Clinician Focused Radiology Staffing Model Eight-Step Evaluation Process Helps Achieve Optimal Results

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1 White Paper Clinician Focused Radiology Staffing Model Eight-Step Evaluation Process Helps Achieve Optimal Results By Peter D. Franklin, M.D. Anyone who works in radiology today has been touched on a daily basis by the many challenges that face our industry: radiologist and technologist shortage, increasing interpretation demands from physicians, competitive pressures, decreasing reimbursements, ever-changing modality applications and inefficiencies with information and image management workflow. When it comes to radiologist staffing, it is getting more challenging to appropriately staff with the full breadth and depth of radiology expertise needed to support all modalities and physician specialties. Radiology staffing options that are available include: on-site full time radiologists, local group practice contracts, locum tenens, subspecialty teleradiology and traditional night time teleradiology service providers. A single staffing model just doesn t adequately support physician and patient needs anymore. Imaging facilities are using a blend of on-site and virtual staffing models to get the right mix of general and subspecialty interpretation expertise to ensure physician satisfaction, increased referrals, improved patient outcomes, mitigation of malpractice exposure, and ability to support new revenue streams as a result of high end modality purchases. What role does subspecialty radiology play in this equation as a primary deliverable, a complementary service provided when required, or a luxury considered as a nice to have? Imaging centers can gain a competitive differentiator based on the quality of their report which is directly related to the subspecialty expertise of the radiologist. In hospitals, radiology is a key revenue center, and administrators are looking to subspecialty radiologists as a means to increase referrals by targeting specialty physicians such as: orthopedic surgeons, neuro surgeons, spine surgeons, podiatrists, chiropractors, etc. Advancements in MRI and MDCT coupled with clinically specific reports enable imaging facilities to quickly establish a competitive advantage and increase revenue streams. What is the appropriate strategy for your facility? Answering this question requires the imaging facility to go through a discovery process in order to evaluate and select the appropriate model. These steps will help guide you through some thought-provoking questions that can enable you to prioritize your needs and determine the most optimal radiology staffing strategy for your facility. 1. Know your referring physician base and understand their specific interpretation needs. Who makes up your core referring physician base today and which physician groups orders the most studies? What is the percentage breakout across all your referrers? (i.e., orthopedic surgeons 40%, primary care/internists 30%, neurologists 5%, neurosurgeons 5%, oncologists 20%). Who are your most demanding physicians and why are they demanding? What do your physicians expect to see in their radiology reports? For example, Does the report provide the detail and direction they need to treat their patients? Does the report refer to specific anatomy and pathology? Does the report utilize medical terms that relate to their area of clinical specialty? Can physicians get quick access to a radiologist for consultations? Does the report turnaround time meet physician needs? Do you offer a post operative QA process? Have you been providing them the reports and service they need? A survey may be needed in order for you to garner specific satisfaction information.

2 Page 2 of 8 How important is physician satisfaction to you? What are the key things you can do to improve it? Do you know which physicians in the community are not being well served by other radiology providers and could these physicians be sources of new referrals? 2. Understand your business, referral base, procedure volume, report turnaround, reputation, growth opportunity and goals. Breakout the number of exams by modality, by procedure type, and by area of subspecialty. Rank the profitability of procedures from highest to lowest. How can you maximize profitable exams? Determine which modalities are planned to be purchased, and whether or not you have existing radiology expertise to interpret images from these new modalities. Do you know the optimal mix of general radiologists vs. subspecialists (i.e., musculoskeletal, neuroradiolists, body and cardiovascular specialists) to appropriately support your imaging volume and physicians needs? How have your physician referrals grown or decreased and do you know why? Determine which new referral groups you plan to target, and whether your subspecialty radiology expertise can serve these new targets. How do you evaluate the success of your radiology department or imaging center? Are your key benchmarks based on clinician and patient satisfaction, report turnaround, report quality or revenues? How do you differentiate your radiology services compared to your competitors? What do you want to be known for? Do these messages come through clearly in your marketing materials? What is your reputation in the medical community? 3. Know your competitors. Who are your key competitors? Is it the specialty physician groups, hospitals or imaging centers? How close is the next imaging facility? Do you all have comparable modalities and services? Who is doing their interpretations? Do they have more subspecialists? What is your competitor s reputation and what are their key differentiators? 4. Determine the key criteria you need in priority order for developing your optimal radiologist staffing model. What procedures do you need a general radiologist to cover? (i.e., STAT, emergency room, injection coverage, CT, X-Ray) What types of subspecialty radiologists do you need to support specialized physicians (i.e., orthopedists, neurosurgeons, neurologists, cardiologists, spine surgeons, rheumatologists, pediatricians, etc.)? Do you need contracted radiologists for vacation coverage? Do you need radiologists who proactively consult with your physicians? Do you need night time emergency coverage? Does it matter if radiologists are on-site, local or remote? Is a blended approach of on-site and virtual subspecialists the most optimal solution? The criteria should be driven from what will best support your referring physician base and patient needs as well as specific business or radiology departmental goals. Typically, subspecialty expertise, cost, location, consultative approach w/referrers, services/support, recruiting efficiency are key factors for decision makers. The most challenging aspect of radiology staffing is finding the subspecialty experts. The additional training required to be a subspecialist is a disincentive to enter the practice and fewer residents are taking fellowships. The subspecialty shortage today could be a particular issue for imaging facilities hoping to grow volumes in clinical areas such as neurological MRI or abdominal CT, according to the Healthcare Advisory Board. 5. Understand the staffing model options available to you and determine how each meets your specific requirements in priority order, or very likely it may be a blended approach that best supports your needs. Compare apples to apples. Understand the benefits and differentiators between each. On-site, full-time general radiologist On-site, full-time subspecialist

3 Page 3 of 8 Contracted local radiology group Locum tenens Subspecialty teleradiology Traditional teleradiology (i.e., night time preliminary reads) Interpretation Provider Type On Site, Full- Time General Radiologist On Site, Full- Time Subspecialty Radiologist Contracted Local Radiology Group How it Works? Advantages Disadvantages Benefits Imaging facility recruits and hires full-time, on-site general radiologist. They work days and weekends, and may be supplemented by night time service and locum tenens for vacation coverage. Imaging facility recruits and hires full-time, on-site subspecialist (i.e., neuro, MSK, cardiac imaging, PET/CT). They work days and weekends, and may be supplemented by night time service and locum tenens for vacation coverage. The imaging facility signs a contract with a local group of radiologists to provide all interpretation services. The group may be a combination of on-site and virtual rads working days, evenings and weekends and may be supplemented by night time service. On-site rad will act as radiology medical director as needed. The group handles professional High availability for injection coverage, X-Ray, US, CT, mammo, fluoro, BD, etc. Marketing face to hospital surgeons or local healthcare community. High availability for subspecialty interpretations. Marketing face to hospital surgeons or local healthcare community. Group is responsible for recruiting. Comfort level and local awareness of using doctors in community. If a larger group, a good chance of subspecialty expertise on staff exists. High recruiting/salary costs. Narrow level of expertise and should not be reading more complex subspecialty studies (i.e., MSK, neuro, spine) which could result in malpractice exposure. High recruiting/salary costs. Hard to find subspecialists, especially in rural areas. Radiologists may not effectively read all general, on-call, vacation coverage and subspecialty interpretations, or their level of expertise may diminish if they do not get enough volume of subspecialty work. Dedicated subspecialty experts typically do not want to read general studies. Need to check quality of systems, security and infrastructure if using a teleradiology system. Company stability will this group be around for a while? Support and Services need to ensure that radiologists participate in medical staff meetings and proactively consult with referring physicians. Facility has no control over radiologists or having the right mix of subspecialists vs. generalists on staff and knowing who actually Convenience of being on site. Cost Savings - Typically a lesser salaried radiologist than an on-site subspecialist. Radiologists costs easier to predict. Convenience of being on site. Flexibility subspecialists handle various types of exams, plus subspecialty exams. Radiologists costs easier to predict. Reduces headaches and costs related to recruiting. Provides access to broader group of radiologists and expertise (if a larger radiology group). Supports local physician community relations.

4 Page 4 of 8 service billing. Locum Tenens Imaging facility contracts with a Locum Tenens (temporary staffing) service provider who places a radiologist(s) on site for a specific amount of time. May need to be supplemented with additional night time service. Subspecialty Teleradiology Group Fast access to radiologists. Flexible scheduling. does the work. Hospital administration may have to act as facilitators between radiologists and medical staff. Radiology group may also have ownership in a competing imaging center which may create a conflict of interest for the hospital. Expensive, especially over a long time frame ($650,000 per year vs. $400,000 average radiologist salary). No quality control variable skill sets, expertise levels, experience and report consistency. Less likely to be able to get subspecialty experts. Company stability will this group be around for a while? Support and Services need to ensure that radiologists participate in medical staff meetings and proactively consult with physicians. Need to check quality of systems, security and infrastructure if using teleradiology system. Company stability will this group be around for a while? Licensing physicians have to be licensed in the state where the procedure is performed. Support and Services need to ensure that radiologists participate in medical staff meetings and proactively consult with physicians. Reduces headaches and costs related to recruiting. Provides access to a broad pool of radiologists (however, staff may be varied in terms of expertise and experience). Imaging Teleradiology Increased facility either signs allows any facility in physician satisfaction due contract for group to any location to access to high quality, clinically manage all high quality specific subspecialty interpretation services subspecialty expertise reports. (combination of onsite no limitations Competitive radiologist(s) because of geography, advantage by focusing on supplemented with availability or cost. report quality and virtual access to Convenient, dedicated subspecialty subspecialty one-stop shopping for expertise of radiology expertise) or utilizes on-site and virtual staff. group for virtual subspecialty staffing to Reduces subspecialty reports handle all headaches and costs only. interpretation needs related to recruiting. There can effectively. Improved report be a combination of Group is quality reduces/eliminates on-site and virtual responsible for over reads/second subspecialty rads recruiting. opinions. working days, Cost evenings and effectiveness imaging weekends and may facility can utilize be supplemented by subspecialty experts when nighthawk service. needed vs. having to hire On-site or full-time, highly-paid virtual radiologist will

5 Page 5 of 8 Teleradiology Group (traditional night time coverage) Injection Coverage act as radiology medical director as needed. The group handles professional service billing. Typically just a DICOM connectivity box to hook up to modalities is required. No PACS is needed. Imaging facility signs contract with teleradiology group which typically handles preliminary or wet reads to support night time emergency room reads. Typically just a DICOM connectivity box to hook up to modalities is required. No PACS is needed. Imaging facility pays the teleradiology group on a per report basis. Consider a retired radiologist or local or locum tenens general practice physician to handle injection coverage. Good for on call, STAT reports at night, especially needed in hospital/er settings. Easy to find vendors who do this. Relatively low cost for reports. Less costly and easier to find than radiologists. Quality of reports (lacking subspecialty expertise on staff). Cannot control the quality of radiologists. Radiologists more likely to have been trained and/or live outside U.S. Potentially higher turnover - radiologists in this environment may get burned out quickly. Another resource to manage. subspecialists. Mitigates malpractice exposure. Improves fulltime, general radiologists efficiency and satisfaction level by providing evening/ emergency preliminary reads. Easy and cost effective way to provide the appropriate coverage needed. Increase radiologists satisfaction by eliminating/reducing their time spent on this. 6. Build your needs matrix based on procedure volume and type analysis, goals and budget, etc. The best way to build an optimal staffing strategy is to ensure you are meeting the needs of your physicians. Determine how much general interpretation volume you do compared to subspecialty volume that requires specific expertise. Then determine the best way to staff according to your needs. With the options available today, you can find the appropriate strategy by blending a combination of on-site and virtual radiology coverage. Procedure Mix Sample - To Appropriately Match Procedures with Expertise Sample Size Total General General Subspecialty Subspecialty Radiologists from 200+ Procedure Radiology Radiologists Radiology Needed By Procedure Type bed Volume Procedure Needed By Procedure and Volume Community Volume Procedure Type Volume Hospital and Volume X-Ray 30,000 30, CT 6,000 3, ,000 1 Neuroradiologist, 1 MSK Specialist, 1 Body Specialist MRI 3, ,000 1 Neuroradiologist, 1 MSK Specialist, 1 Body Specialist Ultrasound 3,000 1, ,500 1 Body Specialist

6 Page 6 of 8 Nuc Med Total 1,000 43, , General Radiologists in Total 1,000 8,500 (assumes a mix subspecialty procedure types) 1 Nuc Med Specialist 1-MSK, 1-Neuro, 1-Body, 1-Nuc Med (Not enough image volume to justify hiring all for full time work) By reviewing this example one can see, that in order to get the most appropriate expertise matched up to procedure type and volume, it requires six radiologists two general radiologists, one musculoskeletal specialist, one body specialist, one nuclear medicine specialist and one neuroradiologist. The challenge is that the volumes for the subspecialty cases are too low to justify the hiring of all these full-time subspecialists. Typically the imaging facility would hire the general radiologists, who will also have to read subspecialty cases, in which he or she may not have expertise, or one general radiologist and one subspecialist would be hired to do everything, and then the subspecialist may loose their expertise level in their particular area of subspecialty. The knowledge base that today s radiologist must maintain across all modalities and medical specialties is far too great for any one radiologist to be expert in everything. By tapping into a radiology or teleradiology group that has a large number of dedicated subspecialists and can also offer on-site general radiology support, an imaging facility gets the optimal staffing strategy to support its procedure volume and physician interpretation needs. F&S Example After an evaluation was done by F&S for a prospective client, it was determined that the radiology department which interpreted approximately 100,000 annual cases could reduce its full-time, on-site staff of three radiologists to one complemented with access to the subspecialty teleradiology network. This would provide the hospital with a more appropriate pairing of radiologist expertise needed to support the specialty referring physician base. Physicians Served Orthopedic Surgeons Internal Medicine/Primary Care Cardiologists Traditional Model Imaging Facility (Approximately 100,000 Procedures) Neurosurgeons Neurologists Chiropractors Rheumatologists Spine Surgeons Podiatrists Oncologists OB/GYN Pediatric Distributed Subspecialty Teleradiology Model Imaging Facility (Approximately 100,000 Procedures) One On-Site Radiologist Complemented By Subspecialty Teleradiology Network 3 On-Site Radiologists To Handle All Studies From All Modalities More Than 30 Subspecialists in the National F&S Teleradiology Network Musculoskeletal (MSK) Experts Neuroradiology Experts Body Experts Cardiovascular Experts Pediatric Oncologic F&S Support Services - RT Support Modality Protocols - IT Support - Transcription - Licensing/Credentialing - Marketing Blended on-site and virtual radiologist staffing model.

7 Page 7 of 8 7. Research your radiologists and check references. Review the radiologists CV s. Uncover the level of expertise, academic experience, education, fellowships, presentations, papers, etc. Are the radiologists board certified? Do the neuroradiologists have Certificate of Added Qualification (CAQ s)? Ask how many specific studies by subspecialty area (i.e., MSK shoulder, MSK knee, Neuroradiology spine, etc.) the radiologists have interpreted to determine expertise. True expertise level is achieved only after a minimum of 10,000 cases in a specific area of subspecialty and then requires that much annually at least to maintain it. Check their references which should include referring physicians. Ask for samples of their reports or to do test interpretations and show them to your physicians to see if the reports meet their needs. Gain insight as to how proactively the radiologists collaborate with clinicians. With radiology groups or individuals utilizing teleradiology systems ask their current clients about report quality, turnaround time and service level. Ask about teleradiology infrastructure, bandwidth, security, and scalability to support growth. Ask about the implementation process/costs and client support services such as IT, RT, credentialing and licensing. 8. Build benchmarks to evaluate performance revenue, costs, physician and patient satisfaction, etc. Benchmark your key performance metrics such as report turnaround time and referring physician satisfaction. Seek feedback from referrers on the report quality, turnaround time and consultation service of your new radiologists or radiology group. Evaluate your procedure type and volume to ensure that you have the right balance of radiology expertise that ideally supports your interpretation needs. Adjust your staffing arrangement as needed to always ensure your physicians and patients are getting the radiology services they need. In conclusion, by focusing on the physicians interpretation needs and procedure types and volume as a means to develop the optimal integrated staffing strategy between on-site and teleradiology staffing models an imaging facility can get the right mix of general, subspecialty and night time radiology interpretation expertise to ensure physician satisfaction, increased referrals and improved patient outcomes. Additional benefits of the blended strategy include the mitigation of malpractice exposure, ability to support new revenue streams as a result of high end modality purchases, and increased credibility in the medical community by improving the level of expertise geared toward each physician group that refers patients to your facility. What is a Subspecialty Radiologist? The rapid growth for subspecialty radiology during the past few years has been driven by a convergence of a number of market and technology drivers: the growing complexity of modalities, the shortage of radiologists, the economic pressures on practices to deliver healthcare at the most efficient staffing levels, and the realization among imaging facilities that report quality can become a competitive advantage for growing the practice. True subspecialty expertise can only be achieved by interpreting a high volume of specific cases and most traditional imaging facilities do not generate a high enough volume of annual subspecialty cases (MSK, neuro, etc.) per radiologist to build or maintain expertise. For example, typical imaging facilities generate approximately 1,500-5,000 total musculoskeletal (MSK) cases a year, which must then be divided up between the radiologists. It is the opinion of F&S that expertise is achieved after a radiologist interprets 10,000-15,000 cases in a dedicated subspecialty area and then requires an annual volume of 10,000-12,000 cases to maintain his or her expertise level. True maturation is achieved at 30,000-50,000 cases. It is also very challenging to find on-site subspecialty experts across all geographical areas since the radiology shortage is even more pronounced with subspecialists. This is why subspecialty teleradiology networks are emerging as a solution to the shortage and expertise challenge because they employ the hard-to-find subspecialty radiologists who can live in any location. Images, information and reports are distributed quickly and securely between radiologists and imaging facilities through teleradiology platforms. Additionally, because these virtual networks aggregate subspecialty cases from imaging facilities around the country they have the high volumes required to maintain the expertise levels of their radiologists.

8 Page 8 of 8 About Peter D. Franklin, M.D. Dr. Peter Franklin is the co-founder and Medical Director of Franklin & Seidelmann Subspecialty Radiology. In this role, Dr. Franklin is responsible for radiologist recruiting and training and is the key liaison between the radiologists and the company. Based in Boston, Dr. Franklin is considered to be one of the country's leading experts in teleradiology, having provided the service since its infancy in Prior to developing a teleradiology service, Dr. Franklin served as Chief of Body and Musculoskeletal CT and MRI at Boston University Medical Center and Director of Musculoskeletal and Body Imaging at Somerset Diagnostic Centers. At Boston University Medical Center he created the first CME course that combined orthopedic and radiology faculty for the purpose of teaching both specialties to interpret musculoskeletal MRI examinations. He has promoted this unique philosophy of a combined approach and a close working relationship between orthopedic surgeons and radiologists to elevate the level of diagnostic excellence and improve patient care. This model is now the standard in sports medicine MRI courses. Dr. Franklin provides services to the NFL's San Diego Chargers and Chicago Bears, as well as many other elite athletes and hundreds of orthopedic surgeons. His extensive credentials include: American Board of Radiology, Board Certified Residency: Boston University Medical Center (Chief Resident), Boston, MA Fellowship: CT and Vascular/Interventional, New England/Deaconess Hospital Visiting Fellowship: MRI, University of California at San Francisco, San Francisco, CA About Franklin & Seidelmann Subspecialty Radiology (F&S) Franklin & Seidelmann Subspecialty Radiology is a leading, national subspecialty radiology interpretation provider in the U.S. serving imaging centers, in-office practices, radiology groups and hospitals. F&S provides in-depth, clinically specific reports that meet the needs of orthopedists, neurosurgeons, neurologists, spine surgeons, cardiologists, rheumatologists, and podiatrists, among others that make up the 14,000 physicians who rely on strong academic and subspecialty expertise. The F&S network of more than 30 subspecialty radiologists, who combined are licensed in 50 states, includes: board certified musculoskeletal, body, and cardiovascular specialists, and neuroradiologists with CAQ s. F&S radiologists have advanced training in 3.0T and 1.5T MRI, MDCT, and PET/CT. F&S utilizes a sophisticated teleradiology platform to deliver reports quickly and securely to clients and referrers. Founded in 2001 by two pioneer subspecialty teleradiologists, F&S is located in Cleveland, OH, with more than 140 clients and 90 employees.

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