both referring physicians and patients, who could eventually schedule appointments and make payments online. This also will serve to closely integrate the health care system and, ultimately, provide patients with better interdisciplinary treatment.

Radiologists who wait too long to consider this technology could find themselves on the outside of this circle. “I think the primary care providers are going to have to jump on board with the oncologists, with the OB/GYNs, with the radiologists—we’re all going to have to be one team,” Bidon said. “I don’t think we’re going to have a choice. If you’re not willing to be part of that team, you’re not going to be able to get access to the information you need to build your practice.”

Ann H. Carlson is a contributing writer for  Axis Imaging News. For more information, contact .

CPOE: What’s the Holdup?

Computerized physician order entry streamlines radiology processes, but only a few hospitals have made the leap

For nearly two decades, the health care community has touted computerized physician order entry (CPOE) as a revolutionary technology to improve the quality of patient care. For example, Montefiore Medical Center, Bronx, NY, has reduced the prescribing error rate by more than 75%, according to Dorrie Napoleone, director of information systems. But a recent study revealed that only 5% of hospitals have implemented these systems.1 The slow spread of this technology can be chalked up to a number of factors—but probably the biggest barrier to entry is that implementation has not been standardized, and each hospital has to devise its own procedures.

“There’s a lot of design that has to be done so that you properly automate this electronic workflow, and from hospital to hospital, that workflow is different,” Napoleone said. “It’s not one size fits all.”

CPOE helps hospitals reduce errors, redundancies, and missing information by requiring physicians to fill out specific fields before the order can be submitted. The systems also feature alerts and reminders, which can point out a patient’s allergy to a medication, for example. Radiology departments have particularly benefited from these systems, as they greatly reduce the need to track down missing information.

Win-Win for Radiology

Most radiology departments operate their own software systems, such as RIS and PACS. For them, integrating with CPOE is not the huge chore it is for hospitals, as it serves to streamline and complement the current workflow rather than to entirely revamp it.

“The clinicians don’t have to keep track of paper requisitions,” said Julie Frissora, manager in information systems at Thomas Jefferson University Hospital (TJUH), Philadelphia.

Evidence shows that not integrating CPOE with RIS leads to increased reporting errors, including listing the wrong ordering physician or even the wrong type of examination. “When you don’t link the two systems, then someone has to manually transcribe from CPOE into RIS, and this can introduce all sorts of manual transcription errors,” said Michael E. Matheny, MD, whose team presented its research in this area at RSNA 2005. Matheny is now a postgraduate fellow in medical informatics and an instructor in internal medicine at Brigham Internal Medicine Associates, Boston.

Andy Steele, MD, director of medical informatics at Denver Health, which began to integrate CPOE 7 years ago, also has seen a huge improvement in the accuracy and completeness of radiology orders—50% of which used to require follow-up to retrieve missing information. “Most often, the missing information was the appropriate ordering physician,” he said. “Once you go to CPOE, that’s 100% gone because the ordering physician is whoever logged on.”

At TJUH, the response to electronic radiology orders was so favorable that the ordering physician requested it be rolled out for the entire facility in advance of the scheduled general rollout for CPOE. “In the paper world, the ordering physician could simply write ‘CXR’ for a chest x-ray,” Frissora said. “The computer system can require the ordering physician to enter other pertinent information required by radiology, such as the indications, signs, and symptoms for the study. This resulted in significantly fewer phone calls back and forth seeking clarification between the radiology department and the ordering physician. This, in turn, resulted in improved patient care.”

“The time between submitting an order and the fulfillment of that order has been significantly decreased. Additionally, TJUH used to have about 500,000 verbal orders per year; now, verbal orders are given only in a true emergency, and the automated process for signing those orders ensures that they get signed within 24 hours as required by state law,” said Mary McNichol, director of applications at TJUH.

At Montefiore, integrating the radiology systems with CPOE means more efficient radiology processes. “It really streamlines our workflow,” said Margaret Millar, radiology administrator. “It’s shortened the turnaround time from order to examination completion.” The CPOE system also shows the past five orders for the patient to help avoid duplicate orders or unnecessary procedures.

Technology Wish List

Hospitals with existing CPOE systems hope to find even more ways to integrate patient information into one record, such as including PACS images. “Today, physicians have access to those digitized images, but not in an integrated way with a medical record,” Napoleone said. “And that’s part of our planned project over the next few years.”

Steele hopes to see support features to help physicians choose radiology examinations for patients. “We have so many different types of radiology examinations that choosing the appropriate one is often a difficult decision for a physician to make,” he said.

Standards for vocabulary, integration procedures, and workflow processes will need to be developed across all areas of health care to fully take advantage of CPOE’s potential. “It’s going to be hard to have a well-integrated, seamless health care industry,” Napoleone said, adding that one of the major hurdles is that the United States does not assign unique patient identifier numbers that could help link all of a patient’s existing records.

It also is important to get physician buy-in at all levels of the facility and to dispel any misconceptions. With any large-scale technology integration comes a worry that human interaction will suffer, but there are ways to take advantage of the technology without losing that patient contact. For example, each outpatient clinic room can be furnished with a computer.

“You can actually hold a very good conversation with your patient while maintaining eye contact, and you can input some information as you’re going along,” Matheny said. “If you do it after the fact, I think you’d lose a lot of the benefit of a system like that because you just wouldn’t put in as much information.”

Already, Steele has seen a paradigm shift toward continuous improvement, rather than ending the IT department’s role shortly after the go-live date. “[CPOE] products are still in their adolescent stage—they are not mature products, so you still need to have a group of people to modify and customize those products,” he said. “What you have in the first month will not be what you’d have in year two, so we want to stay engaged and think of this as another tool to improve care.”

Even with the efficiency benefits that CPOE promises, the technology costs are prohibitive to some institutions. For early adopters like Denver Health, technology is an important priority. “In our minds,” Steel said, “technology facilitates providing high quality of care.”

—A. Carlson


  1. Vasko C. Few physicians use comprehensive EHR systems. Axis Imaging News. News. October 13, 2006. Available at: Accessed April 20, 2007.