Mark D. Herbst, MD, PhD.

I am a solo practitioner in radiology specializing in reading MRI scans for independent imaging centers. When I left my former hospital-based radiology group in 1998, I knew I would eventually need to invest in a picture archiving and communications system (PACS) and, after a year of reading film, began the transition. Along the way I have dragged the surrounding community with me into the 21st century, and now receive images from 28 imaging centers around the state, half of them through the Internet via DICOM. Eighteen months after the initial installation, I read everything on soft copy. My experience illustrates how a single radiologist or small group can go digital, and may be helpful to other groups or hospitals that are undecided about taking the plunge.

A combination of factors led to my exit from group practice. At the time, several independent imaging centers were opening up in our area.? The owners of these centers came to my radiology group to ask us if we wanted to read for them. Each time, we had to check the noncompete clause of our agreement with the hospital to see if we could do it, and most of the time we could. However, as more centers opened, often with the same owners, they came closer to the hospital and infringed on our noncompete agreement. At the same time, I realized that the hospital-based practice had become more congested with emergency department demands by nonpaying patients. It is not that they were not paying anything, just that none of the state or federal monies ever made it to the radiology group. This had been a major point of dispute between the hospital and the radiology group and, in fact, has recently led to the dissolution of that group after being together for about 30 years. I left at an opportune time to pursue a career on my own, reading for these independent imaging centers.

Computer Friendly

I have always loved computers, and I admit that I sometimes feel like I am playing rather than working. My first experience in reading from a monitor was with our early teleradiology system, which used frame-grabbed images from CT, nuclear medicine video signals, and plain films from a camera-on-a-stick. Even in the middle of the night, I preferred reading off the monitor than engaging in the multistep process of reading films. There was no jacket-handling, film-hanging and taking-down, or walking up and down along an array of viewboxes trying to keep the images together in my head. They were all stacked in front of me, available at the touch of a key.

In my current practice, I have an image server that receives images from DICOM-ready imaging centers and other centers with frame-grabbers or digitizers, as well as from my front desk digitizer. It automatically sends images to my workstation, where I read them. I annotate as I read, and when I finish a case, I mark it reported and it is automatically sent to the Web server, where referring physicians with a password can see their patients’ images. My storage needs are minimal, 60 days on the image server, 30 on the Web server, and 14 on the reading station. The individual imaging centers are responsible for long-term image storage, so I do not need an archive or off-site storage.

To finance my purchase, I thought in terms of cash flow. How many scans will I need to read to pay for this? I took a loan from the bank, and opened an additional line of credit. By that time, I already had a good track record for my company reading scans on films, and I was able to show that the new equipment would open up new markets and make me even more efficient. I pay for the equipment now by reading one or two more scans per day. With this equipment, that is easy to do. But now I have more scans than I can handle.

Generating Referrals

When I began, I did not want to take business from my former group. I met with the centers in the radiology group’s noncompete zone, and offered them my services for a flat rate per scan. I asked for a minimum number of scans for the first year, to assure myself that I could survive. After that, none of my contracts had minimums.

I took the job of being both businessman and radiologist seriously. I reminded myself who my customers were (patients, doctors, lawyers, imaging centers) and focused on their needs. I treated every scan as if there were four VIPs waiting for the result. I called referring physicians with unusual results or just to thank them for the referral. I lectured at lawyer and physician groups. I attended marketing lunches to meet potential referrers. The whole time, I avoided talking with the physicians who used to refer to me when I was at the hospital, but when my noncompete agreement expired, I called everyone I knew to tell them where I had been.

Initially, I was reading 10-12 scans a day.? Then 20, then 30. I now receive 60-70 studies every day. I cannot read so many and give each one the attention I think it deserves, so I took on an associate, who helps me read the excess and reads everything when I am on vacation.

It pays to prepare oneself for inevitable computer glitches, so I took a two-day computer networking course. If a problem gets beyond my expertise, I call my vendor, whom I credit for having a terrific support team that can troubleshoot remotely within minutes of a service call. I have discovered the glories of random access memory (RAM) and small computer system interface (SCSI) and bandwidth.

So far, I have done without a radiology information system (RIS), because they work backwards from the way I need them to work. However, I am considering a new kind of work-flow program that links disparate types of data together.

I started alone, then got a part-time secretary, then a full-time secretary. Now I have three secretaries, and I am considering a fourth. I have outsourced accounting, transcription, marketing, computer maintenance, and billing.

Contracting with centers is an art. I also try to do my own billing on some cases. I use a digital dictation system, email the voice files to my transcriptionist, and receive the reports by fax or email. I have every patient’s data and reports on my computer network and can look up a report in a few seconds.

Experiment In Reporting

I also have modified my reporting style. When I was a resident and a fellow, I reported studies in a way that I call “university style”. For example, a normal chest radiograph done by a resident might run six to 10 lines long, while in practice, the report often runs one single line. The same applies to MRI scans. I used to report every single feature on the MRI report, whether abnormal or normal. Some physicians liked that, others thought there was too much to read.

?To improve things, and incorporating what I learned from a fascinating seminar at the RSNA meeting a few years ago, I drastically changed my reporting method. I went to a tabular format, with one column of structures, another column of findings, and a third column of impressions or conclusions. This was to be my greatest contribution to radiology, since eventually the whole report could be automatically completed by the radiologist by pointing and clicking in a computer form. Moreover, the data could be immediately entered into a database and later extracted for research purposes. Further, there was no particular personal style to be revealed in the wording, so I could have my associates use the same format and no one could tell whose report it was until they got down to the signature. I worked on about six of the most common studies, and after about four revisions, I was very proud of the result.?

The experiment, however, flopped.? Physicians called wondering where the impression was. I returned calls and explained the benefits of the new reporting method. They politely listened and encouraged me up to the end of the conversation, when they said, “All that is fine, but for my reports, could you add the impression at the bottom?”

?Since then, I changed to a new format, and I have received no complaints yet. I state at the top of the report all of the structures that will be examined, and follow that with only the positive findings. The idea is that I do not have to mention the negative findings, but the physician can be assured that the other features were examined because they are listed in the introduction.? My reporting time is faster, my transcriptionist turnaround is faster, and my referring physicians are happier. Isn’t that what it’s all about?

Encounters with Serendipity

Since implementing my PACS, I have encountered many unexpected benefits of having a digital practice.

n Fast image retrieval. At least one physician calls my office to ask questions about a reading every day. Before PACS, I had to conjure up a memory of the scan from the report, and promise to call the physician back in a day or two when the films came back. Then my office staff would have to request the films, receive them, and deliver them to me, and I would have to hang the films, call the physician and leave a message, take the films down to read other films, and hang the films again when the physician called back. This extra work does not even include the work done by the imaging center that must find the films, and if they are not found, reprint them and then deliver them to me.

Consider what happens now, after PACS. The physician calls. I bring up images as old as 60 days from my image server. We discuss the case. I offer the images on the Web with annotations for review or printing. Done, next case.

n Freedom from arbitrary windowing, cropping, and reconstructions by the technologist. I thought I was happy with the filmed images until I found the freedom of windowing images myself. Before PACS, I had to instruct technologists in the fine art of windowing MRI scans whenever I would start reading for a new center or a center got a new technologist. There are subtle points to consider, like the level of contrast for the T2 weighted images of a brain; and how to window the knee images to show real meniscal tears but not to invent them. Now, I just window the images the way I like them before reading, and change them to bring out subtle features. Why should MRI be so different from CT, where a brain or chest examination is submitted to the radiologist in up to three windows?

Parts of the pelvis and soft tissues are usually cropped out of the image when technologists film lumbar spine MRI scans.? With PACS, I have seen things in the soft tissues of the lower back and in the pelvis that I would never have seen before without this control.

MR angiography examinations are always submitted to the radiologist with the raw data or the individual partitions. These images are the source for the information that is reconstructed to make images that look like angiograms. However, the maximum intensity projection done by the technologist might not have the right angle to show the anatomy or pathology of interest. Now I can construct any angle I need to show the findings.

The ability to reconstruct in any plane even if that sequence is not done.

The debate about whether to place slices through the discs or to stack them in MRI scans of the spine continues, but I have my own solution now. I say stack them. With DICOM images, I can reslice at any plane, and I never miss the pars defects, the synovial cysts or neuromas in the spinal canal, or any other findings that would have been lost between the mini-stacks placed only on the discs.

Sometimes the angle of the oblique coronal images acquired in MRI of the shoulder is not ideal. I can now reslice in different planes to see the supraspinatus tendon perfectly. The same applies to knee, ankle, temporomandibular joint syndrome, and any other study.

Into the Future

In my opinion, digital image transmission and archiving is the indisputable future of radiology. Couriers will vanish and there will be an increased reliance on fast Internet connections by physicians to review their patient’s images and then print them for the medical chart. Patients will receive their images on CD-ROM or other electronic media to take to other consultants for review. I foresee a preference for DICOM over film by discriminating attorneys and physicians, since some lesions can be seen when the images are windowed correctly, but are not seen on film shot with a slightly suboptimal window.

As for the immediate future, four local centers are opening up CT screening sites, and two more MRI centers are being built. Recently, a center added a DICOM ultrasound machine, and I am reading those images. I will need another associate to help me soon. This opens up another problem in licensing and medical liability insurance. With images coming from anywhere and being transmitted to remote sites for reading, does a radiologist need a different state license to read a scan in another state? If so, will his malpractice carrier even cover him for reading scans in that state? Right now, malpractice insurers do not have the answers to these kinds of questions. Today, I am only considering Florida physicians; tomorrow, the world?

EDITOR’S NOTE: Decisions in Axis Imaging News welcomes the submission of your first-person experiences in radiology. Please send to [email protected].

Mark D. Herbst, MD, PhD, is president of St Petersburg Independent Diagnostic Radiology Inc, dba SPIn-DR Inc, His PhD is in physical chemistry, for which he studied nuclear magnetic resonance on red blood cells.