IMPROVING RADIOLOGIST PERFORMANCE - it's not about speed / by Timothy Myers

Radiologists are the most expensive resource a radiology group possesses. Each radiologist must perform at their maximum efficiency in order to provide the greatest benefit to the group.  Radiologist compensation strategies, in order to remain in line with the new payment schemes need to be based on increased quality and efficiency, not just quantity.

There are a finite number of hours available in each day and inefficient radiologists cost their colleagues and partners time that could be used to make calls to clients, take extra time with patients, work with hospital administration or serve on committees. All of these nonreading/nonproductive tasks take away precious productive time but are required for radiology groups to maintain their leadership roles in radiology and imaging. Increasing efficiency is what buys the time needed to perform these additional tasks.

Simply reading faster is not the answer. The speed at which a radiologist reads is similar to how runners run. Each radiologist appears to have a reading “pace” that is set by many factors. If a runner does not run their typical pace, injuries or poor performance can result. With radiologists, going faster or slower than their built-in pace can result in greater inaccuracy and decreased quality.

The idea of simply reading faster rather than improving efficiency to try to increase a throughput of cases has also been studied and reported in a number of articles including an article from the Journal of the American College of Radiology (JACR). The article, The Effect of Faster Reporting Speed for Imaging Studies on the Number of Misses and Interpretation Errors: A Pilot Study. This article “found a significant positive correlation between faster reading speed and the number of major misses and interpretation errors.”

Our own review of quality assurance focused on radiologists with higher reading rates demonstrated that radiologists who simply increase their reading rate frequently decrease their accuracy.  This results in an increased rate of quality assurance discrepancies and the risk of higher level/more serious quality assurance discrepancies. This decrease in accuracy typically goes hand in hand with an increase in the rate of complaints by clients as the radiologist's report quality also deteriorates.

Increasing efficiency has nothing to do with increasing reading speed

Efficiency is not something taught in residency or fellowship; however, it can be taught. At the same time, improving efficiency, if taught and developed correctly has the added benefit of improved accuracy and quality.

Specific areas that need greater attention to improve efficiency, accuracy and quality include:

  • Voice recognition training to ensure maximum use and efficiency of voice recognition. Not just training the system but training the radiologist to use the system.
  • Developing personalized macros and templates for radiologists provides the structured and organized reports demanded by hospital administration, clinicians and patients who will very soon have direct access to our reports.
  • Group personalized templates and macros that can be used to improve billing with CPT codes and descriptions accompanying each report.
  • The ability to produce reports that can easily be data mined to generate information that will improve understanding of individual clinician and clinician group usage of imaging in general and specific types of imaging, hours and days of utilization. This type of data can then be used to target clinicians for improving utilization and providing more information regarding appropriateness and decision support.

Voice recognition

Voice recognition is often overlooked when trying to increase efficiency or throughput by a radiologist. Voice recognition and its various parts are the single most important tool that can be manipulated to improve efficiency.

Voice recognition can be used to great advantage by radiologists who understand it: its limitations as well as strengths. Voice training is typically looked at as something to be endured. Ensuring that the radiologist is training the system rather than the system training the radiologist is the first step.

 Next, developing macros (sentences or parts of the dictation) and occasionally templates (sentences or parts of a dictation with a fill in the blank area or areas) improves the ability to organize and structure reports. This allows a report to be generated as the study is read with a report being completed when the radiologist completes the review of the case. Using macros, which occurs with high repetition, improves voice recognition and significantly decreases voice recognition errors. The use of macros and templates also decreases the need for free dictation which has a moderately to significantly higher rate of voice recognition errors.

 Example of a macro:

ORBITS: The globes and intraorbital structures demonstrate NO acute changes.  The bony orbits demonstrate NO acute fractures.

 Example of a template:

VENOUS STRUCTURES: There is NO evidence of deep vein thrombosis from the common femoral to the [visualized calf veins].

 IMPRESSION:

1. NO evidence of deep vein thrombosis in the visualized venous segments as noted.

 NOTE: The “[visualized calf veins].” is the templated area. This area can be left as is or changed by selecting the region of the template and adding free text or a macro.

 Finally, macros can be used to place CPT coding information for accurate billing (see below).

 Case review

Using an organized approach to review cases ensures that all organs and structures are evaluated. This sounds simple but many times radiologists lose significant time by reviewing organs or areas of a radiograph repetitiously rather than reviewing each organ or area only once.

When eye movements are tracked, instead of relatively straight lines that are reproducible over a series of cases, disorganized reviews follow disorganized patterns or loops which are not reproducible between cases. This disorganized review pattern decreases efficiency and increases the time it takes to review any one element.

 Putting it all together

Using an organized approach to reviewing the examination and dictating using macros and templates as the case is reviewed provides a check-and-balance process. At the end of the case, each organ or system is represented within a clear and concise report. This ensures both the clinician and the radiologist that all areas of the examination were evaluated. Abnormalities can be highlighted in a number of ways to ensure the clinician identifies the critical areas within the report and the areas within the body of the report where more information about the abnormality can be found.

Example normal report:

CHEST X-RAY, FRONTAL AND LATERAL VIEWS.

CPT: 71020 . Chest x-ray, 2 view study , frontal and lateral.

 INDICATIONS: Chest pain.

 COMPARISON: NO relevant prior studies are currently available for comparison.

 FINDINGS:

HEART: The heart is normal in size and position.

LUNGS AND PLEURA: The lungs demonstrate NO consolidations or effusions.

MSK: The visualized skeletal structures demonstrate no acute changes.

 IMPRESSION:

1. There is NO evidence of acute abnormalities.

Example abnormal report with a critical value:

CHEST X-RAY, FRONTAL AND LATERAL VIEWS.

CPT: 71020 . Chest x-ray, 2 view study , frontal and lateral.

INDICATIONS: Chest pain.

COMPARISON: NO relevant prior studies are currently available for comparison.

FINDINGS:

HEART: The heart is normal in size and position.

LUNGS AND PLEURA: The lungs demonstrate NO consolidations or effusions.

CRITICAL FINDING: 25% pneumothorax in the RIGHT lung apex.

MSK: The visualized skeletal structures demonstrate no acute changes.

 IMPRESSION:

FINDING CONSIDERED CRITICAL TO PATIENT CARE:

1. 25% pneumothorax demonstrated in the RIGHT lung apex.

 Conclusion

Each radiologist must perform at their maximum efficiency in order to provide the greatest benefit to the group. Improving radiologist efficiency does not increase a radiologist’s reading speed but it does improve their throughput of cases with greater accuracy and quality. This increase in efficiency allows radiologist compensation strategies to be based on increased quality and efficiency, not just quantity.

This increase in efficiency has an immediate return on investment by decreasing the need for new radiologists as each radiologist becomes able to read more cases. As importantly, time is saved which can be used to improve clinician, hospital administration and patient satisfaction through increased involvement by individual radiologists and the group in general.