Domains of Decision-Making
Billing for Emergency Radiology Creates Competition and Controversy
Mammography Recall Program at UM Near 100%, Costs 16 Cents Per Patient
Estimates of MRI Scan Times for Children Are Often Inaccurate

Domains of Decision-Making

Building an Imaging Department Management Structure

A defining characteristic of health care imaging service delivery in the 21st century is the pressure that stems from balancing the latest in clinical care and significantly enhanced customer service against effective cost management. Nowhere is this felt more than in hospital-based radiology departments that are ramping up to compete effectively in outpatient environments.

Hospitals and health systems find that even as they deploy the latest technologies and open outpatient imaging facilities, their ability to be nimble in charting a course is hampered by organizational structures that are outdated or ineffective. Additionally, if roles and responsibilities are not clearly defined, even the best organizational structure will be fruitless.

We propose an approach to management structure within the radiology department that addresses the need for clarification in responsibilities and accountability, encompassing strategy, planning, implementation, and day-to-day operations. Coined Domains of Decision-making, the approach allows the department to work within the existing framework (eg, functional, divisional, matrix reporting) while creating flexibility for the unique requirements of health care imaging service delivery. How the domains are vetted within a particular department depends on two key factors: national health care imperatives and imaging environmental factors.

It is important to embrace the following health care imperatives when determining reporting relationships, responsibilities, and the skill sets/expertise needed for a particular domain within an organization:

  • leverage leadership (actual and potential);
  • build collaboration and accountability;
  • promote safety and quality improvements; and
  • create a culture that values innovation.

Each organization must determine what skill sets and characteristics related to these imperatives are necessary within any layer of the organizational structure.

Domains of Decision-making

An organizational structure that does not assign the following four domains of decision-making in the form of roles and responsibilities for each position/layer will not function well:

  1. Strategy—includes providing leadership and creating the institutional/departmental vision and goals; the Strategist aligns people and is forward-looking.
  2. Planning—designs and prioritizes initiatives to meet the institutional vision and goals; the Planner establishes direction and leverages infrastructure.
  3. Implementation—holds accountability for project plans, including timelines, teams, and budgets, ensuring that initiatives are completed and accountable for performance metrics; the Implementer motivates and inspires.
  4. Day-to-Day—focuses on productivity and customer service, monitoring daily workload, volume, and workflow; the Day-to-Day sustains performance.

The Domains of Decision-making Chart provides examples of typical job titles, responsibilities, and skills sets for each domain. Note that these domains are not mutually exclusive of each other and should not be considered synonymous with levels of reporting within an organization.

Imaging Environment Factors

In building your management structure, how much the domains are distinctive or overlapping will depend on four factors:

  1. Organizational Culture. Organizations recognize that culture is inextricably linked to broader institutional goals and strategies. For example, if the organizational goals include expansion, then the culture might value ability to change, ease in collaboration, efficiency, cooperation, and integration with other areas. Alternatively, goals driven by fiscal or other considerations, such as competitive positioning, academics, and political issues, might create other cultural considerations. Organizations must be honest and reflective about their cultures and how that potentially affects their domains of decision-making. For instance, is the culture hierarchical or egalitarian? Is it aggressive or cautious in growth?
  2. Service Complexity. An organization committed to enhancing and customizing care—treating patients as consumers with choices—will require additional communication and, potentially, human resources. This factor applies whether you are looking at inpatient or outpatient enhancements.
  3. Operational Complexity. The operational complexity varies depending on whether the organization is, for example, a freestanding imaging center versus hospital-network operation, centralized versus decentralized, modality centered versus disease-process centered.
  4. Technical Complexity. The IT infrastructure—such as PACS, online order entry, decision support, and EMR—which allows for data flow, quality management, and operational reporting will impact the domains of decision-making.

Each organization will have a unique configuration of these factors to consider when determining whether or how much overlap exists between the domains of decision-making. One way to think of the environmental factors is that they potentially are “complicating” elements to the organizational chart itself, not just the domains: Too many gaps between domains could mean redefining positions or even the organizational structure; too much overlap between domains could mean that more staff will be needed in the near future.

Danger Signs

One way to assess whether your organization needs to reevaluate its management structure is to reflect honestly: Does your organizational structure make sense on paper, but:

  • new equipment is being implemented, and ownership for its success is far removed from the operation?
  • examination volumes or market share is not meeting targets?
  • ad hoc or informal “hallway” conversations are the primary tools for communication, as opposed to standing meetings to convey key information?
  • staffing and communications between the outpatient services and inpatient services are subpar?
  • when radiologists are unhappy with decision-making within the radiology department, they go directly to the chief operating officer, skipping the vice president or administrative director?

Providing a sense of accountability across an organization that has been growing and/or redefining its focus might require restructuring so that the domains, not the formal reporting structure, delineate responsibilities and accountability.

Pamela Harlem, MBA, is regional director of RCG Healthcare Consulting, Boston, and Kathy Tabor-McEwan, BA, RT(R), is director of clinical operations at Massachusetts General Hospital, Boston.

Billing for Emergency Radiology Creates Competition and Controversy

In many hospitals, emergency radiology has degenerated into a race to bill. In the years following the Health Care Financing Administration (HCFA) 1997 ruling on the distinction between an interpretation and a review, as well as its first-come, first-served basis for billing, concern over the issue has mounted—particularly since the advent of nighthawk teleradiology,

ACR Emergency Department Radiology Questions and Answers

1) Can a radiologist and/or emergency department physician bill for an x-ray or ECG procedure when performed in the emergency department?
Any physician credentialed by the hospital can bill for an x-ray or ECG procedure if they have performed a formal “interpretation and report,” which addresses the findings, relevant clinical issues, and comparative data associated with the procedure. However, a physician cannot bill separately for a “review” (eg, wet read) of the procedure. A “review” is included in the emergency department evaluation and management (ie, consultation) payment. In addition, the evaluation and management section of the Current Procedural Terminology (CPT) Manual 2005 (Standard edition, page 2) states, “The interpretation of diagnostic test results with the preparation of a separate distinctly identifiable signed written report may also be reported separately, with the appropriate CPT code with modifier.”

2) Which claim will Medicare pay when multiple claims are received for the same service but provided by different physicians?
Generally, the first claim received by Medicare will be paid and, typically, the second claim will be rejected as a duplicate. The carrier should pay for the report that directly contributes to the diagnosis and treatment of the individual patient for which a formal written report is on file. Ideally, only one claim is submitted; therefore, CMS encourages that physician groups in hospitals negotiate in an effort to develop an internal policy.

In a special report released following the 1997 decision and still available online,1 the American College of Radiology (ACR), Reston, Va, issued a breakdown of the guidelines. “HCFA distinguishes clearly between an ‘interpretation and report’ and a ‘review’ of an x-ray procedure. … HCFA also lists the necessary elements of a report,” the decision states. The ACR also highlights HCFA’s decision on billing: “The language regarding multiple claims is critical and needs to be read carefully. … It is to the benefit of the radiologist to have his or her claim submitted first for an x-ray when the emergency physician is also filing a claim.”

Fred Mann, MD, emergency radiologist at Harborview Medical Center, Seattle, and chair of the ACR committee on emergency radiology, takes a slightly different tack, however. He advises that internists and radiologists combine forces for a more holistic, patient-based approach to addressing the issue.

“If we say that the only value of the image is in its interpretation, then you could have some reason for debate,” Mann says. “Lots of studies look at the rates of differences of opinion between radiologists and others, in emergency departments as well as throughout the hospital. There’s a lot of data about emergency departments from many different countries, and different parts of this country. And depending on how you read it, they all show a level of discrepancy—between 2% and 30%, with certain examinations bearing a higher likelihood of someone getting it wrong.

“The state of Washington,” he continues, “has a regionalized trauma care center. At Harborview, our performance on trauma is superb, and one of the reasons is that we work as teams—not radiologists doing radiology just for radiologists. We tend to work together. So if there’s something that I missed, maybe an orthopedist saw it, or vice versa. The interpretation is the tip of the iceberg. It’s only one part of the product. If the interpretation was all there was, then you have controversy.”

Mann, who used to be an internist, advocates a committee-based, cooperative approach. “These turf battles occur in situations where there are other sources of friction,” he says. “We have counsels here to look at how to coordinate care across specializations. It’s a way to identify opportunities for improvement and existing barriers to better care. It’s a cross-functional team focused on specific goals.”

He advises emergency departments not to forget that “what we should be focusing on is the system’s performance at taking care of patients. Unfortunately, the business has become much more monetary in recent years. But from a social perspective, the role of medicine hasn’t changed.”

—C. Vasko


  1. American College of Radiology. Emergency room radiology. Available at: Accessed August 24, 2006.

Mammography Recall Program at UM Near 100%, Costs 16 Cents Per Patient

A recent study by the Department of Radiology at the University of Michigan (UM), Ann Arbor, suggests that achieving a near-perfect compliance rate for mammography recalls might not be prohibitively expensive—the average cost was a mere $.16 per patient.

The study evaluated the cost of UM’s recall program, in which clerical workers place repeated phone calls and send notarized letters to patients asking them to return for a second mammogram if their first screening needed additional imaging. UM’s Department of Radiology is quite proactive at chasing down patients for return visits; in other facilities, this burden traditionally is placed on primary care physicians. “It can be difficult,” says Caroline Blane, MD, the associate chair for clinical services at UM and the lead researcher on the study. “A lot of patients are scared that it might really be cancer. They refuse to come back, or they make appointments and then don’t show up.”

Out of 30,286 patients screened during the course of the 3-year study, just over 4,000 required a second diagnostic. An average of two calls from the radiology center’s staff was all it took to attain a 99.3% return rate; of the 48 patients who did not come in for a diagnostic after only two calls, 28 acquiesced after six calls, bringing the total success rate of the project to 99.5%. Only 20 patients out of 4,025 remained unresponsive throughout the course of the program.

There are clerical and administrative costs inherent to a screening mammography program, as mandated by the federal and state regulations governing breast imaging. The only real incremental cost of UM’s program is the additional wages paid to clerical workers, so overhead is low. Radiology centers have historically been hesitant to enact similar programs, Blane explains, for several reasons—one of which is the assumption that they would be too expensive. But the total price tag on the recall was $4,724, or just $.16 per patient.

Blane also notes that one of the 28 initially noncompliant patients turned out to be harboring an early breast cancer. If standard protocol had been followed—one phone call and one letter to the patient and her physician—the cancer might have progressed untreated. Treatment would have cost far more than the $4,724 spent on the recall program, and the patients’ lives would have been at risk.

Although UM’s program is unconventionally aggressive, Blane says, “I think it will catch on, more and more. I think we’ve proved that the incremental cost is minuscule compared to the benefits. More and more people will recognize that it is a reasonable investment, and the amount they are spending is worthwhile.”

Estimates of MRI Scan Times for Children Are Often Inaccurate

A study in the May issue of Anesthesia and Analgesia1 addresses the issue of inaccurate estimates of children’s MRI and CT scan durations. Researchers at the University of Iowa showed that estimates of scan durations were highly inaccurate—often more inaccurate than estimates of the running times of complicated surgical procedures. The study both seeks out the source of the frequent mistakes and suggests a workable alternative.

Inaccurate assessments of scan times can cause problems for children in particular because of the need for general anesthetic to keep them calm and still. Without knowing with relative certainty when a scan will start and how long it will last, physicians cannot offer parents any conception of how long their children should be without food or drink before the administration of anesthesia.

Franklin Dexter, MD, PhD, professor of anesthesia at the University of Iowa, Iowa City, and Jack Yue, PhD, an ecological statistician at the National Chengchi University, Taipei, set to determine the cause of the persistent inaccuracy. “This was very unexpected, because although we know that it is very hard to accurately predict how long a surgery will take, we assumed that it would be easy to predict how long a CT or MRI under anesthesia would take,” Dexter said in a press release.

The researchers discovered that billing codes were being used to predict scan times. Unfortunately, the codes are widely varied and are based on different areas of the anatomy, and are as such an inaccurate predictor of total imaging time. For example, the amount of time it would take to scan the chest and the abdomen is not equal to the sum of the average duration of a chest scan and the average duration of an abdominal scan. Also, no differentiation between types of scanners was being factored into the equation.

To ameliorate the problem, Dexter asked the technologists running the CT and MRI scanners to estimate how long each procedure should take. Angella J. Dow, BS, a researcher on Dexter’s team, compiled the results into a Web-based program that allows schedulers to check boxes defining the scanning procedure by type of scan, body part or parts to be imaged, and instrument used. The program then calculates scan duration. The duration calculator for estimating the length of time required for a pediatric MRI or CT developed by Dexter and his team is available online at

“Doing a better job of predicting start times not only means less inconvenience,” Dexter noted, “it also means that children are required to fast for only short amounts of time.”

—C. Vasko


  1. Dexter F, Yue JC, Dow AJ. Predicting anesthesia times for diagnostic and interventional radiological procedures. Anesth Analg. 2006;102:1491–1500. Available at: cgi/content/abstract/102/5/1491. Accessed August 24, 2006.