A Flick of the RIS: Data on Demand is Here

We could fill a room with all this data we have now,” says Chris (Kip) McMillan, chief executive officer of Diversified Radiology in Denver. “We went from 10 years ago when it was hard to get data off the RIS (radiology information system) to now being able to quickly run a report on anything you can think up.”

Now the key question, McMillan says, becomes figuring out what all the data means. “You can run a report to prove almost anything,” he adds. “It becomes interpretive.”

He uses the example of computing collections as a percentage of billed charges. By using different criteria for computing billed charges, for instance, whether the charges reflect only coded amounts and how so, the collection percentage can be manipulated, he says, to reflect a 50% collection rate or 75% or whatever. So the way the RIS software is instructed to compile the data becomes critical.

“So to ask…what is the collection percentage has no meaning at all,” McMillan says. “The right question in our work is how much did I collect per Medicare RVU (relative value unit) or percentage of Medicare value.”

When data-gathering queries are properly phrased, the RIS can produce a gold mine of information. McMillan and administrators like him are finding that the data available from the latest generation of RIS can lead to greater productivity and higher practice efficiency, and can even aid decision-making when it comes to expanding or refining a practice.

“Radiology practices are big business, and for most business in radiology and health care in general there are tighter margins and decreased reimbursement,” McMillan says. “Are you accumulating the data to allow for sound business decisions? Are you expanding your market to new procedures? Do your collections need work? You need the RIS to allow you to answer those questions.”

Christine M. Keefe, CPA, is chief financial officer for Metro Imaging in St Louis. She agrees that the RIS has become an indispensable practice management tool.

“What we had to do in the old days was to drive to each location and run a report and then combine the Excel files, but that was impossible since the databases weren’t the same,” Keefe says. “Now we have one big RIS database and all our business and volumes globally are there, in addition to by location.”

Now it is easy to track everything from physician referral patterns to staff productivity, so much so that Keefe has become in her own words a “RIS report junkie.”

Mining the data

Metro Imaging operates five physician-owned imaging centers in the greater St Louis area. According to Keefe, its seven radiologists interpret about 100,000 studies per year. Metro Imaging has its own PACS. Keefe was part of a three-person team that chose its current RIS, which was installed in August 2003.

When the RIS and the PACS emerged as paired technology more than a decade ago, the role of the PACS was to transmit and store images, and the role of the RIS was to handle associated written data. The CT and MR images would be on the PACS, the patient information, examination order, and radiologist’s report would be lodged on the RIS. That same bifurcation continues today, but both the PACS and the RIS have become considerably more sophisticated.

Once primarily designed for patient registration, examination scheduling, and report filing, the RIS now can monitor patient flow, issue automatic reports for normal examinations, send reports by fax and/or e-mail to referring physicians, track film, initiate patient and third-party billing, and do a lot more.

RIS software can correlate information to let radiology practices study such things as workflow, patient/examination demographics, physician referral patterns, staff productivity, or insurance reimbursement. As McMillan noted, the RIS data can be mined for nearly any correlation someone can think to query.

At Metro Imaging, Christine Keefe has developed a list of collectable data that the RIS is used to compile:

• break down Metro’s charges by referring physician specialty
• use charges to track referring physician order volumes
• track trends in insurance carrier volumes
• break down patient demographics to target advertising
• monitor examination trends in specified domains like workers’ compensation cases
• study examination volumes by day of the week
• analyze volume to supply
• audit staff productivity
• track employee RVUs to allot bonuses
• audit staffing per center to maximize efficiency

Keefe says that tracking referral volumes of different specialists has “let the marketing reps know where to spend time and on what specialties.” She says the statistics on referral patterns are studied in a number of ways—daily, weekly, monthly, quarterly—to spot trends that can augment marketing. “The RIS analysis has really helped target those physicians who send us the most business,” Keefe says.

By breaking patients down into various age and gender groupings, Metro was able to target radio advertising to those stations most likely to reach each grouping. Was it effective? “It’s impossible to tell,” Keefe says. “Our ads are more for branding to the general population, so that when a referral is made, the patient can say, ‘I’ve heard of them.'” But the patient groupings did allow Metro to maximize its ad budget, Keefe says.

Keefe says that monitoring examination trends per insurance carrier has sometimes revealed anomalies that Metro has been able to correct. She says one payor used software to send patients to imaging centers closest to home, but the way the software was set up, the patient was being directed to the closest hospital imaging department, not the closest imaging center.

“We brought that to their attention after we saw the numbers, and they corrected it,” Keefe says.

SATURDAYS—YES OR NO?

Keefe says something as simple as a day-of-the-week analysis of examination volumes and referral patterns can result in efficiency for Metro.

“We had thought of eliminating or reducing Saturdays,” Keefe says. “It took me about 5 minutes to run the data. We ended up offering MR-only on Saturdays, and that saved staffing cost.”

What the study revealed was that because of the time needed to perform an MRI, the Saturday volumes could not be accommodated during the week. Curtailing Saturday MRI also would have inconvenienced patients. “But we’ve been able to accommodate all our other imaging during the week,” Keefe adds.

The RIS also helped Metro pinpoint that the workers’ compensation cases it was getting were largely difficult specialty interpretations, while the carrier was sending the easier cases to other imaging centers, Keefe says. After some negotiation, that changed. “It was so easy to look at that data on the RIS and see what was happening,” Keefe says. “It was right in front of your face.”

Metro has also used its RIS data to monitor supply usage between its various centers. “When I see that contrast expense for one center is $10,000 and another’s is $20,000, I can look to see why one is so much higher. I can see if they are doing more of a certain type of exam.”

Shortly after it installed its RIS, Metro undertook a study of staff productivity and found, contrary to its expectations, it would not need to add staff except at one busy site.

“We’ve eliminated some staffing through attrition, and the data allowed us to fine-tune our staffing a lot,” Keefe says. She also notes that the productivity studies enabled a more equitable balancing of the workload. Two sites were seen to be interpreting more examinations per assigned radiologist than the others. “Now the other radiologists are more open to helping out their colleagues.”

Keefe says the RIS has clearly been helpful in Metro’s management of its practice, but she says it is hard to tell what the direct financial impact of having the RIS has been.

“I can’t put a dollar figure on that,” she says. “The RIS is paying off as a practice management tool. There are a lot of different ways it pays off. It was something we had to do anyway.”

DATA IS POWER

The ways in which a radiology practice makes use of its RIS depend a lot on the practice.

At Diversified Radiology, a 1996 merger brought together three old-line Denver area radiology practices into a single mega-practice. Diversified now has about 60 radiologists on staff, operates four of its own outpatient imaging centers, and interprets for 12 hospitals and a number of hospital outpatient imaging centers. Annually, the practice interprets about 800,000 examinations, McMillan says.

Diversified is a good name for this radiology group, both as a business and literally. It has no PACS of its own. Instead it interfaces or integrates its RIS with many different PACS at the hospitals it serves. Its images and data are transmitted over a complex teleradiology system that uses a number of different conduits to move digital information, McMillan says.

The diversification inherent in the practice has meant that the RIS vendor has been called upon to do a lot of the interfacing or integration between the Diversified RIS and the various other systems at the client hospitals. “One of their real strengths is that the RIS vendor will ask us what data we need and what we need reports on,” McMillan says.

Patient and billing information can come from the hospitals or from Diversified’s own staff at one of its centers. Diversified employs a five-person staff that does nothing but code all its examinations for billing, based on information from either the radiology group or the hospital where an examination originated. It is one of the coders’ jobs to make sure that the procedures billed by the various hospitals for technical fees correspond to what the radiology group bills for professional fees. The coders must also make sure that the correct codes are used for each procedure, says McMillan. It is after the coding has been entered into the RIS and the billing initiated that the repository of data on the RIS can be configured for analysis, McMillan says.

Diversified uses its RIS data to look at many of the same factors that Keefe analyzes at Metro Imaging—staff productivity, referral volumes, marketing targets. McMillan says another important use of the RIS is to predict and monitor cash flow.

“We are using much more forecasting in our system now,” McMillan says. “We’re coming up with the right questions to get data on how our group is performing, and then forecast that data into the future. I can tell exactly, based on the past, how much cash I should receive next month from each of my major payors.”

When payments fall short or denials exceed expectations, he adds, that becomes an “immediate red flag” to contact the payor without waiting to learn what the actual reasons are.

“What we’ve done,” he says, “is use our data reporting to tell us that much sooner in the game what’s going on, so we minimize the cash flow impact that much sooner. We can tell what is coming before the payors get around to reporting it to us.”

When discrepancies are noted, the payor is contacted and a query initiated. McMillan says the RIS will profile denial codes per payor so that he can question denials that may be incorrect. “We can catch these things before they become big projects for the insurers,” he adds.

He says the RIS data gives him powerful evidence when he meets with a contracted payor. “Whenever we’ve gotten in a conversation with a payor, I’ve never gone in where I didn’t have more robust information than the payors themselves. That’s a pretty distinct advantage,” he says. “We can continually audit, and we can let them know up front that they’re not doing something right.”

He says payors have learned to trust Diversified and “our intimidating billing system” and that good relationships have resulted. “We tell them, ‘We’re never going to bug you unless something is going wrong.'”

He says this forecasting and auditing has stabilized Diversified’s cash flow. “No group likes hiccups in their cash flow. Those are not good.”

McMillan says the RIS data can also be configured to predict the changes that will follow from amended reimbursements such as reductions under family-of-services rules from Medicare. “I can say based on 2005 data what that impact will be on the new 2006 and 2007 rules.”

He explains that the RIS can be used to track turnarounds, from the time the examination was ordered until it was completed and the report issued. If referring doctors ask, Diversified can tell not only how long a given examination took but how much time the patient spent in the waiting room. This response-time data is also used for marketing to referring physicians.

“There’s very little information I can’t get off the system,” McMillan says. “If you want me to tell you how many women over 40 went through screening mammography who within a year had a follow-up mammogram, I can give you that information.”

STANDARDS NEEDED

Not all is perfect in the RIS data world. McMillan says national standards need to be created for simple things like electronic billing claims. Unlike the well-developed DICOM standards that allow images to be transmitted and shared, standards in HL7 (Health Level 7) used to transmit written data between entities are not well developed and leave a lot to be desired, he says. “The broad statement that you have an HL7 interface doesn’t mean anything,” he says. “It’s the most gross oversimplification for an interface I’ve ever heard. It’s not easy and it’s not plug-and-play.”

McMillan says his RIS vendor has to spend a lot of time creating interfaces or integration between hospital systems and the Diversified RIS.

“We support and hope for the development of any true standards—and in the meantime we get data in any manner we can, and we rely on our vendor to help us accept that data. But the advent of plug-and-play because of a national standard or a community standard, that is not yet on the horizon.”

George Wiley is a contributing writer for Decisions in Axis Imaging News.