The Clarian Health People Mover in Indianapolis, a 1.5-mile dual-track superstructure through downtown, connects Methodist Hospital to the Indiana University Medical Center, which includes IU Hospital and Riley Hospital for Children. Two trains with three cars each traverse the route in 5 minutes, going 28 miles per hour. Inaugurated in June 2003, the electric train is free and popular with patients and employees alike.

When Worlds Collide is a classic early-1950s science-fiction movie in which cataclysm befalls Earth after another planet from a wandering solar system comes along. In the early 2000s, life imitated art in the form of a collision of worlds brought on by the merger of a private practice radiology group at a for-profit Indianapolis hospital and an academic radiology group at a university medical center about 1 mile away—only in this instance, everyone survived.

Initially, though, it seemed that things might not work out as hoped for the uniting radiology groups (former competitors both, each with its own unique operational methodologies and cultures). “There was very little cohesiveness, no common ground, no shared vision about how to provide radiology services,” recalls Kenneth A. Buckwalter, MD, chief of the musculoskeletal section in the Department of Radiology at Indiana University Hospital, Indianapolis. “Our merger with the radiology group at nearby Methodist Hospital meant major change for everybody, and there was a lot of worry and anxiety associated with that change. Distrust, too.”

According to Valerie Jackson, MD, FACR, John A. Campbell Professor and Chairman of Radiology, Indiana University School of Medicine, and the president of the clinical group, she worried at times that the department would implode, but those fears are no longer a concern.

“When we started, people said this would blow up in 6 months,” Jackson recalls. “But we are here, and we are going to continue to evolve and develop.”

Prospects for a happy ending—rather, a new beginning—brightened with the introduction of an ambitious plan by which governance, purpose, and budgeting would all be equally shared by the merged radiology groups. This transpired 3 years ago. Today, there is cohesion and comity to a striking degree.

“Our model of shared governance encourages collaboration, no matter that we have very dissimilar business units,” says Richard S. Helsper, RT, MBA, CHE, vice president of operations for Clarian Health Partners, owner of the hospitals at which the conjoined radiology groups are based. “Since implementing this model, our radiology revenue has grown by 93%, and—although some of this is attributable solely to price increases—our radiology RVUs [relative value units] have grown by 21%. On top of it all, our productivity of the hospital staff has improved by 14%, despite having more complexity of services as a result of the merger.”

Huge Challenge

Clarian Health Partners is a fully integrated health network covering virtually all of Indiana. In addition to Methodist and Indiana University hospitals, Clarian Health Partners’ Indianapolis flagships also include Riley Hospital for Children. The latest additions are Clarian North Medical Center and Clarian West Medical Center, both added since December 2004. The latter pair are known internally as “The Suburban Sites” because of their geographic positioning relative to the downtown area, where the other three main hospitals are situated. Clarian Health Partners also owns, or counts as affiliates, about 12 other hospitals spread across the state. In a typical year, the organization’s facilities admit a combined total of more than 50,000 patients and log 900,000-plus inpatient visits.

Clarian Health debuted in 1997 as a result of a merger between Methodist Hospital and Indiana University Hospital (which earlier had merged with Riley Hospital for Children). It was this merger of hospitals that eventually compelled Radiology Specialists of Indiana (the private group covering Methodist Hospital) and Indiana University Radiology Associates (the academic group at Indiana University Hospital and Riley Hospital for Children) to tie the knot. Negotiations between the radiology groups proceeded in fits and starts, and collapsed at one point. But champions of the merger from both groups and their respective hospitals pushed hard to resuscitate the talks. They succeeded, and an accord was reached at last. The two radiology groups merged into a not-for-profit 501(c)3 corporation, forming a single, wholly owned subsidiary of Clarian Health Partners.

“It’s a real hybrid,” Jackson notes, “in that multiple people with varying roles often work side-by-side in the reading room. I think both sides gained a little better perspective of the value of service orientation for patient care and quality issues: Gains were made on both sides.”

Tensions developed initially over compensation issues that arose within a group that included both radiologists involved primarily in research and teaching and those whose sole concern was clinical work. “It’s a lot better,” Jackson says. “Some salary differentials were put into place for historical reasons that continue to concern people. We are working on a compensation plan that will even out some of those perceived differences.”

Although it was hoped that the merger would create sufficient synergy to boost the fortunes of the mated radiology groups, such did not materialize. “The absence of cohesion prevented us from thinking strategically with regard to assets, acquisitions, and customer service,” Helsper says. “As a result, the radiology enterprise spun its wheels for about 18 months after the merger.”

In addition to overseeing radiology, Helsper is responsible for radiation oncology, clinical engineering, and rehabilitation services, as well as the organization’s ambulatory surgery centers, imaging centers, and telemedicine activities. Clarian Health hired Helsper in 2003, bringing a close to his 11-year stint with Duke University, where he started as the head of the MRI section and later became director of the entire radiology enterprise.

What Helsper found upon arriving in Indianapolis was not pretty. Of the immediate pre- and post-merger radiology environment at Methodist and Indiana University hospitals, Helsper says, “There was no leadership formation; each campus placed its departmental operations in the hands of a cadre of mid-level managers who made decisions about what needed to be done in an exclusively department-centric manner. There was no cross-campus integration or coordination. There were no quality-assurance programs of substance. And informatics technologies had yet to be made available anywhere outside of radiology.”

Capital to fuel growth—at least to fuel it in theory—was not a problem: In 2003, $11 million was available for the acquisition of technology assets. However, because of the inability to engage in meaningful global strategic planning, the hospitals ended up deriving too little value from the dollars spent. “Everything was bought as a one-off,” Helsper recalls. “In other words, you were at one hospital and needed a new radiography system, but wouldn’t stop to ask the other hospitals if they also needed radiography systems so that the combined purchases could generate volume discounts. So you would buy your radiography system and then, separately, your counterpart at another one of the hospitals would buy a radiography system—and not necessarily even from the same vendor.”

Shared Governance, Shared Purpose

The unified, postmerger radiology enterprise at Clarian Health Partners is halfway home to transforming its five Indianapolis hospitals—plus additional institutions spread across Indiana—into a virtual single campus, seamlessly linked via picture archiving and communications system (PACS), radiology information system (RIS), electronic medical record (EMR) system, and other informatics solutions.

“Our immediate goal is be fully paperless, which we expect to reach by mid-2007, but the effort to do so is being complicated in our outpatient areas, where patients still come in with orders written on paper,” says Kenneth A. Buckwalter, MD, chief of the musculoskeletal section in the Department of Radiology at Indiana University Hospital in downtown Indianapolis. “The temporary solution is to have orders faxed in to a central receiving area that assembles, collates, and routes them—again via fax—to the various reading rooms. Upon arrival there, the orders are then distributed to the radiologists by physician extenders.”

Another barrier to eliminating paper is the new rule issued by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), Oakbrook Terrace, Ill, calling for physicians to produce a signed order when requesting use of contrast in imaging studies. “We’re exploring ways that we can [meet this requirement] in a purely electronic mode, but, admittedly, we don’t yet have a solution, so we’re going to have to keep using a manual, paper-based process for a while,” says Richard S. Helsper, RT, MBA, CHE, vice president of operations at Clarian Health.

Despite the challenge posed by the new JCAHO rule, Helsper says his enterprise embraces it without reservation. “Ultimately, it will result in a stronger referring business,” he predicts. “JCAHO wants all of us in health care to follow best practices, and we agree with that wholeheartedly. The goal of best practices is to reduce the potential for medical errors and patient care problems. It’s not going to be easy, fun, or friendly to implement this [system], because to a significant extent, it will involve more changes to our culture. But implement it we must if we’re serious about reducing medical errors, which we are. Ten years from now, people coming out of medical school and technologist programs will not believe it possible that we could have ever done things any way other than with a signature for contrast.”

Asset Allocation

Further complicating the journey to an all-electronic environment is the lack of worklist flexibility. “Our enterprise PACS—which has superceded the PACS we were using before the merger of our academic radiology group with the private-practice group at Methodist Hospital—does not offer adequate filtering of image sets, such as body parts,” Buckwalter says. “Our subspecialist radiologists here at Indiana University Hospital were accustomed to working with filtered image sets. What we need is a worklist that, to some extent, can be changed on the fly, a worklist that will allow us to send cases that require subspecialist attention to the appropriate subspecialists and in whatever demographic parameter combinations we want.”

On the upside, Clarian Health encounters no difficulty these days when it comes to the allocation of the technology assets that feed into those informatics pieces. For this, it can thank the administrative model of shared governance, shared purpose, and shared capital that was adopted about 3 years ago.

“We have the ability to readily shift equipment around to our various locations as needed,” Buckwalter says. “Let’s assume that one of our freestanding imaging centers has an aging 2-slice CT scanner. Instead of buying a more modern replacement, we can take a 16-slice CT scanner from any of the downtown hospitals and give it to the center. Of course, doing this creates a need to replace the scanner taken from the hospital. Rather than buy another 16-slice scanner, we can—because we’re talking now about a flagship facility—justify spending extra dollars to buy the latest-and-greatest whizbang piece of CT technology. This is a very useful strategy, because we don’t have enough capital dollars available to outfit all of our hospitals and centers with the latest and greatest in equipment.”

—R. Smith

Leadership Teams

The product of this unsustainable state of drift was loss of business. “We were not in a position to pay sufficient attention to satisfying the needs of our referring clinicians and the patients,” Helsper says. “Because of that, more and more of [our patients] were going outside the Clarian system for the radiology services that they required. Radiology was losing market share, even though Clarian as a whole was doing well and gaining market share.”

All was not lost, however. According to Helsper, the radiology enterprise enjoyed several foundational strengths. “The merger created a single platform from which we could proceed,” he says. “We had solid, talented people on both the physician and operations sides. And we had abundant resources that we could tap into through Clarian.”

The structure through which these strengths could be leveraged was lacking, however. So, Helsper sought a remedy by introducing the model of shared governance, shared purpose, and shared capital—an operations formula he had seen used successfully in other types of postmerger businesses. The first step entailed a complete reworking of the organizational charts for the radiology enterprise. Henceforth, as spelled out by this model, radiology’s future would be placed in the hands of a trinity of leadership teams culled from the various campuses—each team with its own special and well-defined set of responsibilities.

The first of these teams was charged with oversight of departmental operations. “Now heading each downtown hospital’s radiology department is an administrative director: Nancy Davison [RT, MBA] at Riley Hospital for Children; Todd Stanley [RT, MBA] at Indiana University Hospital; and Carlos Vasquez [RT, MBA, CRA, and a member of the American Healthcare Radiology Administrators board of directors] at Methodist Hospital,” Helsper notes. “These directors are supported by a leadership team of the different business units within radiology. Every few weeks, the directors and managers meet as a leadership team to map out initiatives in response both to Clarian’s global directives and to needs identified at our local department level.”

The second leadership team addresses issues surrounding the radiology enterprise’s information systems (IS). This area is one of major concern, owing to the breadth and depth of the technologies involved; for example, Clarian Health’s picture archiving and communications system (PACS) from GE Healthcare, Waukesha, Wis, is said to be the largest in North America, with more than 200 dedicated workstations at the three downtown hospitals alone. Buckwalter, who participates with this IS team, says it formerly was permissible for any PACS user to directly contact the IS department and request alterations in the way the PACS functioned—without regard for how the desired modifications might affect workflow for other users.

“The IS leadership team was created to prevent this kind of counterproductiveness,” Buckwalter says. “Currently, requests for changes to the PACS are vetted by the IS leadership team, which includes very technology-minded radiologists and physicians from the flagship hospitals. The team only approves change requests that are convincingly projected to benefit the greatest possible number of users. And it’s not just changes to the system’s function that are vetted in this way; it’s everything from software upgrades and workstation deployments to authorization for acquisition of new technologies.”

Change of Mind

The third leadership team is a high-level strategic-planning and financial-decision-making committee that—among other important duties—supervises and guides radiology’s capital budgeting. This team is spearheaded by stakeholders known as Geo-Chiefs, who are the radiology administrators and medical directors from each downtown Indianapolis hospital and the imaging center institutions as a collective group; eight individuals in all—four are business executives, and four are clinicians. Others who serve on this team as content experts include the head of radiology information services and a handful of nurses and quality assurance specialists. Every member of the team has a voice, although only the Geo-Chiefs enjoy full voting rights. Helsper, meanwhile, who is executive sponsor of the committee, has no voting rights but does wield the power to veto any capital allocation decision he determines to be ill advised; notably, to date, he has vetoed none of the committee’s decisions.

“The beauty of this approach is that one campus’s asset-acquisition proposal won’t fly unless the representatives from that campus can persuade the others that the purchase being advocated will benefit them in some way, too,” he explains. “Right there, you have strong incentive for cooperation and collaboration. This also has the very beneficial effect of forcing everyone to look outside of radiology to see what their customers want and need, something the individual institutions weren’t accustomed to doing in the past. Before, they couldn’t appreciate how making choices that, for instance, delight the surgeons in other departments of the hospital can translate into more business for radiology.”

Although the shared governance/purpose/capital model has wrought many enviable benefits, the price of securing them was the imposition of an unsettling massive change of habit on everyone in the radiology enterprise. Naturally, there was resistance at first.

“Those who objected most were the ones who felt that the former way of doing things gave them more ‘wins’ when it came to items they wanted inserted into the budget,” Helsper says, adding that he used systemwide data on asset acquisitions to demonstrate that “some of the great deals people thought they were getting for their own campus weren’t all that great in light of deals struck at the other campuses for similar acquisitions.” Those revelations helped bring those users around to realize that the only way to obtain a good deal from here on in “would be through cooperation, collaboration, and consensus.”

Helsper also promoted buy-in by making a point of walking the corridors and chatting with individual, nonleadership physicians, technologists, and administrators to find out what questions or concerns they might have about the new method of conducting business. “This exercise provided great opportunities to educate and offer reassurances that even though there might be some rough spots with the process we’re going through,” he says, “in the end, it’s going to work to everyone’s advantage.”

Signs of Success

Helsper points to recent equipment purchases as a sign that the model is today performing as billed. “At Indiana University Hospital, a new state-of-the-art MRI and a 64-slice CT have been installed, and plans are being finalized to upgrade and expand a formerly underused cath lab that is being transferred to radiology,” he says. “At Riley Hospital for Children, we’ve built a brand-new interventional lab and added an MRI. At Methodist Hospital, we brought aboard an extra 64-slice CT and a 3-Tesla MRI; by the time this is published, we will be adding a new neurobiplane IR [interventional radiology] suite and redesign of all IR will be complete. By the end of the year, we will be adding PET/CT.”

These acquisitions might not seem like much, given the size of the radiology piece at Clarian Health Partners—until, that is, those purchases are placed in proper context. “For several years prior to the introduction of our model of sharing, the only acquisitions occurring involved equipment replacement, never the addition of assets for purposes of enterprise expansion,” Helsper says. “Now, with the new capacity that’s been gained, we are growing the business, such that referrals that once may have been lost have come home again.”

At this juncture, shared governance/purpose/capital is a way of life only for Clarian Health’s downtown hospitals and those of the imaging centers and new suburban hospitals. Helsper promises the model will not be confined to just those five campuses for long. “Over the next several years, we’ll be extending collaboration across the organization to facilitate our drive for total integration and harmonization of all locations where radiology services are provided,” he says.

And the practice merger that lay the groundwork for shared governance has disproven the naysayers. “It is unique, but if people are determined to make a unique situation successful, they can make it successful,” Jackson believes. “People should not be afraid of change. Academic medicine is far different than when I started practicing 20 years ago. It needs to be run as a business, and people must look at new models. Whether they are new relationships with the hospital, whether they are new departmental corporate structures, or whether they maintain the old traditional model, everybody needs to work harder, and there is going to be more accountability. That is the way of the world today.”

By most measures, then, it seems clear that the collision of worlds embodied by the merger of diverse radiology groups within the complex Clarian Health environment has proved to be the start of something very positive—for the radiologists, certainly, but also for the referring clinicians and for Indiana’s health care consumers. “It required some thinking outside the box,” Helsper says. “The goal was to increase customer satisfaction, and that is exactly what has happened.”

In the movie When Worlds Collide, only a tiny remnant of humankind emerges from the cinders of the shattered planet. At Clarian Health Partners, however, everyone ends up better than before the earthshaking merger. That kind of ending might not make for good Hollywood box-office numbers, but it sure makes for a radiology group with a sense of well-being and a lot of satisfied customers.

Rich Smith is a contributing writer for Axis Imaging News.