In Radiology, Turnaround Time is King

In today’s health care environment, radiology is being asked to be the Medical Six Million Dollar Man – the specialty is expected to be better, stronger, and faster than before. And, integral to that achievement is the quickest radiology report turnaround time possible.

The quest for the most rapid turnaround time (TAT) isn’t new – in many ways, it’s been the Holy Grail of radiology for nearly a decade. But, there’s a growing number of tools now available that are designed to shave away the amount of time it takes a radiologist to read a study and return his or her diagnosis to a referring physician. The question plaguing providers – and industry experts – is how fast is too fast?

“Turnaround times are variable. Some tests require 15 minutes to read, such as chest X-rays for pneumonia or CT scans for brain bleeds, and others require longer,” said Eric England, MD, radiology assistant professor and residency director for the University of Cincinnati College of Medicine. “The biggest issue is that this is being used as a way to measure the quality of radiology services. Rather than the quality of the report, more emphasis is placed on the turnaround time.”

Importance
According to a 2013 Imaging Performance Partnership TAT survey of 86 hospitals, imaging centers, children’s hospitals, and academic medical centers, hospital and practice leaders rank efficient TATs among their highest priorities – assigning it a 5.7 and 5.5 out of 6 rating, respectively.[[{"type":"media","view_mode":"media_crop","fid":"43301","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5942693187877","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4715","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 107px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Peter Gudella/Shutterstock.com","typeof":"foaf:Image"}}]]

The emphasis placed on TAT has already sparked changes, based on survey results. Between 2009 and 2012, reading times for non-advanced imaging in all care settings dropped by 54.5%. For example, emergency department (ED) TAT dropped from an average of 2 to 4 hours to between 30 minutes and 2 hours; inpatient times from same day to 4to 8 hours; and outpatient from 24 hours to 4 to 8 hours. Making these changes is vital to demonstrating radiology’s impact and importance, study authors wrote.

“Ensuring radiologist performance on fundamental aspects of reading and reporting is a critical starting point for radiology group leaders looking to remain competitive and demonstrate value to hospital partners,” authors wrote about the survey results.

The Sweet Spot – Can Everyone Reach It?
There’s been much discussion about just how quickly radiologists should be able to read studies. As it turns out, there’s not one timeframe that works for all providers, England said.

Currently, according to several existing studies, the golden TAT number is one hour for much of the industry. And, private practices hold an advantage in reaching that threshold and going lower, he said, because reading reports is their only focus. With workflow strategy tweaks and technological advancements, these groups can potentially drive TATs down to 30 minutes.

That’s not the case for academic medical centers. These institutions, including England’s, must consider their teaching responsibilities to radiology residents when designing institutional TAT standards. The time spent having residents review studies, giving feedback, and providing a second read means academic centers will likely have longer TATs than private practices.

“Academic administrators must work hard to be innovative in how they increase the throughput of cases without jeopardizing the quality of residents’ studies,” he said.

To truncate TATs as best as possible, department leaders at the University of Cincinnati opted to limit the number of ED cases in which residents participate. They now use iPads to make it easier for providers to sign-off on cases dictated by residents in a more-timely manner, and they also made one attending physician on each shift responsible for signing off on all ED cases.

So far, extensive TAT analyses at Cincinnati and other institutions have shown that a one-hour time hasn’t degraded report quality, but concerns do exist that pushing it lower could have a negative impact, he said.

Steps for Speed
In a recent Institute for Healthcare Improvement (IHI) report, IHI leaders and representatives from the radiology standards-based solutions provider Radisphere, discussed the need for performance standards if institutions want to control and manipulate their TAT. Performance measures, such as diagnostic accuracy, utilization, and the need for special interpretation all contribute to the final TAT and when referring physicians are notified. 

In response to this call, the American College of Radiology launched the General Radiology Improvement Database, giving practices a way to compare their TAT to other facilities and discover new strategies that might be helpful.

In addition, in 2012, medical information technology company Sectra surveyed a wide swath of referring physicians – neurologists, neurosurgeons, urologists, orthopedists, internists, and general surgeons – to see what changes would improve their relationships with radiologists. Improved turnaround times ranked highly.

“Achieving quick report turnaround times obviously requires an efficient RIS/PACS solution with closely integrated tools, such as speech, intelligent display protocols, 3D visualization, and other clinical applications,” said Hans LugnegÃ¥rd, product manager for Sectra’s Diagnostic Imaging Suite. “Another key for improving efficiency is data mining, which enables bottlenecks to be identified and the effect of implemented changes to be measured.”

Carefully evaluating department or practice workflow and activities can also identify changes that could contribute to lowering TAT, according to Nicole Hardin, radiology director at Children’s Hospital & Medical Center in Omaha, NE.

Going through this checklist could be beneficial, she said:

• Identify paper-based functions that cause delays

• Create standard hanging protocols for a variety of reading situations that occur

• Collect data to support investing in new hardware, software, or personnel

• Train physicians to use systems to efficiently organize and share images, teaching files, and reference case information

• Ensure image viewing and storage systems can support increasing workloads

• Upgrade 3D reconstruction software to improve image quality and TAT

• Consider separating PACS administration and RIS administration responsibilities for potential time savings

Industry research from natural language and voice recognition software vendor Nuance also points to TAT-reduction benefits created through this type of product. Because these tools use templates and autopopulate many fields, facilities and practices that use any speech recognition software can see up to a 90% drop in TAT, as well as an 85% reduction in costs associated with report transcription.

Case Study: Cincinnati Children’s Hospital
While technology can help facilities drive TAT down, Cincinnati Children’s Hospital discovered through an interventional study that long-term change will require more than mechanical intervention. Changes in workflow design, reading room requirements, and structured reporting are also helpful.

In 2012, the hospital put its theory to the test in an 180-day study. They tracked the number of radiology reports read for the emergency department and the TAT for 90 days, and then collected data on the same measures for 90 days after instituting a variety of new strategies to reduce TAT.

Cincinnati’s radiologists e-mailed the radiology chair, detailing the need for lower TAT, and providers also received daily e-mailed TAT reports with comparative data. The department increased staffing, e-mailed providers efficiency tips, and provided one-on-one efficiency training when needed.

After 90 days, the department reached its goal: the percentage of studies read and returned in less than 35 minutes increased from 82.2% to 92.9%. In fact, average TAT fell from 15 minutes to 10 minutes.

Overall, England said, achieving lower TAT is achievable for almost every practice, hospital, or group. It’s a step facilities must take in the pursuit of improved patient care.

“You don’t want to have a patient sitting around all day for something that you could take care of relatively soon,” he said “They’re likely to get sicker if they sit in the hospital too long.”