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Disclaimer: Described video not needed. The visuals in this video only support what is spoken. The visuals do not provide additional information Lisa: Hello and good afternoon. We appreciate you joining today's Imaging Virtual Pulse, where we're going to be discussing the emerging business models in radiology. As everyone starts to join, I'm just going to go over a couple housekeeping items. If you are having any issues with your sound, you can check the Audio section in your dashboard where you can either join via your computer, but if you are having issues that way, you can always dial in via the phone number and passcodes that are in that audio section. We do want you to ask questions, so as we're going through this discussion, please put those into the chat in your dashboard as well. There is a question section where, as the session, goes, please feel free to ask, and we will try to get to as many questions at the end as we can. Lisa: After this session, we are going to be sending out an archive of the recording as well as the opportunity to register for the next Virtual Pulse. We do want you to complete the survey, if you can, at the end. That will automatically launch at the close of the webinar, and we'd appreciate your feedback. Again, we have a great agenda for you today. We have two speakers with us that we'll meet here shortly with our host, Russ Cardwell. Again, they're going to be having this discussion with the emerging business models in radiology. Then at the end, we will get to those questions. Russ, I am going to pass it on over to you so you can introduce our speakers. Russ Cardwell: Excellent. I'm Russ Cardwell. I'm Vice President of our Imaging Sales with 3M M*Modal. I'm delighted to do this Virtual Pulse #3 in our series. Today, we have Chad Wiggins, who's the CEO of Charleston Radiology and also a board member of RBMA. We also have Dennis Wiseman, who is the CEO of Radiology & Imaging in Corpus Christi, Texas. We are delighted to have them with us today. We wanted to get into, continue our discussion that we've been having about some of the radiology pressures that are in the market today, reimbursement and some of the ways to mitigate or improve that. Today's topic is going to be about emerging business models in radiology. Before we get into the meat of that, I do want to let our guests introduce themselves and tell us about themselves, their experience in the industry and the market that they serve. Chad, would you go first, please? Chad Wiggins: Absolutely. Thank you, Russ. It's a pleasure to be with everyone today. It's an honor to support, I think this is a wonderful mission that you're putting forth, to continue educating the population of some of the challenges that we're having nationally. I am from West Virginia originally and did undergraduate studies at Marshall University, graduate studies at Xavier University in Cincinnati, where I met my lovely wife of 22 years, Christi. We now reside in lovely Kiawah River, South Carolina, and I've had the privilege of being the CEO of Charleston Radiologists since December of 2018. I bring 24 years plus of executive level experience, both hospital system, private practice, both in radiology and orthopedics. Russ Cardwell: Thanks, Chad. Dennis, can you go next? Dennis Wiseman: Yes. Dennis Wiseman. I'm the CEO of Radiology & Imaging of South Texas in Corpus Christi, Texas. We cover CHRISTUS health system and two wholly owned imaging centers. Grew up outside of Baltimore between Baltimore and Atlas, went to Miami for college, met my wife down there, Alva, and three children, one that's in Miami going to college and two boys who are in sixth grade and eighth grade now. I have been running radiology practices since 1998. One of them started in Fort Lauderdale, moved to Miami, a group there that was, I think at the time, probably about the fifth or so largest private practice in the country. Then subsequently in Corpus Christi, Texas, where I've been there for six years now. Russ Cardwell: Excellent. Thanks so much, Dennis and Chad. Well, we're excited to have you here and your rich experience will certainly be appreciated, I'm sure, with our audience today. Can we dive, first, into some of the top challenges your organization is facing today in the market? It could be technology or reimbursement. What are those top challenges you're facing today? Maybe, Dennis, I'll have you go first on this one. Dennis Wiseman: Obviously, reimbursement is always a top challenge, because there are an automatic DRA cuts of 2% to 3% on a yearly basis. We did receive, radiology, receive about a 6% cut this year. We're looking at another, depending on the specialty, either diagnostic or interventional, we're looking at somewhere between a 6% and a 10% cut for next year again. Those are the constant challenges that we have ongoing, each and every year. How to mitigate that is like swimming in shark water, basically. Chad Wiggins: Covered in chum. Dennis Wiseman: The other aspect is recruiting now. I think everybody's feeling that pain. You have the ability for individuals to work from home, which we've had for some time since transitioning over to a computer-based PACS system, but with COVID and all the influx have occurred, it has further proven that individual physicians, diagnostic physicians can work from home and staff hospitals less than what they were accustomed to, if you will. Trying to find somebody that physically wants to either come to a city, sit in a hospital seat versus sitting at home and reading, those are the challenges that we're facing most recently. Russ Cardwell: Yeah, that's certainly consistent with some of the things I've heard. Chad, would they be similar challenges in your market, or would you have anything additional to add? Chad Wiggins: Ours is, Russ, yes, I have the same challenges that Dennis does here in the Charleston market. Additionally is maintaining relevance with your health system and transitioning away from just being a contracted service to a partner. That is going to be reinvestment into the practice, technology, human capital, the willingness to expand your services across the continuum and really make the system reliant upon the value add that we bring to the table and the depth and breadth of talent that we have from a physician team. We are looking right now at a heavy re-investment into the IT structure, and it's daunting to get private practice physicians who are working extremely hard to focus two and five years down the road and reinvest into the practice, because you're reinvesting into a very tumultuous time in our specialty. Chad Wiggins: You have to have the foresight and you have to have that strong willingness to withstand the onslaught of health system encroachment from employment, national practice encroachment on transaction and I'm a zealously independent individual, personally, and I push that very strongly with my physicians. I will do anything to protect them and the practice and keep them as independent and thriving in our market as possible. Russ Cardwell: Yeah. That's quite a challenge, a set of challenges in front of you both and, really, for all leaders in the radiology industry these days. This certainly is, again, a continuation of some of the budget pressures we've heard. Our first Virtual Pulse, we had Dr. Schoppe talking about the budget neutrality impact and how it was a win to only have a -4% reduction across the industry. Obviously, some markets are higher and lower, but that the expectation would be similar for future years. If we ever got to a year that was a zero, no increase, that would be a huge win. Chad Wiggins: Yeah. It's sad. Russ Cardwell: Maybe you can tell me a little bit about some of the strategies about how you've touched on some a little bit, some of the strategies, either with your hospital partners or you touched a little bit on IT, but Chad, do you want to go first on this one in terms of how you redesign the relationship, maybe, with your hospital partners? Chad Wiggins: Absolutely. We are working on that strategy right now, Russ. We survive off of two PACS systems right now, one hospital-based, one owned by the practice. We're trying to change the thought process and create what we call stickiness to our Provider Services Agreement with the health system. What we mean is, we're going to look at it more as offering the technology solution, have the hospital get out of that aspect of radiology, let us manage what we know best. Then you create a more symbiotic relationship. That's going to get to what everybody's trying to strive for, which is unified work lists, the distributed work lists, maintain PACS, maintain your voice recognition. Sell that back to your health system in a partnership approach. Chad Wiggins: Then what happens is, they become dependent on us as we're dependent on them for the volume. Rather than having annual conversations of relevance and listening to national practices come in and try to undermine, what's happening here is, we're going to take the approach that we can provide. We're the experts, and we're going to do everything possible to give the best patient experience. We're starting that dialogue. They're being very receptive, but it's going to be a very time-consuming and challenging road. Russ Cardwell: I'm sure there'll be many stakeholders to convince along the way, too. Chad Wiggins: It starts internal. Trust me, Russ. Russ Cardwell: I'll bet. Dennis, how about you? How are you trying to redefine that relationship with some of your local providers in your market? Dennis Wiseman: I come from a group in Miami that, the hospital system relied on our physicians and leadership to direct them in aspects. You're talking years ago when you first got into PACS and/or voice recognition and our equipment. Some hospitals just purchase these things without any interjection from the group, and that relationship that we did have with that hospital system was very good in the fact that they let us lead the way for them. Now, they're the ones that wrote the checks and they're the ones that were part of the visits with us, but we are the ones that drove the bus, if you will, during that process. The current hospital system, at times, is a little forward-thinking, but a little backward, normal. I say backwards. It's normal, I guess, if you will, that they're the ones that are in charge and wants to keep things going. Dennis Wiseman: Alluding to what Chad said, I think it's a time-consuming, painstaking at times, conversation that you have, but again, we're not managing their system. We're managing a subset of what we do internally with the help of them. Either they're purchasing it or going through what Chad had described of them purchasing it, managing it and offering that product, et cetera, to the system. Maybe a little bit difficult during the process for Chad, because it is a national hospital system, even though they work in regions, if you will, but it may be a little bit easier for those independent hospitals or private hospital systems, too, to go with that. I'll go back to my statement with previous group that I worked with in Miami. They had about 340 IT individuals in their system, of which only six of them worked in radiology. Of course, you're talking about people that have, unfortunately, not a breadth of knowledge. Chad Wiggins: They don't have depth of knowledge. Right. Dennis Wiseman: Within radiology and/or hospital-based aspects and IT solving, if you will. Russ Cardwell: Yeah, that makes sense. You just hit on something that's pretty interesting. It's the IT folks that have the breadth of knowledge, but maybe not the depth in radiology, which brings me to another question I had with regard to, how do you balance the demands from your hospital customers, which we've started to talk about a little bit, but also, you have your own outpatient businesses that you're running as well? Do those needs and those priorities compete with one another, and if so, how do you work through balancing both? Chad Wiggins: They do, Russ, and I applaud our physicians. They're very adept at walking that tightrope. It's an interesting dialogue, because we have many customers. The most important customer we have is the patient, of course. That's the engine that drives all of this. If we keep that in mind and we stay sensitive to the patient experience, which is going to be more important each year as we move away from fee-for-service to value-based reimbursement, the patient's going to drive that dialogue. To answer your question, I applaud our physicians here in Charleston. They have a wholly-owned imaging center that has been thriving for 13 years, single-site, multi-modality. They are very quality-minded, both in their approach as clinicians as well as they reinvest into the center. We are cutting-edge technology. Chad Wiggins: The dialogue is interesting because you have to use it very adeptly, meaning you educate your community that we're the same physicians, the same quality and depth and breadth of talent that you get in the hospital setting, but you're getting it in an outpatient setting with greater access, same level of quality at a lower cost. That inherently is competitive dialogue against your hospital system, so we're outside of our catchment area, and that eases that tension, but nonetheless, you have to be very careful how you dialogue, because if you say we're better, then the hospital goes, "Wait a minute. Are you not providing the same level of service?" It's very interesting how you play this match. Russ Cardwell: Yeah. Dennis, you? Dennis Wiseman: I agree with that. I think we're probably a little unique in my market, because we do compete with the hospital, but we also offer services that they don't offer. We actually have one of our imaging centers across the street. It's a nine-iron away from the hospital. Chad Wiggins: Seven-iron for you. Dennis Wiseman: Tomato, tomahto. It's weird and strange when I first got there, but looking at the relationship that we do have with the hospital system, that it has eased any tension whatsoever. There's never been a contentious aspect of us having an imaging center when you walk out the front door of the hospital. Again, we work symbiotically with the hospital system in regards to services, either same services or different services. They rely on us to help them out in times of need where their system may be down or they don't offer those services. Chad Wiggins: Obviously, the interventional aspect, Russ, is very important. We have seven FTE of interventional radiology talent in our practice. That is, in my opinion, very important for a strong practice to not only survive and maintain independence but actually thrive in the market, because we are touching the patient. We are providing those procedure bays. The talent that they bring to the table, the medical staff really becomes reliant. The ERs become reliant, and it's integral into the care continuum at these hospitals. Any time there's internal friction of diagnostic positions versus interventional positions, we try to calm those waters and say, "You know what? It's a codependency. You need each other." That allows the group to come and be forward thinking. Russ Cardwell: That's great. I was just going to say, you touched on it earlier with the idea that we're moving into a, from fee-for-service to value-based care. Consumers are going to have much more influence and be more interactive with their care, maybe, than they have in the past. The relationship that these IR radiologists have with the medical staff can have a big impact with your reputation in the market and how consumers view you and your services. How would you elaborate on that? Chad Wiggins: I see, in the next not two years, but probably within the five to seven-year range, Russ, what you're going to see is outpatient imaging is going to change from a revenue center to a cost center. We have to change our thought process, because it's going to be the entry point, much like primary care was the gatekeeper in the '90s. Imaging centers are going to be the gatekeeper into the care algorithm, and it's going to be a cost, but what you're going to do is you're going to front side your cost to make the appropriate diagnosis, make the appropriate intervention. Then you set the care for the patient and you're going to ultimately have a lower-cost outcome while maintaining a high-quality outcome. We need to think about that, because that's a major schism that we're going to have to bridge when we're looked at as a cost center, but we need to participate into the value-based model to get a piece of that downstream savings. It's going to be a challenge when you make that move. We have to prepare now. Russ Cardwell: Yeah, that makes sense. Dennis, I think maybe related to that question is one about these employment trends. We've been seeing more radiologists become employees of radiology groups or even medical systems, for that matter. How would you talk about that in relationship to the consumer becoming more involved in their care? Do you see that aiding? How would you talk about the employment trends affecting patient care for radiology? Dennis Wiseman: You always get into the aspect of, once you become employed, and we've seen this time and time again with other groups that had been employed by the hospital system. There is a certain amount of money that is given to these physicians up front that wanes over time. Then it becomes a productivity-based aspect of things. It's a hard pill to swallow. I think it's relevant in some areas of the country, maybe rural communities, et cetera. I don't think there's a need for such or there should be a desire of the physicians to go that route in the larger or in mid-sized communities, if you will. You also have the two-play. You have the independent groups that are outside of the system, whether it be RadPartners or US Radiology, Mednext, what it used to do, or whatever it may be trying to get larger or you have the hospital-based employment aspect of things. The continuous care being a hospital employee, I don't see how that affects anything, to tell you the truth, whether you're an independent. Chad Wiggins: True. Very true. Dennis Wiseman: I think, again, alluding back to what Chad said, I look at our group. We don't have, or the hospital doesn't have breast imaging, women's imaging in their hospital system, in any of the hospitals. We provide that service outside. We do have interventional and those are the individuals that are touching the patients. It's not, the days are gone of the physician reading off the alternator and walking into the doctor's lounge and chatting with the physicians and/or picking up the phone because of nuance or dictaphone or voice recognition, whatever it may be. Therefore, the only people that are really having any interaction with those patients are the IR physicians or a mammographer. Chad Wiggins: Mammographers, yeah. Dennis Wiseman: That's how you, honestly, in my opinion, keep a relationship with the hospital, because now the patients, if they're filling out these survey forms, have somebody to talk to. It hasn't changed much from the day of, how did I get this bill from radiology? I never saw anybody. Who is this person? Chad Wiggins: Who are you? Dennis Wiseman: Yeah. It's probably a little less frequent now than it was when I first started in this business, but still, they could say Doctor X or Doctor Y, I remember him because he spoke to me or she spoke to me, one of those two. Again, going back to your question in regards to the process of being employed, I don't see that changing the care of a patient at all. Independent, a doctor's a doctor. It's not going to matter whether they're independent or they're employed. Chad Wiggins: I think- Go ahead, Russ. Russ Cardwell: Go ahead, Chad. Chad Wiggins: I think just to take that, to pivot a bit on that question is, one of the challenges we have is, the latest round of radiology residents and fellows coming out have a different mindset. They want an employment. In a private practice, it's all for one, one for all. Now, it's not a love-in by any means. We have debates, but at the end of the day, the physicians want to be reliant upon each other as shareholders, and some of the younger talent coming out are saying, "I want to come in. I want an employment contract. I never want to go to Chad's office. I don't care, and I want to provide good-quality clinical care, go home." I have a conversation with our leadership frequently that that's not necessarily a bad thing. They're not going to have the same level of risk, but they're also not going to have the same level of reward. Chad Wiggins: It's difficult for physicians to change their mindset and have an employment model as a track within the practice, but we will need to do that. We'll especially need to do it in the mammography setting. As that continues to grow, because we have a strong mammography presence here in our imaging center. In speaking with some candidates, they absolutely want to come in, do their shift and go home. It's changing the philosophy of groups in real time. Russ Cardwell: Yeah. I was just going to make the analogy. I don't know if it's fair. You can comment, but as hard as it is to go from fee-for-service to performance or value-based care, it's probably the same for having these equal shareholders of radiologists within a group to having an employment-based model. It's easy, maybe, to see the other side, but how you transition is the real difficulty, right? Chad Wiggins: Absolutely. We went through a complex refinance recap project on our real estate assets here in Charleston over the last eight months. The younger guys, I had to educate them, but I had to educate the older guys that we have to reset this or else we're not going to be relevant in the market from a recruiting standpoint. The older, tenured guys are like, "Just have them go borrow." We're not relevant any more. If a top quality physician coming out of Wake or Duke or Vanderbilt comes to us and it's going to be a stroke of a half-million to get into the practice or he can go 90 minutes up the road and [inaudible 00:24:59] a check for $25,000, where's he going to go? Russ Cardwell: Right. It makes it easy. Dennis Wiseman: Not coming out of school with the debt that they have. Chad Wiggins: 100%. Russ Cardwell: They already have a debt. Dennis Wiseman: And/or a family, and only working their tails off during that process and making, what does a fellow make? Maybe $100,000? Less than that? They're not coming in to borrow, to buy a house and I'm not going to buy into a practice which I am not going to see any rewards of that in the next couple years. I go back to what Chad was saying also. We're seeing it, too. The individuals, good, bad or indifferent, want to come out and they just want to work the 8:00 to 5:00. They don't want to work nights. They don't want to work weekends. They don't want to do that, and again, that's their prerogative, but it's a different mindset of what was out there before, internally and externally. Chad Wiggins: Exactly. Exactly. Dennis Wiseman: The biggest concern that I see, we as a practice, all my practices had a fair share of shareholders and employee physicians, but at some point, if you're in a smaller group like I am at the mid-teens, who do you have left? Especially if you have older physicians. Chad Wiggins: Very true. Dennis Wiseman: Who are there? You're going to have one physician left as a shareholder at some point? Chad Wiggins: That's 100% asset. Dennis Wiseman: Correct. Correct. Again, it's a fine line to walk. Maybe it's a scenario to where we're in the times currently and they may shift again in another X number of years, but it's relevant on both sides of things. Chad Wiggins: Very much so. Very much so. Russ Cardwell: That makes sense. I know just yesterday, the ACR, the Radiology Leadership Institute, they had a webinar about consolidation, consolidation happening in hospitals, imaging groups, payers. Just every side of the market is having this consolidation. These employment agreements are some of the results that we're seeing. That's my thought of it, but it presents you all with a different set of challenges, I think, as you move from these models. Chad Wiggins: Yeah, we're working on initiatives now to expand [inaudible 00:27:11]. It's going to be hard to do that. We're going to have to [inaudible 00:27:11]. Let me work on my mic. Apologize, audience. Is that better? Russ Cardwell: We've got you now. Chad Wiggins: Okay. You're right. Consolidation can, the issue is that if you are doing nothing as a private practice, you're actually regressing, and if you do not define, I know this is waxing poetic, and I sound like a Hallmark card, but if you don't define your strategy, either the payer community, the hospital community or the national practice community is going to give you your future. They're going to tell you what to do. I keep bringing that to the table to our stakeholders internally and saying, "Folks, we have to be strategically minded. You have to invest in yourself. You have to invest in your practice. You have to be willing to grow, and you have to quit looking at 12-month aliquots of W2 and K1 and hit a reset. Chad Wiggins: It needs to be a horizon of two to five years because what you want to do is, now we're appealing to the legacy aspect of these practices and saying, "Look, you've invested 30 years of your life into your organization. You want that to be another 30 years and another 30 years." It's starting to resonate. Our physicians are zealously independent guys. They're really, I applaud them. They're forward-thinking, but they're also nervous because you're investing in yourself at a risky time. Dennis Wiseman: I agree with that comment also. You have a scenario to where most groups, or all groups that I've worked with so far, is whatever you make, you take out of the kitty at the end of the month or the end of the week or the end of the year. Chad Wiggins: Or the end of the day. Dennis Wiseman: Again, it's a little easier if you're a hospital-based physician practice, a lot easier because you're not investing in anything except for manpower in the future. With an imaging center, you can't think that way. Going back to, and I've had this exact discussion with our physicians of, hey, you've been here since 1980. You've been here since 1990 and 1991, '95, 2000, whatever it may be. Wouldn't you like to see this legacy continue for the individuals that just joined our practice or the individuals that haven't joined our practice yet? Don't rob the kitty, per se, every year, just to make sure that you get your money out today. We're not talking about a lot, and we're not talking about a penalty, because you can put the money back in. You can pay that individual before April 15th and make sure that you make them whole in relation to taxes. Dennis Wiseman: There's many different ways of skinning the cat in that aspect, but again, instead of all of a sudden every seven years, you have to reinvest in new equipment at two million, five million, ten million, whatever that amount is depending on the imaging centers you have, why not have a reserve in there to utilize that, and you're not affecting cash flow at that particular time, because again, as we see, a couple years down the road, it's going to be less than it was today. Chad Wiggins: Or you can just take it out of your pocket. Dennis Wiseman: Yeah. Chad Wiggins: There's two pots of money. I've heard that before in my career. [inaudible 00:30:34] Russ Cardwell: Hey, I will wrap up with my last scheduled question, and then we'll go to the audience, but Chad, I'll probably start with you first and then go to Dennis. What would be three things that you would leave the audience with, or the three things that you're focused on to try to improve your business model in your market, that our audience might take away as well? Chad Wiggins: Quality, experience and respect. What I mean by that is, no longer is radiology, this really sounds bad. No longer is radiology in the dark. We have to promote ourselves and explain the value we bring to the patient care. I'm very focused on quality. Our group is very focused on quality. We're also reinvesting into our IT to create greater efficiency because our team works very hard and we have to maintain the balance between productivity and quality. I'll always err on the side of quality over productivity. I would rather us recruit and normalize their day so they have a healthy work-life balance, because I think we render better patient care. I applaud our physicians in Charleston. They're focused on that. They participate in so many of the boards at the hospital systems. We are integral into the care, how it's rendered, and we have to maintain relevance. You have to always be minded that there is one engine driving our specialty, and that's the patient. It's nothing else. If you do that, most of this will settle off. Russ Cardwell: Patient-centered care. Yeah, when you're focused on that, it's hard to go wrong and deliver high quality. Chad Wiggins: Yes, sir. Dennis Wiseman: I would add physician engagement to that. It's not, again, we've gone from physician engagement de facto because of the old school of pre-PACS and sitting in the physician lounge, whatever it may be, to- Chad Wiggins: Great point. Great point. Dennis Wiseman: That engagement is not only with physicians, but it's also with the patients. Come out and, if there's an ultrasound, peek your head in the ultrasound room and speak to the patient. It doesn't have to be just attack all the time. We are getting that in mammo, and you are obviously getting that in IR, but I think it needs to heed well for those individuals, especially sitting in an imaging center. Maybe it's a non-breast site, a women's imaging site. Again, you can walk down to CT. You can walk down to MR. Even if it's one or two patients a day, it's not the end of the world. Chad Wiggins: We do a much better job of that, Dennis, in the imaging center setting than the hospitals. Dennis Wiseman: Yeah. Chad Wiggins: Much better. We have a high patient focus here and it works very well, very well. Russ Cardwell: Yeah. That's been clear in talking to you over the years, Chad. Your patient focus is excellent. Thank you guys. These are some of the questions that I thought would be relevant for our audience, and Lisa, I guess I'll turn it back to you now for any questions that may have come through. Lisa: Yeah. Absolutely. This really has been a great discussion. We do have some questions. Before we get started, I am going to launch just a quick poll that, if you are interested in getting more information about any of our solutions, to please let us know through the poll. Some of the questions that we do have, the first one is from Rodney Scott, "Are you looking to implement a cloud solution for your PACS or do you have a large enough IT department data center to install an on-premise solution?" I'm not sure if either Chad or Dennis want to answer. Chad Wiggins: I'm sorry, Lisa. Dennis, you see what happens. Dennis was asking me a question. Could you please repeat it? Lisa: Sure. Are you looking to implement a cloud solution for your PACS or do you have a large enough IT department or data center to install an on-premise solution? Chad Wiggins: We are, that's a great question. We are actively evaluating that. We are on-site. We have the typical server farm and we are investigating as we speak. We are attempting to go virtual, and we have a very good IT partner that's external and we have two very good PACS administrators on site, but we're of size now that we need to virtualize ourselves, go cloud-based. Part of it is just the sheer capital that is expended and then the redundancy, the security of the data and just the ease of us. As we move towards a true unified worklist solution, we're going to need to virtualize every aspect that we can. Yes, we are. This is a very hot topic because it's not inexpensive, but we are moving rapidly towards that. As you know, we are a current Fluent customer, and we're very pleased with that. We're going to maintain that. The good thing is, we have some very good, technical partnerships and we're going to continue to grow that, but we have to change our thought process. Controlling the physical plant from an IT perspective is an antiquated thought process and it's almost dangerous, to some degree. Lisa: Great. I think this goes along with that. What would be your advice to other groups, considering the use of imaging AI going forward? A follow-up to that is, then what is the feeling among radiologists in your group using it? Two-part question. Chad Wiggins: Sure. From our perspective, I would say welcome it. To my colleagues out listening is welcome AI. I think that it's here, and it's only going to increase in use. To our physician community, especially my team, we have to look at it as a tool to enhance our quality, not something that's going to replace us. It's not supplanting the talent. It's actually improving the performance of the physician, allowing them to focus on the true care. If we use AI, it'll create efficiencies and it will allow us to perform better. It's a daunting conversation to get physicians to think in that regard. Dennis Wiseman: We've already seen it in CAT, right? Chad Wiggins: Exactly. Dennis Wiseman: This is nothing new. It's a new platform. It's a new exam that we're going to be utilizing it for, but it's something that we've already done. Maybe in a small section of our number of radiologists that are out there, because it's only in breasts, but it's either you've got to learn how to utilize it, or you're going to be told to utilize it, so you might as well get in on the front end of the aspect. Again, it's not going to be a scenario to where all of a sudden, we're out of a job, like some of the individuals in the auto industry, because robots took that over. That's not happening here. The computer system's not taking over. It is a tool to hopefully make us better as groups, as radiologists, as individuals, to see something that otherwise, whether nine out of ten or 19 out of 20, couldn't see with the human eye. Chad Wiggins: Correct. I agree. Lisa: Absolutely. Russ, did you have anything to add to that? Russ Cardwell: No. Just I think this AI or medical imaging AI is here to stay. There will most likely be a shakeout. What? There's something like 100 providers today. There will be some consolidation, but the tool itself, I think, is very complementary for radiologists and helps them deliver better patient care, which is really what it's about. It's here to stay. I don't have any further questions, but again, I want to thank Chad and Dennis here. Lisa, was there any more questions? Lisa: No, there wasn't. I just wanted to make sure that we did say to the audience that we will be having our third Virtual Pulse, Imaging Virtual Pulse coming up in November. I'm sorry, fourth. Gosh, where is this year going? Fourth, where we will be talking with Bill Algee, Director of Imaging Services at Columbus Regional, where he'll be going into a discussion similar to today with Russ about a day in the life of an imaging leader. After this, we will be sending out an archive email with the recording if you do want to listen in again, with the ability to register for the next one. Again, we do really appreciate the feedback, so please complete the survey at the end, but other than that, that's all I wanted to cover for the final thoughts. Russ, why don't you go ahead and close out for us? Russ Cardwell: Very good. Again, thanks, Chad and Dennis and the audience, for being a part of our Virtual Pulse series. We look forward to the next one and wish you all a great day. Bye-bye. Lisa: Great. Thank you. Chad Wiggins: Thank you. Have a great day. Bye.

(DESCRIPTION) Slide, New year, new webinar platform! A great company is showing what interesting applications a fantastic product can bring for motivated users. Blank elements are labeled in an image of the platform. On the left, a media player, Resources field, and a Q&A box. In the middle, a slide box and Ask An Expert button, and on the right, a speaker bio with a photo and a box with two survey questions. Title slide, 3M Imaging Virtual Pulse. Close the gaps between people, process, and technology. May 2022. Logo, 3M - Science, Applied to Life. An image of two doctors studying a laptop with four scans on a screen behind them. (SPEECH) Good afternoon, and welcome to our May Imaging Virtual Pulse, Closing the Gaps Between People, Processes, and Technology. Before we get started, I did want to go over just a couple of housekeeping items. (DESCRIPTION) Slide, New year, new platform. On24 Webinar Platform for a better user experience! Check speaker settings and refresh if you are having audio issues. Ability to move engagement sections. Ask questions! Engagement tools and C.C. available. Resources section. Complete the survey. Fine print: The information presented herein contains the views of the presenters and does not imply a formal endorsement for consultation engagement on the part of 3M. Participants are cautioned that information contained in this presentation is not a substitute for informed judgement. The participant and/or participant's organization are solely responsible for compliance and reimbursement decisions, including those that may arise in whole or in part from participant's use of or reliance upon information contained in the presentation. 3M and the presenters disclaim all responsibility for any use made of such information. The content of the webinar has been produced by 3M, and its authorized third parties will use your personal information according to 3M's privacy policy (see Legal link). This meeting may be recorded. If you do not consent to being recorded, please exit the meeting when the recording begins. (SPEECH) If this is your first time joining us since last year, you might notice a new platform. It's a great new user experience with a lot of different tools. But with that, I just want to make sure everybody knows where everything is so they have the best experience. So because this is a web-based platform, there is not a call-in number like we have had in the past. So if you are having issues with the sound, check your speaker settings. Go ahead and refresh if you are having audio issues. Clear your cache as well as closing out of any VPNs or extra tabs. Because with the bandwidth, sometimes that can affect things. There is a lot more ability to engage with us with some of our tools. You can see in the top left the live stream. If you do need closed caption, that is available for you. We do always encourage questions. We'll get to as many as we can at the end. You can put that in the Q&A box. We also have resources for you. If you did not attend our webinar in February, if you'd like to go back and listen to that, you have that ability to listen in, as well as just more information on our products and solutions. If you're interested in learning more, we always encourage you to complete the survey at the end. We like to know how we did. So if you want to complete the survey at the end, we would really appreciate it. And lastly, if you are interested in learning more, in that middle section, if you click on that, it will take you to a forum. And if you are interested in learning more, we'll certainly follow up with you after. Again, questions and answers, as much as we can, we'll get to at the end. And if you are having any issues, I'll try to do my best to help troubleshoot in the Q&A. But without further ado, I'm going to go ahead and pass it over to Russ Cardwell, our VP of Imaging Sales, to go over the agenda and get started. So Russ? (DESCRIPTION) Slide, Agenda. Meet our speakers, discussion overview, Q &A. (SPEECH) Excellent. Thank you, Lisa. And yeah, I like this new platform already. So thanks again for the intro. We're going to talk about people, processes, and technology here. I did want to introduce our guest speaker here today, Ken Cortez. (DESCRIPTION) Slide, Meet our speaker. A photograph of Ken sitting on a white cushion on a cherry wood bench wearing a suit. (SPEECH) He's a principal with TnT Advisors, and before that he was at Marin General, Marin Health out in Marin, California serving as VP of Ancillary Services. And before that, radiology director, and sometime before that an actual radiology technologist. So he's very much an expert in our field today in radiology. So we thank you, Ken, for joining us. Thanks for having me, Russ. Yeah, absolutely. So we want to get into this question about, how do I determine if I have a people, process, or technology problem? (DESCRIPTION) Slide, Discussion Overview. (SPEECH) And this is probably especially true as the industry transitions to value-based care, and we continue to feel some of the reimbursement challenges. But before we get into that, I thought if you could just explain. I gave a brief overview of your background, but if you can also share some of your experience throughout all these phases you've seen in health care industry, that might be helpful for our audience, as well. Sure. So I started in imaging in 1987. So I thought about that today. That's 35 years next month. That's a pretty long time. And really, I followed in my father's footsteps. My father was a tech. He always came home with amazing stories about what he had seen. And if you'd ask me when I was 16, I probably would have said something like, I'd have been a general contractor, and those kinds of things. But I ended up applying for X-ray school, and it was one of the really great decisions that I've made. It's been great. I was fortunate enough to start at a small community hospital where everyone wanted to teach, the radiologists, the emergency room doctor, the surgeons, et cetera. So I got to really understand medicine as a whole and imaging's role in that. And we play a really big role. We're the team that's finding the answers to the questions regarding patients, most times. And it's pretty exciting. Nurses get a lot of credit, and they should. In nursing, you get, many times, stuck in one kind of discipline, so emergency room nurse or surgical nurse, where imaging touches every age group, every type of patient. So it's been a great ride. And I started, as you mentioned, staff tech, and then a lead tech, then a manager, then a director, executive director, and then finally a VP. Yeah, I knew I missed a few titles in there, but I know you've covered the gamut. Well, it was great, and I worked at a lot of different places all over California, so small and big. Yeah, and I think that's what I wanted the audience to just listen, is that you've covered a lot of different roles, a lot of different organization type settings. And so you do have quite a bit of experience to offer. I'm sure that will come out as we go through our talk today. So maybe we can start with some traditional ways that organizations work through their inefficiencies. Maybe you can share a few examples of some of those traditional ways. Yeah. I think you hear it all the time. There's lean philosophy, Six Sigma, et cetera. Those kinds of things are the things that almost everyone is using. And we were fortunate to make a couple of good decisions at Marin. We were in a long-term partnership with Philips for not just imaging equipment, but service and services as well. And so we were able to take advantage of their depth and breadth of their company, one of which is services like lean training. And so Russ Peckinpah, who's the CIO over there, has got a great team in IT. And we wanted to start to organize the leaders and get them all on the same page. I think early on, one of my prior bosses understood the impact of lean training. And she brought on an expert, if you will, in lean training. But I think it didn't really work as well as, maybe, she hoped, because it was just one person. And so while that person had this great understanding, it was difficult to spread that, of course, across the organization. So a couple of good decisions we made, Russ and his team, Scott [? Patacochi, ?] who's the director of the project management office, and Michelle Parker, director of applications. I think we wanted to, A, use the IT department to run the PMO department. So that's number one. Because in health care in particular, you're not doing anything without some sort of technology component. You can talk about [INAUDIBLE] as much as you want, but I guarantee at some point, it has some sort of technology integration. So that was one of the first things we did. And then we brought in Philips to train leaders in lean training, and not just managers and directors, but we brought in a lot of front line leaders. So these are the people that you're always using for projects in their particular area. They're your subject matter experts, et cetera. So while they don't have the outright leadership title, many times, they are the team that's moving that forward. So we wanted to train that whole group with some lean training. And I think we trained 40 or 50 leaders, maybe more, with some lean training to start so everyone understood that we have a process. And we started with using A3s for any sorts of projects. And if you know anything about those, it's basically a one-page document that has the who, what, why, where, when, and how, all on a concise document. So when we started projects, we started in that way. And then we had many meetings across many disciplines. Now, it's many projects. It could be an imaging project, but it touches the emergency room. Physicians have a hand in it as well. So we wanted to make sure that we provided some training, and we took that advantage that we had in that Phillips partnership to do that. So we didn't send anybody anywhere. They came to us, which was another thing. And we actually did some projects accordingly. Very good, yeah. It sounds like that was very helpful. And obviously, getting a wider group of people involved in that training, I'm sure, made the whole organization pivot around that, and I'm sure brought about change more quickly and more thoroughly. So good example there, Ken. On these virtual pulse conversations that we've had over the last, I guess, five or six quarters, you've kind of weaved in a lot of payment policy and reimbursement impact. And I'm going to, over the time of these questions, we're going to connect some of these traditional ways, lean and Six Sigma, to try to find improvement. But just to go down this reimbursement path a little bit, we know CMS made its site-neutral payment policy a few years ago when it changed reimbursement strategy. Prior to that, many organizations were rapidly acquiring or building outpatient imaging centers to maximize that reimbursement. Then the CMS policy reduced that, essentially reduced that reimbursement for outpatient imaging. So what has been the impact of that reimbursement policy change, and what observations are you seeing now that that policy has been in place for a few years? I think hospitals and hospital groups were obtaining these outpatient imaging centers to increase their footprint. But also I think there was a focus to, several years back, to make sure that when a patient that doesn't need to be in the hospital, there's no reason why someone that is low-acuity, mobile, should come into a hospital to have some of these services. So I think the idea for many institutions was to expand their imaging to the outpatient side. And I think back then, you could charge hospital reimbursement rates and things before the CMS change that you just mentioned. And I think it was a good idea at those times, but there's always those kinds of changes happening. CMS made a similar-- payment, reimbursement, reductions occur in outpatient clinical laboratory through something called [? PALA. ?] I think there's always going to be things like that and changes in legislation that are going to make it more difficult to get reimbursed. I think that's just the nature of the business. And I think that makes people have to focus on being efficient, going back to the Malin discussion we were having earlier. Yeah, exactly. Yeah, that's what I was-- I thought that's where you might take that question. But you've got to continue to try to work out where the inefficiencies exist to get more efficient. Yeah, and I think you've got to start in the beginning. We built a 10,000-square-foot Breast Center, high-risk Breast Center. And we started that from the beginning. So early on in the planning of that, we brought in end users to go through and do spaghetti diagrams on patient flows on that. And you can make changes to your design based on that, if you do it early enough. So I think there's a lot of strategy that happens to mitigate things like reimbursement, reductions. And I think a big part of that is just becoming more efficient and designing those efficiencies into your projects. Yeah, that makes sense. so just to build on that a little bit more, we know that some private payers are now just only reimbursing at that lower outpatient imaging center rate. And I know some of the work you're doing with your new-- with your consulting business is helping organizations go through building decisions. So what are some of the key factors organizations should consider in the planning phase, as they make this build or acquire decision of imaging centers? I think there's a big strategy component to it. I think that here in California, a few years back, one of the big providers, Anthem, basically sent out a letter to health care organizations and said, we're going to stop paying at all for CTs and MRIs done in hospital outpatient departments. They were not going to pay for CTs and MRIs to be done at the hospital. They had to be done at outpatient imaging centers. So even locally, CMS has made decisions. But even providers have made those decisions. So I think for us, a piece of strategy is being efficient and increasing some volume. So when we did that Breast Center I was discussing earlier, we were very thoughtful in that because we had some understanding that women make the health care decisions for their families, or mostly make the health care decisions for their families. So while breast centers in and of itself, many times, are not a very profitable venture, we knew that we would be increasing our strategy in making sure that women who come for their yearly mammogram and things like that saw us as the place to get all of their health care. Men frequently won't see a doctor unless something is really, really wrong. That could be a year or two, whereas women are much more diligent. And so I think you have to understand your profitable centers in your organization. And even when you make decisions that are not necessarily increasing your bottom line, bringing patients and volume in other areas to your organization is smart. I think that was one of the good decisions that we've made. Yeah. So those who are actually going through a building phase and making that decision to actually build a new imaging center these days, obviously we've been hearing about inflation and building costs, not only costs, but also access to some of these supplies. How has that affected, again, some of you've seen in the market, or if some of them are even organizations you're working with directly? Yeah, it's been very impactful. I was recently doing a project, an ambulatory surgery center. And I think the total footprint of the center was about 17,000 square feet. And went through the design, test pits, et cetera. And ultimately, the company decided not to build the ambulatory surgery center there, but actually size that down and put in a radiation oncology outpatient center in that 17,000 square foot. So this big project was a big ambulatory surgery center, ended up servicing two service lines. Because it simply wasn't going to pencil out to be in that space that big. And those are the kinds of things you have to make decisions on, and tough decisions. But supply chain has been rough. So a big part of doing a center like that is equipment procurement, some of which is architecturally significant, meaning that as the general contractors and subcontractors are building that center, pieces of equipment that are going to be in that center are on a timed delivery. And we were seeing things that had a three-month delivery time going to two and three times that number. So supplies, the same thing, the price of steel, the price of lumber. I think not only has the price increased on those, but the time to delivery has increased, and that has been very impactful for anyone trying to build something new. It seems like that would be very difficult to manage and be able to project manage-- you mentioned project management earlier in this call-- just to deal with those disruptions, when you've got expectations of certain time deliveries. So I'm sure that hasn't gotten any easier here. Well, I do want to also ask you about data analytics. Because I'm sure that also helps drive some of these decisions on whether you build or acquire. But in recent years, obviously, data analytics have gotten lots of attention for their ability to better manage operational business, but also refine strategy. What areas have you seen where analytics helped guide decision making in the past, and what kind of tips may you have for our audience about things they might be using analytics for? I think big data is big. And I think what a lot of places struggle with is either data overload or data that's not meaningful. So just piles of data can actually make it more confusing for organizations. I think the first strategy is to really understand the business that you are you're in. Not every hospital is really in the same business. Some are focusing a lot on their specialties, inpatient procedures, et cetera. Others are more focused on outpatient. And I think that really understanding yourself to understand how to use some of this data that is out there. And there's companies that-- there's a company that's now called Included Health but it was called Grand Rounds. And that was a company that was born out of-- they would say necessity is the mother of invention, right? So it was started by a Stanford radiologist, interventional radiologist whose son was ill. He had all the resources of Stanford, et cetera, all at his fingertips, but nobody had the answer to help his son. And he ends up picking up the phone and calling a physician in Johns Hopkins, something that you and I can't do. But he, because of where he was. His access, yeah. And so he sent over the information, and this guy said your son has ABC, here's what you need to do. And this physician, to his credit, said, wow, if it wasn't for who I know, my son may have a really terrible outcome. And so this company, at that time Grand Rounds, they were pulling all that data in. The top orthopedic surgeons aren't necessarily doing the most surgeries. The top cardiologists are not always prescribing specific medications. So I think that data, in and of itself, can sometimes do more harm than good. So really understanding and getting good data for your specific organization is more important. Absolutely. And obviously, filtering through it all. Data by itself doesn't really help you with anything, but the insight from the data is really the valuable part. I know I was-- this is probably going back 10, 12 years, but just on basic operational metrics, I knew of a large imaging group along the East Coast, who they assessed just the volume of their mammography readers, and they found one that was reading about 1/3 the average of everyone else. And so after talking with them, they found out that they just read slower, but with a higher quality, and they weren't really interested in going faster. And then they worked out an arrangement to make that radiologist still work there, a little bit different rate, because everyone else was producing at a higher rate, but it was a mutually acceptable decision. And I think data led to that conversation, and then they got a mutually agreeable outcome. So I think-- that's just one story, but there's many out there. I was thinking of a similar story. So again, earlier I mentioned that we were in a long-term partnership with Philips. And one of the things that they did was brought some of their partnership leaders all together with their entire team, from R&D, to sales, to marketing. They brought their group to listen to these partners on how they should make some changes. And one of them was a large radiology group on the East Coast, and he had great data. And earlier I was discussing one of my favorite topics, which is applications training. And this physician was describing that he was looking through his data on all of his imaging centers and couldn't figure out why this one MRI was not producing at the level that some of the rest are. And I clearly said, I think he's about to make the argument I was describing earlier. And what they ended up finding out was, there was one technologist who was just not as comfortable on the equipment. And so this tech took a little longer to start their scanning, wasn't comfortable with what they were seeing on scouts, and things like that. And so that ended up being the one reason why this one particular MRI scanner was not as profitable as the rest all over the city. And I think that the way that companies now do-- and they're all the same, GE, Philips, Siemens, et cetera, Toshiba-- applications training is a transaction. You buy a million-dollar piece of equipment, you get x amount of application trainings with x amount of people. If you want more than that, you have to purchase more, and those kinds of things. And I think that's one, when you talk about processes and technology and things like that, this is one of those areas in imaging that I think we need to really change how we think about applications training. As much turnover as there is, what you generally have when you get applications training is you have your subject matter experts. They get most of the training, and then they're doing the teaching going forward for the rest of those things. In two years, you could have a lot of turnover. So all of those people have to be retrained, and now they're being trained by not the maker of this million-dollar piece of equipment, by one of your staff. And I think that what health care does a lot is it does the army training model. You see one, you do one, and then you teach one. And I think a lot of that is lost. Those million-dollar pieces of equipment, $2 million-dollar pieces of equipment only do all of the things that those companies say they can do if the right person is operating them with a really good, comfortable understanding of that piece of equipment. So many companies say, our machine does this. It only does it, as I used to say, that it only does it on my least comfortable, least-experienced technologist on a Sunday at 2 o'clock in the morning. So I think that that's where application training is underserved. I think companies, big companies should start thinking about applications not as a transaction, but as a marketing and sales tool for their equipment. When I was down in Southern California, we had one of the first 64-slice spiral CTs on the West Coast from Toshiba. And we were their show site. They brought many, many prospective customers to see their piece of equipment in action at our hospital. And we were fortunate enough to have some really good technical staff here that really did understand that piece of equipment and used it to all of the capabilities that were advertised. And I think that-- I would say that that technologist that we had there sold a lot of CT scanners for Toshiba at that time because she was so good. And so I think that process of applications really should change, less of a transaction and more of an ongoing relationship. Yeah, we've known each other a long time, Ken. And you've been very consistent with that theme, that applications training is really paramount, just because the reason you just said, where the individual operating that piece of equipment becomes, in large part, how successful and how much of that technology can even be used. And I think you've helped touch on one of the three pillars here, which is, you talked about how do we improve people, process, and technology. Most organizations will say people is the most important asset, most valuable asset they have. But then again, if we're not enabling them with the right training to operate whatever tools they're supposed to use, then we're not getting the most out of those people, and the organization is not benefiting as much. And in our case, in health care, patients aren't benefiting as much either. So again, thank you for those stories. Both of them are very relevant, and again hit on that point of getting the proper applications training not just up-front, but over the lifecycle of that equipment. I think I have just one more of our-- one more question here. Getting to root cause is becoming a very popular catchphrase now. Do you have any other-- we talked about lean and Six Sigma and some of the analytics tools to get insights. Is there any other insights you have, or any other suggestions you may have for organizations about how they might get some insights around improving their people, process, and technology? I think there's plenty of tools out there. Again, I think you need to understand your organization so you'll be able to understand which of those tools will work for you. I have a colleague that is down in Monterey at CHOMP, the Community Hospital of Monterey Peninsula, and he wanted to focus on patient satisfaction. And actually, if you ever end up doing one of these related to patient satisfaction, you really should have a conversation with him. His name's Eric [? Demonaco, ?] down at Monterey. But what he did was take some-- and I'd call it relatively low technology-- but he brought in a system. It's called Excellence 24/7. And what it did-- he and I were having a conversation one time about patient satisfaction. And when a patient has a bad experience, and you aren't able to solve it there, and they've left the building , it's too late to recover that patient. That patient is now gone. They have in their mind what they think of your organization and whatever potential misstep happened. So he instituted using a QR code in all of his waiting rooms, inpatient and outpatient. And if the patient had an issue, they could scan this QR code and have a text conversation with leaders in the imaging department. And what that allowed you to do was to engage with that patient while they're still here, and maybe fix their issue, the issue that was happening, and turn around their service. He used a similar technology when scheduling patients. So patients, after they've been scheduled, what if they have a question related to their procedure or the prep for their procedure? There was a number of patients that come in, and they didn't follow the prep correctly, and they have to cancel our exam, and now they're gone back, and have to reschedule and do the whole thing over. That's inefficient for everybody, and it's really poor customer satisfaction. You can address their questions prior to them getting there, and you can solve some of these questions. And I think for patient satisfaction, we had good patient satisfaction. He did too. But after he started to institute things like this, he drove it up to the high 90 percentage for patient satisfaction, and they ended up adopting that organization-wide. So there's opportunities like that with technology, where it can be really helpful, really make a meaningful impact. Yeah, and there's been a lot written about with organizations trying to improve their patient experience. That sounds like a great idea. And to try to improve that situation right in the moment, before they leave the hospital. Because you're right. Once someone leaves the hospital there, then they're going to form an opinion, and they might tell three people about a bad experience rather than a positive experience. It's typically, at least a lot of the times, those ratios work where you tell people a negative experience more so than the positive. Well, that's what people do, right? People, they'll jump on Facebook and Twitter the moment they have a really bad experience. You don't always get that when you have a really great experience, but you'll always get it when you have a bad experience. That's right. That's exactly right. Well, that's a really good insight. And maybe we'll have to have Eric on a future Virtual Pulse. I think you should. He's really, really good. And he's been around the block as long as I've been. So he's great. You definitely should have a conversation [INAUDIBLE]. Very good. Yeah, that sounds that sounds exciting. Well, Ken, thank you for sharing these insights. I've gathered something here today, and I'm hopeful everyone else in the audience did as well. Lisa, I think we're back over to you. (DESCRIPTION) Slide, Q & A. (SPEECH) Awesome. Well, thank you guys both. It was a lot of information and a lot of good insights to hear. One question that we did have come in-- and I think it's a really good one, given the topic of closing the gaps with the people, processes, and technology. And I'm sure it's a pain point because of what we are all starting to hear-- and it's been going on for a few months now-- of this great resignation, which I'm sure is greatly impacting everyday processes. I'm sure that there are a lot of gaps that will happen with that. And so how has that impacted operations, with turnover being so high? That's a really good question. It could be the million-dollar question. I think that when you-- I think this great resignation, it's basically-- and I think maybe the pandemic has been part of the reason. But I think that employees have realized that there are many more options out there than maybe previously thought of. So maybe not at acute care hospital, but maybe straight outpatient imaging, maybe other areas of health care to leverage their experience. For me, the part of my job that I really love the most was all of the capital construction projects. So now that's what I want to do. And now I represent owners that are building and doing these building projects to manage that project for that. So I think there's many more opportunities out there for employees. And I think some of those data analytics and things like that can improve how employees do their job, and makes them want to stay at a place that is making those changes. You have to be cognizant that, like everybody else, like patients, as a customer, employees have other options now, as well. So I think it's pretty bad when you have employees resigning at a high rate. That makes operations difficult. And they are [INAUDIBLE]. It is unfortunate. To piggyback on that, what advice would you give, even to just employees in that situation, to alleviate that frustration from a management perspective? Do you have any guidance that you would give to your employees for that reason, of that kind of understanding? Yeah. I've always-- a couple of things. I would never begrudge any employee to move to a situation that's best for them. That's what I'm going to do. That's what Russ is going to do. That's what you'll do, Lisa, right? You're going to make the decision based on what's best for you. So I would never begrudge anybody on those things. If they have something that's working for them, and they want to move on to another place, then I think they should. I think what I also did, though, was encourage those employees to bring some ideas and solutions that they think will work and will improve the organization. And I think when you do things like that, good things happen. I think hospitals, for instance, that have magnet status, magnet status is often considered to be a nursing designation. But in reality, in order to meet magnet status, you have to have a very good interdisciplinary group, a hospital that's all on the same page, working together. So when those companies like that get together, it's always an interdisciplinary conversation. Because you'll frequently hear-- and I used to hear all the time-- well, it's not our fault, it's the nurses' fault. It's not our fault, it's the transportation's fault. Well, let's get those groups together and work through what those issues are to create a better process. And I think the top-down leadership, I think those days are gone. It's old, and it doesn't work. You need the people that are doing the heavy lifting for you to be part of the solutions. I like that answer. Because I think it's easy to complain. It's a little harder to offer a solution. But I do believe that-- and I'm stealing a line that I heard probably 15 years ago-- but engaged employees make for engaged customers. So if the employees of the organization can work through that interdisciplinary process, they're going to feel more engaged, and it's going to show when patients show up. And I think the experience will be different in a positive way. Yeah, I think if you've ever had that conversation with Eric, I think at first, when you put that QR code down for patients to come, employees were a little reticent. They're like, oh, now I'm going to get complaints all the time. And they were a little worried about that. But in reality, they're part of the solution that solves the problem for that patient on there. Now you have a grateful patient rather than an upset patient. So it works, and you can't do it without them. Absolutely. Good questions, Lisa. Yeah, absolutely. Well, thank you both again for all the information today. It's been a really great segment. And so what I'm going to do is go ahead and wrap up. (DESCRIPTION) Slide, That's a wrap. (SPEECH) For everyone that did join today, we certainly appreciate your time. Like I mentioned, there is a Resources section. So if you do want to listen in to the last one that we had in February, you can review it there. If you do want to listen to this session again, we will be adding it to our website in the next few weeks. And again, we always do appreciate you completing the survey. It just helps us know how we're doing. And so again, I certainly appreciate both Ken and Russ's time. And be on the lookout, because we will have another segment for the Imaging Virtual Pulse, either late summer or early fall, that we'll be sending information to register as well. So again, thank you all for your attendance. Russ, is there anything else you'd like to add? Just like to thank my friend Ken for all his insights, sharing it with our audience today. Thanks a lot, Ken. Thanks, everybody. I appreciate it. Great. Thank you all. Have a good rest of the day. Bye-bye. Bye. (DESCRIPTION) Russ waves.

(DESCRIPTION) Title card, 3M, Imaging Virtual Pulse. Take the work out of workflow. Logo, 3M Science Applied to Life. Two video feeds along the left. Image, A doctor at a laptop. A technician looks at the screen with him. Behind them there is a monitor with four images. (SPEECH) Well, good afternoon, and thank you all for joining today. We are kicking off our first Imaging Virtual Pulse for 2022, and today we're going to be discussing taking the work out of your workflow. (DESCRIPTION) Slide, Housekeeping. Sound check, ask questions, certificate of attendance, we want your feedback. Live captions. (SPEECH) Just before we get started, I did want to go over just a couple of housekeeping items. If you are having any audio issues, check your speakers if you did join through your computer. You do also have the option of joining by dial-in information. That is in the dashboard of your portal through GoTo Webinar. We do provide a certificate of attendance that will be emailed to you after the webinar, and we do encourage you to ask questions. You're able to do that as well in the Q&A section of your dashboard, so please ask those throughout and we'll get to as many as we can. And lastly, we do always appreciate your feedback. So after the webinar, a survey will launch. And so please let us know how we did and if you'd like us to follow up with you for any other information. So (DESCRIPTION) Slide, Agenda. Meet our speakers, discussion overview, Q and A. (SPEECH) for today, we're going to go over taking that work out of your workflow, we'll introduce you to our speakers, and then we're going to get right into the discussion and get to Q&A. (DESCRIPTION) Slide, Meet our speaker, Rishi Seth, M.D. Fairfax Radiology Centers, an Inova partnership. (SPEECH) And so I am going to go ahead and pass this over to Russ Cardwell, who is our VP of imaging solutions, who's going to be handling today's discussion. So Russ, take it away. (DESCRIPTION) The presentation closes. The two video feeds take up the whole screen now. (SPEECH) Thank you for that intro, Lisa. So I'm delighted to be here today with Dr. Rishi Seth, whom I've known for many years. So Rishi, before we jump into Taking the Work Out of the Workflow and a lot of topics we're going to cover, would you mind just giving the audience a little bit more about yourself, and your experience, and a little bit about the organization you're with today and what market it serves? Sure. Absolutely. First of all, thank you for having me, and thank you for 3M and M Modal for putting this together. It's a great series. I'm really glad you guys are doing it, and honored to be invited as a guest. So thank you. My background, I did a residency and informatics fellowship at the University of Maryland, and I got the opportunity to train with some of the big giants of radiology informatics, which kind of put me on the path to this career and was very helpful. I did a neuroradiology fellowship at Northwestern University, and then I've worked at a couple of different practices over the years. My first job was down in Florida, with Baptist Health, and in Miami. And then I joined Radiology Associates of North Texas after that, and I was there for almost eight years. And there I got a lot of experience with informatics and private practice, and how everything works, and how a large organization manages IT and informatics. And I was the Director of Imaging Informatics there for a number of years, and then for family reasons, came out to the Northern Virginia area and recently joined Fairfax Radiological Consultants. And that's who I'm working with right now, in the Northern Virginia-DC area. That's great. And again, I remember we first met when you were in Texas there, and you were doing a lot of innovative things with your group there. So all right, well, let's jump in. So the first question I have is, we hear a lot about radiologist burnout and fatigue, and can you maybe talk about what comes to mind when you hear it, and how do you define it? Just so we can all get level-set with how you frame it. Yeah, totally. So burnout is a big, trending topic right now, because it's affecting so many of us. To me, burnout is this emotional and mental exhaustion brought on by prolonged or repeated stress. And that's one prong of it. And the other prong is not being adequately compensated for the work that you're doing. And that may be monetary compensation or recognition-- I think there's a lot of ways. But the combination of those things to me is where we're getting this burnout. And it is affecting a lot of us. The recent Medscape survey from this year, just a few weeks ago, showed that radiology is in the top 10 for physicians. 49% of radiologists feel like they're burned out, which is an incredibly high number when you think about it-- that 50% of our workforce feels like they're burnt out. And I think COVID has a lot to do with that, but even pre-COVID, our numbers were in the mid-40s. So it's growing year over year, and there's a lot of kind of increasing pressures upon all of us in health care. And for radiology specifically, I think it's increasing case volumes. There's some trending focus on RView. There's changing practice pressures. There's changing practice ownership. There's a lot of changes that many of the radiologists are not accustomed to, and I think that's leading to some of the burnout we're seeing. And that's kind of how I see the problem and its definition. Yeah. Great. Thanks for that. I think that's pretty common, but it's always good to get level-set, so thanks for that. I think technology is often seen as one of the solutions to help address radiologist burnout. It's not the panacea of all solutions, but it seems to be something that many people think is an answer. What are some of the technology that you've seen provide a net efficiency gain, or less friction in terms of what is required of your daily work? I think that the question is stated really well, that a lot of this is the friction part of it. What are the roadblocks that cause us to have those repetitive stresses that lead to burnout? And a lot of our job is PACS, right? So what are we doing on a daily basis that's so repetitive and doesn't add any value? And are the PACS vendors really upping their game, and building new software, and making improvements to make sure that those efficiencies and those friction points are decreased? And you're seeing some of them do that, and some new stuff coming out, and the new user interfaces. And there's really a nice push towards improving user interfaces and decreasing the amount of clicks you have to do, but I still think there's a long way to go in that process. Other things are workflow orchestration. I think that's a huge part of how we go through our day, is interacting with what study we're going to read next, and what we need to do in our day to move on from one case to the next, and how do we manage that? And what stresses are created by the workflow and the processes that exist? Net efficiencies, artificial intelligence as everybody knows, is growing. It's getting better. It's getting stronger. We're seeing it in our daily lives now, but it still has a long way to go, you know? And I think some parts of artificial intelligence are really helping decrease some of those frictions, but it's still very early. And I'd separate artificial intelligence into two sections. There's the non-interpretive and the interpretive. And for the interpretive would be imaging-based, like hemorrhage detection, pulmonary embolism detection. And I think those are helpful, but they don't really decrease burnout or stress. I think they do help, especially some of the stroke perfusion things, and cardiac, and things where there were a lot of repetitive actions that you had to do and a lot of tedious measurements that you'd have to make. I think there's significant improvement there. But to me, a lot of the burden is in the non-interpretive side, so focused on NLP-- a lot of things that M Modal does. Improving the quality of dictation-- how do we make it better, and how do we make our reports stronger and cleaner without having to do some of the tedious parts of that process? So if you're dictating a text message on Siri, it's going to go through and clean up that text so the anthologies are correct, and the words are correct, in the right order, and the grammar is correct, and the punctuation is correct. It's amazing, and we have to step up to that game. We've got Grammarly and other things like that, that will highlight mistakes, potential mistakes in your report when it comes to grammar, and we need to do the same thing when it comes to nonsense dictations and terms that shouldn't be used, and those types of tools, I think, are helpful. Automated impression generation. Part of your day is just talking, and talking, and talking, so things we can do to minimize the burden of having to repeat the same phrases over and over again I think go a long way in addressing burnout and that's where we can use technology to improve those things. Yeah, that's great. I actually had another customer tell me, I have a paper that has all these measurements for a DXA and all I have to do is sit there and repeat them, which is ripe for either a recognition error, or I slur my words and then it doesn't get typed right. And so I think that's a good example. They use the phrase-- which is why I always I always bring it up and remember it as--"we want to kill the parrot." I'm parroting these words, and I don't want that parrot around anymore. Exactly. So I'm going to jump into a question about workflow orchestration, because that was one of the answers you mentioned. So can you describe some of the models with workflow orchestration? Again, I think that has a pretty broad approach, and I think it'd just be great to hear what type of models that you've seen work or would be helpful to streamlining workflow. Yeah, absolutely. So the goal of workflow orchestration is really getting the right exam to the right radiologist and at the right time. And you've heard that over and over. It's been repeated many times over the last years, but no one's got it right. So there's no software out there that can get the right exam to the right person at the right time. It's very complicated, and it's very hard. In Texas, we spent a lot of time building our own workflow engine. And we got really good at it, but it's not perfect because every practice is different, and every requirement is separate from another, and every practice has different culture. And you just have so many different factors there, so it's a very hard thing to do. And we've come a long way, but there is no perfect system out there. So sometimes it needs a little bit of human interaction on top of it, but really, getting that benefit of not having to spend your day looking for the study to read next, and going back and forth from a work list and saying, OK, this is the exam I need to read, or this is why I need to read it, and having that thought process, and then waiting for that exam load into your PACS-- those are things that may feel like seconds, but every time you do it that's a repetitive action that creates burnout in the middle of waiting for those actions to happen. And it's another stress. So there are ways to do it. And to me, there's a push model and a pull model. And the push model is to say, hey, we've got 100 exams and 5 working radiologists. Let's divvy these up appropriately based on the number of exams, and the RViews and what people have accomplished, and lay it out. And I think that's good in certain situations where you've got a smaller group of radiologists, you've got a private practice setting with less interruptions and less stat cases. But it doesn't always work, and sometimes you run into situations where that model breaks. And so the other model is a pull model, where you give the radiologist a list and say, these are what we've curated for you to think and decide what's the next best thing for you to read. We'll try to do our best to tell you, this is what we believe is the most important. And then you pull from there. And if you have interruptions or things that happen, that makes your work a little bit easier. And every practice is different, and there's good things and bad on both sides. Obviously, on the push model you kind of feel like you're a hamster in a wheel, and you're just sitting there being force-fed, and I don't think there's a lot of satisfaction in that, personally. I think being able to decide is where you get some of that satisfaction. But on the same side, if you're the person deciding, you're working off a common list, there's going to be questions about cherry-picking and is that the appropriate exam for me, or what should I read next? Or how can I help this person or not help? And so there's a lot of challenges in that workflow model, and as your practice size increases, those challenges also increase because as you have different diverse environments, it's hard to plan for some of those things. Yeah. So again, I think that's great. I'm aware many PACS vendors have this Auto Next feature, which is kind of the push model-- the hamster in a wheel mentality you're kind of suggesting. But on the other side, if you give the pull model, then there's the option for cherry-picking. So I think there's pros and cons to both, and I think the culture was a great way to kind of address that, so thanks for that. You had mentioned interruptions in that answer too, and that's another place I'd like to kind of spend some time on. Because we know that interruptions can really lead to burnout, and it's difficult for the human mind-- doesn't matter what is being interrupted-- to get back to the original task, and that could lead to some of the burnout. So can you explain some of the intelligent workflow design you've seen in your experience to help reduce the burden that radiologists face as it relates to all types of interruptions, whether it's phone calls, or emails, or whatever it is? Yeah. Absolutely. So going back to kind of frame that question, you said it right. Every time you get an interruption, depending on your PACS or your workflow system, that may-- in order to answer that question from the tech saying, hey, can you look at this case that I'm about to send over and make sure everything looks OK-- you have to hop out of the case you're doing, open up a new case, hang that, and then answer the question. And then close that case, and then go open the case you were working on again. And if there's not a system to park that case properly, then you have to rehang that original case. You were cut off in the middle of where your thought process was, and that's a potential for error. So if you're a checklist person that likes to go through checklists, sometimes you have to start over from the top of your checklist. Or you get distracted and you forget what you were working on or miss that information. So I think it's a significant problem, especially in the hospital inpatient setting where there's-- even the outpatient-- there's constant interruptions. There's phone calls for many different things. So I think it's an important problem to solve, and I think there are some potential things. One thing that I find very beneficial is having a call center to triage some of that. So if there is an operator in a call center that handles those incoming calls and triages them to the right individual, that can reduce the times you're interrupted. I can't tell you how many times I get phone calls and they're not for me. They're for somebody else, or they're trying to reach the CT scanner, or they're trying to reach a different doctor, and it just wastes your time. So if there's a person that can be in the middle of that process to help control that, I think it's great. And the other part of it is we're trying to often hunt down physicians. And this can be a five-minute process, or it can be a 25-minute process to get a phone call or a page out, or get a return. And then that's another interruption when they actually do return the phone call. So having a call center to be there in the middle of that process to facilitate getting somebody on the line for you-- whether it be a tech, or a physician, or a PA-- it takes a lot of that burden away from you. And in that interim, you can actually improve your productivity by having that process. So I think that's one big thing. The other thing is, we get a lot of emails or messages about potential coding errors. So you'll get interrupted in your day-- hey, can you please put this addendum? This contrast was incorrect, or there's a laterality mismatch, or something was incorrect, or your report got transcribed as acute stroke instead of no acute stroke. So these things happen all the time, and you have to stop to do that. So if we had natural language processing actively running in our reports and capturing that information as we go along to say, hey, you've got the right MIPS and macro information, you've got the right billing information, you've hit all the quality measures, as that improves and becomes more robust, I think that is a significant improvement in reducing the number of interruptions that we see in our day. And it benefits us by putting out a better quality of reports, having less billing mistakes, and not having as many addendums and issues in reporting. And hopefully, patient care improves as well as quality improves. Yeah. That makes sense. One of our past guests on this Virtual Pulse Series was one who shared that he gets about 20 emails a day just on billing errors across his department. And of course that's a lot of time to sift through those emails, push the work to someone else to go then create the addendum or whatever. So you can just tell how that's not a very productive use of time. It's necessary, but if there's a better way, everyone would be interested in it. So we talked about PACS a little bit, work lists, AI-- a lot of different areas. What would you suggest to the audience in terms of what they should do as it relates to vendor evaluation? Because there's, as we know, lots of them out there. Yeah. I think the vendor market has exploded, especially through AI, you know? I think the last time we got to go to RSNA, the whole AI showcase, there were hundreds of vendors out there. And so I think you're getting a big expansion, and a lot of new products, and a lot of really interesting stuff coming down the pipeline, but I do think those things need to be evaluated fully. I find the best thing to do is to talk to current product users and find out how they're utilizing that product, and how it's working in their environment, and how that environment differs from yours. Because there could be new limitations in your environment that you didn't really think about, that you have to address before things will work with that thing. So doing site visits is really important, and actually seeing those products in live, functioning form, is very beneficial. I mean, you can do demos all day long, but seeing the product in a functional production environment really is different than seeing the demo in a test environment that's very controlled. The other specific point I'll make is, when we talk about worklists, and when people want to improve their efficiency, they want to go out and buy a worklist and say, OK, now all of my workflow will be contained in this thing that's going to launch all the hospitals I work for studies into my environment. And that's just not how it works. You have to understand that a lot of it can be solved by technology, but it's also relationships. Those contracts need to be made in place with those separate hospital entities, or your entity, to drive workflow either from one PACS archive to another archive, or to launch multiple different PACS on a single system. There's a lot of backend work that exists to manage these products, so understanding what your expectations and goals are is really helpful as you select a vendor when it comes down to workflow. For artificial intelligence, I think it's really important to also figure out how that AI tool would work in your environment, again. So I've seen it recently where there's a difference in scanners that creates a change in quality of that toolset. So it may run perfectly on one set of scanners, but it doesn't work as great on a different vendor. So figuring out how that works, and maybe visiting or talking to someone that has very similar equipment as you, I think is key in that process. And then understanding the service levels and needs that you'll have with any type of product-- how much service will you need? What's the type of downtimes exist? What is a product's uptime? What are their upgrade cycles? How do they do their upgrades? I think that's really important to ensure that your radiologists can continue to work and not be burdened by downtime related to that product, because that's going to decrease satisfaction. Of course. All excellent points. So again, I think some of those concepts, some people know, but I think, hopefully, there were some new nuggets in there. I think there was. So we've talked on this. Again, this is like the fifth virtual pulse in our series that we've done. One of the themes that was especially popular last year, but it's a continuing theme, is just the reimbursement decline that's been hit to radiology. And so I just saw an article, I think it was published in January, about over the past decade it's been about it's been a 44% collective reimbursement decline, which is obviously substantial. So there was kind of a bit of-- I don't know if celebration's the right word, but relief, maybe-- that this current year was only a 1% decrease. So again, in light of the reimbursement declines, a lot of people try to solve that through technology. So how do you best invest in new technology with this reimbursement environment being what it is? Yeah. I mean, that's a great question, and I think a lot of practices have kicked the can down the road because of that. Every year is like, oh, we're going to get hit by this. We're going to get hit by that. And it may happen, but things change, and luckily we've been doing OK. For the last few years, things have been fairly stable. We've seen some gains in some places. We've seen some losses in others. But I think to hold back on investing in technology now, because of a fear of decreased reimbursement over the next 5 to 10 years, is a mistake. I think you have to invest or you're going to be left behind, at least in the basic tools, you know? And you have to spend the money to get the tools you need because those things will actually improve the overall long-term health of your practice. And not spending the time and money to really have the right toolset for the radiologists when it comes to PACS, dictation, analytics, NLP, kind of early AI stuff, you're just going to be held back in moving forward. So I think even though there are some significant concerns and pressures up ahead, I don't think that waiting to invest is the right approach, at least in the basic. I'm not saying that everybody needs to go out and buy 10 AI products right now and today, but you need to start looking at your infrastructure. And if you're on a PACS system that everybody complains about and then you're saying, well, it's up to the hospital, you have to lay those roads. You have to go talk to those administrators. You have to figure out what is the impact, and what is the solution to really improve your practice and the workflow of your radiologists. Because I can show you over and over, when we bring in a new tool that we've vetted, it will improve workflow. It will improve satisfaction. You just have to find the right toolset for your radiologists. Bringing in the right 3D application, finding the right stroke or hemorrhage detection software, or how to interface-- what tools can help you interface with your ER, or your stroke team, or your surgeons? Those things matter quite a bit. And it's tough to be at the mercy of some of the hospital systems at times, where you think you can't change that. But as radiologists, we do have a big voice in what products do get selected, and there are, obviously, contract cycles. And knowing when those contract cycles come up and knowing the different technologies that exist at those times, I think it's helpful to always be aware of that and try to understand what you can do to improve your workflow, or at least find out what exists out there, and what it would cost, and what the process of putting it in place is. That makes a lot of sense. We've certainly talked a lot about technology, and I think that's what a lot of people might think of in terms of trying to help with radiologist burnout, but what other ideas do you have that maybe aren't technology related, that can help solve the burnout issue that we again keep hearing about? Sure. Yeah. I mean, I think there's a lot of stuff that you can do. It may not be-- it's kind of technology, but ergonomics I think is important. Making sure that you guys have the right monitors, the right chairs, the right mouse, the right keyboard. We spent our entire day on some of these things. Having standing desks is really beneficial, and I see you're standing up right now, and it's a benefit to have that. And if your systems aren't set up that way-- having that sedentary lifestyle, and many of us may not get up from our chairs-- I think it's nice to have at least those benefits, even if they're not very expensive at all to get some of these things. So that is a kind of an easy way to address some of the physical fatigue parts of burnout. I think work-life balance is big. I think radiology used to be known as a great lifestyle field, but I think the pendulum has swung back the other way as compared to a lot of other specialties at this point. And a lot of radiologists feel like they're working a lot harder these days, or doing more shifts. And our weekends can be kind of disastrous at times. And so I think we need to think about how we do staffing. How is our time off controlled? Are we doing an ER style, with x numbers of shift per month, or are we making sure that our time off is actually sacred time off, and we're actually not on-call, or can't be pulled in, or what we do with that is on our own? So kind of managing work-life balance I think is huge. I think especially in the times of COVID, we're all talking about remote work and working from home, and I think that's a big benefit. It's great to have a shift at home to break up every other week, to have that ability to do that. Or if you're a remote worker, being able to be at home for your evening, overnight call, weekend shifts is a big benefit. Obviously you have to have that operational staff if you're covering hospitals as well, but I do think the ability to have that, it can be pretty beneficial in the mental health of those physicians. I think data analytics is important in understanding what people are doing in the practice. I think one component of burnout is actually feeling that there is inequity or transparency. And if you look at somebody else and say, I'm working so much harder than that guy, then you're feeling like you're not being compensated for your work. Or since most radiology practices aren't pay-per-click or productivity based, it's more stark, that difference, if you feel it that way. So I think being transparent with how people are doing is helpful because you'll actually realize that most people are kind of in that center ground of where they are, but they feel like they're at the top end or they feel like somebody else is at the bottom end. So when you show people they're kind of on that same distribution curve, I think it goes a long way in saying, OK, we're all working together and we're all working hard. But at the same time, I think there is a benefit to supporting the people that are at the top end of that curve. Either if you have some sort of top end productivity bonus, or recognition for the people that are really bringing the practice along, I think that's important. It goes a long way, the feeling of recognition, and feeling like the work you're doing is recognized as a group or financially. And I think that does reduce some of those burnout issues that may exist. The other thing I'd bring up is the mental stress of the repetitiveness. And I don't know if this is technology again, but the mental stress of being repetitive in dictation is pretty taxing. So I think there are ways that you can improve that burnout feeling or stress with some technology out there. Like Rad AI is one of them, where you can see that there's an improvement in satisfaction and productivity by installing some of these products. | it may not be technology where it's like PACS related, but some of those things are really beneficial when it comes down to mental fatigue and burnout. That makes sense. Again, a lot of good ideas for some technology. I can tell you yes, I have enjoyed my sit-stand desk now for a few months, and it does make a difference. Well, let's move over to peer learning. And this is a topic that has kind of come up, I think, more so in the last several years. But as there's been a greater push toward the focus on quality, I think there's been this kind of discussion about peer review and peer learning. Can you just compare and contrast? When you hear a peer review and peer learning, what does that mean? Sure. So peer review is random peer review, where you have a random assignment of two, five cases a day, where you need to review those cases and give them a score from one to four based on how they did. It's supposed to be random. Either distributed randomly to you, or you pick the first five or 10 cases you look at and perform peer review on them. And then peer learning is more of a qualitative tool that's based on actual focused learning. It's not random, and you have to meet certain criteria. So that would be number of cases submitted and attendance at peer learning conferences. It's supposed to be non-punitive, which is the big benefit. I think people often feel like peer review in itself is a punitive process, where you're going to get in trouble for a mistake, or it's utilized when there's a mistake. And at the same time, we know that peer review is A, not done properly, and it is not really beneficial. And so there's a lot of concerns with peer review, in general. I think it was a check-mark that people had originally marked off as this is something easy to do. I'm going to just say one to all these things, and we're going to move on and get it done with through our day. And there's a very small fractional benefit to that. But the people you talk that are on the peer review committees, they actually find a benefit. They say oh, it's great to look at these cases that actually get submitted either by the hospital or by other radiologists, and I learn from every one of those. So the idea of peer learning is to expand that benefit to the entire practice. So I definitely think that peer learning is the way to go, but there are some hurdles there that every practice is going to have to deal with to make sure that their prior learning system meets the needs of the practice and is beneficial. So it's very easy to continue to peer review, but peer learning is going to take some challenge and more work to set up, and more continuing, ongoing work, but I think that that's a benefit overall, for the long term. Yeah. So clearly, peer learning seems to be more beneficial to the radiologists as they're learning. At least in my experience, I've seen my hospital base and health system customers have a better time trying to get a peer learning program together than radiology groups. Can you talk about why that might be more difficult for radiology groups, to get something like a peer learning initiative off the ground? Sure. And I think some of it's educational, and learning what it's about, and trying to figure out what are the metrics. And so there's a number of really good articles in JACR of Radiology that have good frameworks out there, and I the ACR has a good framework on their website as well. So one would be just understanding what you're supposed to do. Two is hospital approval-- I think this is a big one. Many of the hospitals have been sold on the peer review process as what they want is their OPPE solution. So going back now and changing their mind, and saying, hey, this is now what we want to do, is a bit of a challenge. And then understanding that it fits the requirement, I think that that's a big hurdle that people have to spend some time understanding and talking to their hospitals. And especially in practices where you've got multiple hospital systems that you're working for, then it's quite a bit to get everybody converted from peer review to peer learning, and so you don't have to kind of redundant systems going at the same time. And that's a bit of a challenge. But if you're in a smaller system where you're primarily one hospital system, I think it's smaller. And the other thing, peer review, like I said, is easy, and it's known, and it's simple. And people do it either accurately or inaccurately-- it just gets done. But peer learning is more work and it's participation by everybody to either prepare these lectures, or listen to these lectures, or understand and review the cases that get sent to peer learning. And then I think in the peer review system, depending on how it is utilized, it's essentially anonymous. You don't know which cases were reviewed or not reviewed, depending on the architecture. So anonymity was a little bit easier. With peer learning, the anonymity part of it is a little bit tougher. Because depending how you set up your system, it could be obvious to anybody who read that case or who missed that case. So maintaining anonymity I think is important, and trying to figure out a way that people don't feel like it's a punitive process I think is key. So one thing we talked about while we were trying to build the system is having somebody send you a peer learning, but allowing yourself to un-anonymize that and share it with everybody so that then there's not a hurdle. So if you feel like it would be a benefit for everybody to learn from, then you as the individual are the one that promotes it to that process. And sometimes it may take a custom solution to build it out because there aren't really very many people that have built a peer learning software out there. So if you have a complex practice, you may have to create a custom solution around it to capture all those cases. Yeah. That makes sense. Does it also seem to fit that if a system is designed and it feels punitive-- whether it really is or not-- but if it feels punitive, could that also contribute to the burnout conversation? Yeah, absolutely. I totally think so. I mean, if somebody is already on the edge, and then you're asking them to say, hey, now you have to do this, and then we're going to call you out for your misses in front of everybody, I think that's a disaster waiting to happen. So I think there has to be a lot of groundwork that goes in to say, hey, this is truly a non-punitive process. We're not trying to call out anybody for their mistakes. We're just trying to learn here. So I think at the end of the day, it's a benefit, but I don't think you can just walk in and say, hey, this is how we're implementing this. I think you have to actually put in some work and talk to your physicians. Get buy-in. Have committees. Discuss it, thinking about what is the best approach for your practice to institute a program like this, and then start making some steps towards it. Excellent. Well, we've covered a range of topics. And Lisa, I think we've come to the end of our planned questions, but hopefully you've received a few through the chat from the audience. Yeah, absolutely. And thank you to you both. It's been a great conversation. And so the first question we have is, "how has your organization been able to properly staff in the COVID era?" I think it's been challenging, and I think that's created a lot of concerns. I think we've had really good leadership and operations that handles that process and understanding what our volumes look like. I think it's changed, right? In early-on COVID, things were really slow and volumes dropped off, and then they spiked up again, and then they've normalized. And so staffing has been kind of an up and down thing, but we kind of know now if there's a new variant what to expect, or what not to expect. And I think having more data analytics and understanding of your global practice health, it helps make those decisions. But I think that's very hard for everybody, all of us that went through that, to know early on how to approach [INAUDIBLE] But I think we've all kind of understood now what it's like, but it was definitely a challenge at the time. But luckily, we had some really good people working on it. Great. The next question we have is, "can you talk about the impact venture capital is having on radiology?" And then kind of a follow-up to that in particular, on radiology residents choosing what organization they want to join. Sure. I think venture capital, I think everybody knows now it's grown quite a bit. There's been a lot of acquisition and merger throughout radiology and health care, in general. And venture capital can have some benefits when it comes to some of these technology and data analytics solutions, especially in situations where you've got a smaller group that may not have the administrative power, or may not have the best health care or insurance contracting where they can step in and improve some of that stuff, and put in place some of their toolset that they come with. But to me, I think it's a long-term negative impact on radiology because I think it's another marker of burnout or stress if now you're no longer working for A, yourself, or a radiologist, and you may not be even physician-owned at that point. So this comes with its own set of burnout concerns. You may be asked to do more. Your productivity requirements may be changing. Your salaries may be lower. You may not have the ability to be a partner in that practice, or you may be a class B or class C shareholder. So I do think those things add to an overall negative impact on burnout. And I think for those reasons, we're seeing a lot of unfilled positions. And in a market where it's already difficult to hire new radiologists, I think it could be challenging for those people because you're playing with a different set of rules, I think. But in the right situation, I think there can be benefits to venture capital. It's just for me, personally, I think private practices that invest in infrastructure, and administration, and IT, really come out to benefit overall, in terms of having a practice where you can bring and hire new young physicians into your practice. Great. We have, I think, time for one more question. Dr. Seth, you mentioned automated impressions as an example of non-interpretive AI that improves efficiency and helps with burnout. Can you share more about how it does. Sure. The product that I've used is Rad AI. And you know, we interrogated the product. We had a session where myself and a small team of radiologists tried it out, and you seem kind of skeptical about yeah, this is going to go through and review my report, and then create an impression. But amazingly, it almost feels like it's inside your head when you're doing this and you start trusting it more and more to actually put down the right impression for you, based on their algorithm. So I think the tool itself is somewhat remarkable in a number of ways. I think one, you get a decrease in repetitive fatigue from repeating the same words, especially on chest X-rays and things where you're often repeating the same statements over, and over, and over, or fracture follow-ups, and things that you've said 1,000 times in a week. So that repetitive stress is decreased, and kind of mental stress around doing that is decreased. The second part is your productivity increases because you're kind of moving faster through these cases and not having to sit there and repeat those same words. So you spend more time looking at the images and less time looking at the report. The third thing is quality. I found that every time that their algorithm created a mistake in my impression, it was because I created a mistake in my findings. So the quality of my reports improves. So there are a lot of interesting benefits to some of the growing AI and NLP software out there, so that's where I found that product most interesting. Great. Thank you so much. And so that is the last of our questions. So Russ, do you want to add anything else before we wrap? Just my thanks to Dr. Seth. Again, your expertise has been shown throughout this time, and just want to say thank you for your time to share with our audience today. Thank you, Russ. Appreciate your time today too. Absolutely. We certainly appreciate it. And to our attendees today, we appreciate your time today. We will be following up with you in the next couple of weeks to register for our next session, which will probably happen in, hopefully, the May-June time frame. And so look out for your emails so you can register. Again, we will also be posting the recording of today's session on our website as well, so if you do want to go back and listen again, you certainly can. And lastly, we always appreciate your feedback. And so at the conclusion of the webinar, a survey will launch. And if you could let us know how we did, we certainly appreciate it. And so again, to Russ and Dr. Seth, we appreciate your time today and we will talk to you all next time. Thank you. Thank you. Thank you. (DESCRIPTION) They smile and wave.

Disclaimer: Described video not needed. The visuals in this video only support what is spoken. The visuals do not provide additional information Lisa: Is now starting. All attendees are in listen only mode. Good afternoon and thank you for joining the November Virtual Pulse Webinar Series. In this session, we are going to be going over a day in the life of a Radiology Director. Before we get started, I did want to go over a couple of housekeeping items. If you are having any issues with your sound, you are able to check in the audio section of your dashboard to either join via your speakers or you could join via your phone with a dial-a-number and pass codes. We are going to be sending an archive of this recording after so you will be getting that in the next week or so. Lastly, we do really appreciate your feedback. After the webinar, a survey will launch automatically, and we would like to hear from you. Let us know how we did today. Let's go ahead. I am going to kick things over to Russ Cardwell, who will be introducing our speaker today and going over our agenda. Russ, why don't you take it away. Russ Cardwell: Very good and thank you so much, Lisa. Again, thanks for our fourth in our series of Virtual Pulse this year where we talked about some reimbursement changes, different legislation that is affecting our industry, and different business models. Again we thought we would change it up today and have a talk with Bill Algee, who I have known for many years. We were talking at least eight or probably longer than that, years together. Bill is an icon in our industry. He has been a President of AHRA and served on the Board of Directors as you can read on the screen. He is very active in other areas of our industry. We are delighted to have Bill Algee, the Director of Imaging Services from Columbus Regional in Columbus, Indiana. Thanks for being with us today, Bill. Bill Algee: Hey, thank you very much. I appreciate it. Russ Cardwell: Yeah. What we thought we would do, again this is an open dialogue where we continue to talk about issues that face our industry. We wanted to what is the day in the life of a Radiology Director like. First of all, before we jump into some of the questions, maybe you can tell us about yourself, your experience and a little bit about the market that your organization serves. Bill Algee: Right. First of all, Happy Radiologic Technologists Week to everybody, to our techs or have techs working for them. It's a great week to be doing this. I didn't realize when we scheduled this that it was going to be this week, but it's pretty cool. As a technologist myself, I am very proud to be one. Like I said, my name's Bill Algee. I work at Columbus Regional Hospital which is located about 40 miles south of Indianapolis, in Columbus, Indiana. On November 2nd, I was here 35 years. I was fresh off the farm right out of Xray School. I came here about six months after school. I have not left. I have had a couple of opportunities to leave, actually more than a couple, but I have always found this to be a good place to land. I have found the organization has been a good place to work, and they always let me grow, do the things that I want to do and grow as a professional. That has been great. Bill Algee: We are a community based hospital, 250 beds is what we are licensed for. Like anybody else that might be listening, it is a hospital based system. We are trying to work toward single beds, and we try to keep single beds. When we get to about 150, people start freaking out a little bit. Oh, we are busting at the seams. So we start making up adjustments for that. Overall, it is a great community hospital. Its [inaudible 00:03:35] are very vibrant. We've done a great job of staving off the big groups from the north and the south. We are kind of nestled between Louisville and Indianapolis, but we have done a great job of holding our own, so it's been very important for us. Russ Cardwell: Very good. Thanks for that update. I think it is good that people understand what market you are serving and the challenges you are facing. Bill Algee: Russ, let me add one more thing. I did forget to mention. We have a main campus. I also have an outpatient imaging center called CDI, which is Columbus Diagnostic Imaging, not the old CDI which stand for Diagnostic Imaging. I just want to thank them for changing their name. That was very helpful. We really appreciate that. We also have a Breast Health Center too that is literally across the creek from us. There you go. Russ Cardwell: Nice. No, that's great. Thanks for adding those other locations. Let's jump right into it. Again, this will be like a fast ball right over the plate. I know in our industry there has been reimbursement in PACS that have affected radiology for years. I mean going back to the Deficit Reduction Act of 2006. That really in my mind is what started it all. But there has been a number of pieces of legislation that have affected our industry. Last year, the Budget Neutrality Rule basically it was supposed to be a dire 10 or 11% cut. There was a late minute adjustment to make it a 4% cut. What does that mean? Russ Cardwell: We are hearing that there could be another round of these cuts. I have heard in the 6% range for next year. Maybe it will go right up until Christmas again until there is some saving legislation that makes it less. Can you talk about what impact that might have on you? I know as a community hospital you hire a third party reading group, but it probably still has an impact on what happens for the patients' user. So could you talk about that for a little bit? Bill Algee: Yeah, I think whether you have your own group, a third party group, a big conglomerate group, radiologists have to be partners. We have to work together, we have to help support each other in a variety of different ways. It's definitely something that we're looking at even more now. I think the greatest thing I've seen to your point is then next year another 3% cut. That can't keep going. There's a lot of things going on in our industry right now, in healthcare and in imaging. We are going to talk a little more about those things like human capital and those kind of things that have to at some point correct themselves. Otherwise, there is going to be a huge mess. Bill Algee: We do have a group that is a local group that is linked to our facility. We have not had a national group. I know a lot of facilities have linked to more of a national group, and we are really nestled here in Indiana. We wanted to keep a hometown feel. Most of the guys live here. If not, they know the guys that they've hired because they've worked with them in the past so they are a pretty tight knit group which is great. I think we all have a stake in the game of trying to make sure we help our imaging partners, radiologists making sure that they can survive. Bill Algee: I think right now it is a struggle just in imaging in general, from that perspective, especially with Radiology. I think that there is not Radiologists falling out of the sky. They are not graduating from school 10 times more than what they did 10 years ago. The number is shrinking, and it is making it worse. As doctors going to medical school looking at what specialty they want to go into and you see these cuts continuing to happen. It does, do I really want to do that, is it really going to be here in the next few years. Is it still going to be a local group or will it go to a national group. All of that stuff plays into their decision making. Russ Cardwell: Yeah, I have actually heard of the same things. The enrollment of some of the residency programs is getting lower year to year. They hear things like AI, artificial intelligence, which we are going to talk more about later. I think the reimbursement, the AI, all that contributes to this factor of fewer younger people want to get into the field. We do want to talk about how that will impact our industry. Focusing on the cost reduction for a moment, what is your organization trying to do to reduce costs? What are you hearing from other Radiology leaders to try to reduce costs? You have inflation on one end and lower reimbursement on the other end and that's squeezing you in the middle. Are there any ideas you can share with our colleagues on the phone today or maybe what other leaders you are hearing from talk about strategies? Bill Algee: I think it is not business as usual, that's for sure. Anything you were doing two, three years ago we don't have that luxury anymore. I think most people use some type of benchmark data to look at productivity, they look at that for your volumes which is one of things that we all look at and track. I think at one time people were benchmarked at 50th percentile, maybe 60th percentile, 40th percentile. Now people are typically benchmarked at 40th percentile. Some are at the 30th percentile. The challenge that comes with that, good, bad, whatever, is when you get to those points and you are running on a pretty low reserve so to speak with people. When you do have the situation that is going on right now, and it is going on everywhere and people leaving hospitals to join agencies. That's just a challenge. I think to your question what we have really tried to do is try to figure out where the balance is and what makes sense. Bill Algee: Some of the stuff we have tried to do when you look at capital and when you purchase capital equipment, that is a huge expense. Radiology and Surgery probably spend more money than anybody else on capital in an organization. Obviously, that is huge, huge dollar figures. I look at the last couple of years, and I spend more time looking at used equipment, refurbish equipment, manufactured re certified equipment because does that make more sense, does that get you through the realm. I think the idea, at one point in time, every time we buy equipment I always ask what is the lifetime of this equipment? You always put 7 years. I think anybody that is listening to this would say they put 7 years on it forever and then it has gone to 10 and then you go God knows. Until you can figure out how to get the money and until you can figure out how to make a good case for it. That doesn't mean you don't. It just means that you really have to look at things differently, because those dollars all have to go somewhere. As you said, it is really challenging. Controlling the expense is really, really, really more of a challenge today. I said this before a couple of years ago on a discussion with someone, more today than any other time we are being squeezed to do more with less. Today, we are being squeezed to do more with less, right? Bill Algee: I don't have a magic wand. If I had a magic wand I would probably be sitting somewhere on a beach. It is a challenge for sure. You have to look at all different aspects. You have to think from managing that perspective too, you have to look at it is not business as usual. Incurring costs it looks at do we need the same number of staff here at the same time we have always had them here. For a while, I think a lot of people have always worked 12 hour shifts. At one point, we had 16 hour shifts. Now they have come back and said you are not going to do that anymore. You have systems working Monday through Friday. Now we are really challenged to be a lot more flexible and trying to meet what our staff needs are as well as trying to meet productivity levels. It is quite a challenge and I wish I had the magic bean. Because if I did, I would sell it. Russ Cardwell: It sounds like you are definitely looking at the capital equipment expense as one way with the refurbished equipment as one thing with productivity measures but also trying to balance that with your employees. Looking at all the main things, people, process, and technology. We talked about equipment there for a moment. Maybe we could just tag onto that with this next question which is we know there are supply chain issues that are delaying the delivery of some equipment. You talked about the refurbished market so maybe that's already here in the U.S. but other equipment we know is manufactured overseas and needs to get shipped here. Are you still new equipment and if so do these supply chain issues does that have an effect on the care you can provide your patients? Bill Algee: Yeah definitely. I have, talk about a day in the life of a Director, three projects going on right now replacing some Rad rooms, replacing our PET CT and also a CT Scanner. Why not do three great big projects all at once. Why don't you spread them throughout the year? That makes no sense. To your point, though, one of the vendors that we have been looking at and having some great conversations with is the lead time on delivery is 25, 26 weeks. I can remember a time when they would say if you cut the P.O. on this date, I can have it to you in 90 days. Honest to God, I have not heard 27 weeks or 25 weeks. When he said 25 weeks, I said, "Excuse me? Did you say 25 weeks." Come to find out it is not just one vendor. It is happening to a couple. Whether the vendors are here, based in the United States, manufacturing in the United States, it is irrelevant. Because we all know, all those parts come from all over the world. They are coming from somewhere in China or somewhere like that. They are manufactured in Germany. There is just stuff everywhere. Bill Algee: Yeah, we have a little bit of a time frame, and I had to tell some cardiologist that we are going to get what we need to continue our project we are working on, it is not going to be tomorrow and it is not my fault. Which I thought was the most important part. They are always looking at a finger to point at. I think in general supply chain is an issue. There was a local business discussion here yesterday, I didn't even get to attend it, but one of the things I was told out of it was, they were talking about the only people right now that have it worse right now from a supply, meaning capital perspective than hospitals and healthcare is the trucking industry. Everything anybody gets in the world comes on a truck. That's a huge, huge issue for sure. Russ Cardwell: For the new equipment you don't have, it would be a delay for getting those projects online but for the ones that are a replacement I guess you are just servicing the older equipment that much longer until the new equipment comes. Bill Algee: I hear stretching. Like I said before I think a lot of us are in this shape where we didn't replace things in five years, seven years, even 10 years. It works. It still provides great images. It is not bad in any way, shape or form. You do have a little more time where you have some down times, and expected down times. In technology, there has been a lot of advances so you want to take advantage of those. You just have to keep this bad boy limping along for a little while longer. Russ Cardwell: Yeah, and I can imagine that can add some strain to your job. Definitely. We will come back to technology in a moment, but I do want to jump in to some of the human capital. It doesn't really matter what the industry is. Everyone is short of people right now. Every health system that I talk to has a similar challenge. Are you able to staff properly? What do you have to say about some of these signing bonuses that we hear about? Maybe it is more Nursing and some of the areas that affect Technologists as well. What do you have to say about this whole labor dynamic that is happening in our market right now? Bill Algee: The magnet has to stop. That would be my statement. We have some openings here. We have about a 10% vacancy rate right now which is really pretty low when I hear what my peers have. I'll give you a great example. In the Indianapolis area in that market, one of the big health systems up there, I got an email yesterday, they have 49 openings now in the health system for Rad Techs, 49. That's crazy. Now I don't know that could be CT Techs, Diagnostic Techs, MRI. It could be a variety of things, but still 49 is huge. We did a little research not too long ago and found from the Indianapolis market down to the Louisville market there were 57 Rad Tech openings for Diagnostic. The numbers are astounding. I have never, ever heard of anything like this before. It's crazy. Bill Algee: I think people are jumping ship for a lot of different reasons. I think some of it is COVID. Some hospitals when COVID came along, they mandated people get COVID vaccinated. So some of those folks have said, "Adios, I am not interested in playing there." Now, as of last week, that has been a change. You won't be able to play now. You won't be able to work in a hospital if you're not vaccinated. At least, until somebody files an injunction and it sticks for a while. That would be great. People left for that reason. I know other people that left due to COVID and they just left the market. That has left an opening. The travel agency business is insane. We have offered before for Techs for an agency at a rate and they have come back. They won't even touch it. You're not even in the ballpark. I say, "How can we not be in the ballpark?" It is just so much and there are so many openings, people can just choose and go wherever they want. Eventually that will all catch up but we have got to really work together. Bill Algee: One of the things that I have taken, in my role in the IHRA led me to become friends with some people here in Indiana and other Radiology Directors. One of the things that we are doing on Friday we are having a meeting. I think we are having hopefully 20 ish people, maybe 25 Radiology Managers and Directors to talk about, how do we tackle this beast. My theory is we are going to have to figure out how to fix this beast because nobody is going to fix it for us. We have to figure out how do we do this. That's a struggle. We hired somebody from a new hospital, a mutual hospital north of us, for a position here, and that person called Liz, one of my managers and said, "Hey, they have had x number of more people have quit since I took this position. They really need to me to stay on until December. Can I stay? Will you let me come later than what we had planned?" Liz said yeah. We have to help each other out. We have got to try and figure this out because none of us are going to win. Nobody is winning right now. Bill Algee: The amount of money we are paying agency people, nobody is going to win out of that. The only people that are going to win are the agencies. I am not bad mouthing the agencies. They serve a great purpose. Absolutely no question. It is just this other phenomenon that is going on. It's crazy. If any other Directors that are on here or anybody that is on here that has to figure out a way to fix this problem, just shoot me an email. Bill Algee: I am hoping in our call on Friday we spend some time talking about just some ideas you have about what they are doing there. If nothing else, we all can all cry in our beer a little bit because we are all in the same boat. That's the great thing about Imaging and the great thing about our industry, I think, is we are all in the same boat. Maybe it is different boats, different ships, we are all sailing and paddling in the same direction. I have always found that we support each other and help each other out. That's something that I don't hear when I talk to my peer leaders in the organization. That's a great thing I am very proud of to be a part of. Russ Cardwell: Yeah. I have been in Radiology dedicated for the last 17 years. I have noticed a similar unified spirit that way where people do advance their goals but it is in the same direction as well. Good comment there. Just a quick comment to anyone listening, if you have any ideas, like Bill has said, maybe you can put them in the comments or if you have a question maybe we can get to that at the end about how to improve the situation. There is a finite number of resources but if there is a signing bonus to steal from one another, the pot it isn't getting bigger to help the industry. That is what I am impressed about with this, I don't know if you would call it a Summit or what you would call with this group in Indiana, but it is a good initiative. Bill Algee: I didn't name it anything. I think I probably said, "Woe is me." It's probably what I said. Just to get us all in the same room. I think that there has been some very disturbing things that happened through this. I know somebody in California, this entire nuclear team left giving notice the same day. I know somebody in another facility that they were having trouble so they gave everybody in MRI $5 pay increase. It just flips everything else upside down for them too. It creates this dynamic. It's insane. I'm at a loss. I wish I knew how to figure it out. I am definitely trying to figure it out. I'm definitely open to suggestions if anybody has any. Russ Cardwell: We'll see what other people might have as comments or questions here as we get through with this. I just have two more questions I want to get to. We can get to everyone else's questions out there. We just talked about the employee side and the signing bonuses and stuff for employees. Is there anything you are doing to try and combat employee burnout. Again, that could be on the technical side or things to make your Radiologists more comfortable. The pressures are incredible, but just any tips to ease the burnout feeling from all of the staff that provide services for you. Bill Algee: I think one of the things with this being Radiologic Technology Week, we've done some stuff this week too. We have been doing some things. We have been buying food periodically. I know you guys are getting hammered, I am bringing dinner in tonight. Or it's I know you guys are getting hammered, I am bringing in ice cream. It's those kind of things and sometimes that is enough. Other times it is like Dude I don't need that. I need a body. Get me a body. Let's try to get you another body. Sometimes it's not a Tech necessarily. We have Tech Assistants here. Or maybe I flip someone to another shift just to help out because we know that things are really struggling. We are really trying to be proactive that way. Bill Algee: I am rounding a lot more. I am trying to be out and thanking people, and I mean it from the bottom of my heart. I have been in there. I know how it feels. We have to keep that connection with the staff and our teams. I don't refer to my team as a staff. I refer to my team, we are all in this together. If one group is failing, we have to pick each other up, dust each other off and go on. That's how I want it to be. I got to go around today and pass out some cups. We got cups for all the staff. We put some logo things on them and stuff like that. It brightened the people I was able to pass them out to today. I think another thing we have done too is having our senior leader our V.P. from our organization and has come down and rounded up the staff. "Thank you for being here. Thanks for all you are doing. I know you are getting your bottom handed to you." Bill Algee: We did that during COVID too. It was really tough during the height of COVID because I think people really thought more about... They kept talking about front line. Radiology was never mentioned when we talked about front line. They were, right? Everybody that walked through the doors of the Emergency Room and got a chest xray. And those kind of things. It's getting them to understand you don't have to be named as being part of that because you know you are and we know you are and that is what really matters. I think that it where we try to keep people focused. Focus on yourself and doing the great work that you do every day and the awesome things you are doing to help your patients and all the other stuff and what other people say, it doesn't matter. You know what you do. Russ Cardwell: Yeah. That is a good lesson for all of us. We don't have to worry about what people are saying so much. It is nice when the recognition comes and I think getting your V.P. to come down is a great idea. The food and the ice cream is a good idea but just the encouragement along the way, I think that is probably good advice. So we talked about some of the challenges, the human capital, the people side of the business. That would kind of lend itself to does technology offer answers to some of these things. Maybe not all. Probably going back three or four years RSNA and other meetings where Radiology AI vendors are in full bloom. I lost count. It is probably over 100 companies now that do this. I want to basically focus the question on do you see Radiology AI as being a way as controlling some of these cost pressures you have. Is there any precedent for market consolidation among emerging Radiology Technology that you have seen in the past. Bill Algee: Yeah. Yeah. It is kind of funny. I remember back in the early 2000s going to RSNA walking out on the floor. I think, at the time, I felt like there were 350 PAX companies. Every booth you went to was selling PAX. It was everybody and his brother. I remember telling the person I went with, "This is great, but it can't sustain itself." This is going to end, right? They'll be four, five, six and I think today there is probably four to six, maybe 10. Bill Algee: I think AI will be very similar. I think right now it is all very nichey. You have one module stuff going on, you have some cardiac stuff going on, not you are getting some AI stuff that can help read chest xrays a little quicker. Those kind of things. I do think, back to the earlier discussion we were having about being a Radiologist, the availability and their entrance into the market as a physician. I think some of that is a little spooky for docs. Why would you want to spend your time and dollars going into a field as a Radiologist, but you see what is happening with AI and you go, "Hmm." Ten years from now, fifteen years from now, am I going to be needed? Russ Cardwell: Yeah. Bill Algee: Will there be as many. I would contend that yes, you will, because I don't see AI can do every single thing a Radiologist does. But will it do some things? Sure, I think there are definitely... I think AI has to be looked at as an adjunct to what's going on and what is being read by a physician. I remember we were talking about the ER. When the ER first come on the scene, When your image comes out it is going to go through a reader, and it is going to tell you what is wrong with it, the densities that it finds. It still does some of that but you still have to have a human eye to look at that. You absolutely do. I think there is that. Bill Algee: I think it will consolidate itself down at some point. There are some really cool stuff out there, it is... To your point, now I only have so many dollars because we had the discussion a few minutes ago, the pool of money is not getting bigger. The pool of money is getting a lot smaller and I have to figure out where am I going to put my money. That's the challenge. It's an ugly, ugly thing. Russ Cardwell: Again, these are very common challenges, I think, amongst all providers across the nation. Your expertise and your leadership, I knew you are in IHRA and other circles, I think everyone appreciated hearing from you. Lisa, this is kind of the end of our prepared questions. Maybe there are some other questions that have come in through the chat. Lisa: Yeah. We do and the conversation has been great. I am sure those that are on appreciate all the insight. So we do have a couple questions. For those that are on, if you have any questions, you can certainly add them now to the question dropdown in your dashboard. We will get to as many as we can. The first question is with the staffing shortage that we are now seeing we have discussed changing how our pay is structured and moving towards tiered positions, cross trained. We can perform one, two or three modalities instead of different pay grades for each modality. We are seeing our general Radiology staff moving to an advanced modality due to significant pay increase. They work the hardest and we pay them the least. Do you have any experience with this structure? Bill Algee: Yeah, we have had multi-modality Techs that work in Diagnostic and CT probably for a number of years. So how our structure works there is they have to work actively in both, and they do get paid at a different rate. They do get a bump for doing that. At one point in time, we talked about having them clock in and out at a different pay rate. If one day they were scheduled in CT and one day they are scheduled in Diagnostics. They finally went this is just a mess because I want the flexibility of when Harris catches on fire, I can just move my Diagnostic Tech over to CT. I don't have to worry about them running the clock, I don't have to worry about fixing it. People ae valuable to your point. That is a great way to start looking at that. Bill Algee: Peer pay is something that we have talked about here that we use in our organization periodically when we have shortages and people are covering shifts they wouldn't normally cover for long periods of time. Of course, not only are we short because people are leaving. We have a number of people on FMLA because that is how it works. I don't think anybody plans it but it sure feels like that sometimes. Right? But I think that is a way that we use that peer pay. It's different. I have read a couple of different things and a couple of different forms. People pay $7 an hour additional, $10 an hour additional or even $20 an hour additional. I think those kind of things really started in Nursing and they trickled down to us. I know for a fact, I believe that every place in the company is paying tier paid nurses for quite a while. I have no issue with it at all, nothing. Eventually, it does get down to the imaging folks too. Lisa: All right, so our next question is, do you have any advice to those considering the use of AI going forward? Bill Algee: I think for using AI, and that is one of the things we really haven't dived into too much, but I think we are going to be looking at it here more so. We have a very active lung nodule review board and a very active one screen program. I think there is a niche for AI in there. YOu have to figure out who the right partner is for us. I think you have to look at what are you trying to get to? Are you trying to fast track diagnosis. Are you trying to reduce Radiologists reading time. What are those things that you are trying to get at by using AI. I think all of us can play a role in it. We have been working on what new equipment we need to buy right now. Yeah, I think there is definitely a place for it. It is not the end all to be all. I think it is a tool, that's the way to word it. It's a tool. Lisa: Absolutely. Russ, do you have anything you want to add to that? Russ Cardwell: I just want to say I want to tie in to what Bill has said. I have heard other experts in our field talk about AI and its impact. I think maybe the sentiment three or four years ago might have been, "Oh, it is going to replace all radiologists." I think now the pendulum has swung back to being a complementary tool. Maybe there are certain things that the AI can do by itself, but I feel like the majority are saying it is very complementary. The Radiologist who is highly trained, specialized and has the human reasoning to say, "Oh that is an extra nodule or no it is not." The human mind is still a place where AI has not gotten to yet. Bill Algee: I take that back too. I think back to where you saw multiple vendors doing dose tracking. Everybody got hopped up on dose tracking. You saw a lot of stuff on dose tracking. The reality of it is if you have dose tracking you are only tracking the dose in your facility. The minute that patient goes to another facility and has them study them, the dose tracking is only as good as what you have, because now it is off. You have to figure out what are the things that really work for you and your organization and makes sense. It is just a personal choice. Lisa: Absolutely. Another question we have and I know you mentioned when we started you have a lot of irons in the fire right now. So this might be a loaded question. What are you focusing on right now as a Radiology group? Bill Algee: Right now, I am focusing on those three projects I have going on They are going to go to our Board on December 15 so those are right up front. But I am really focusing on staff, staffing and what we are doing with that. I have two great managers. I am very blessed. Lisa and Liz are phenomenal people, and we talk about it almost every day, we text about it almost every day. Bill Algee: Trying to figure out, what is going on, what we hear out in the market from other places, their friends that kind of stuff so that we can get that information back to HR to have HR say, "I know what you are getting on this information from your marketing ops, but here is the reality of what is happening in the marketplace that we are seeing right now. We are having people leave for it. People ae telling us what is going on. I think those things are the things... I spend most of my time working on that right now and trying to figure out how we don't end up at 40%. I heard about another facility the other day they have a 50% vacancy rate of their Technologists. I cannot even fathom that. I just can't. I don't know what we would do. We would have to tell somebody, no and I think everybody that is an imaging professional in this call would go, "You can say no?" Lisa: With everything that is going on, certainly the employment trends are not unique to even just healthcare. We are seeing it anywhere. So is there anything within that growing employment trends, again it is happening across the physicians, even in the Radiology Departments that you are seeing. How is this also affecting the community hospital space? Because of all this that is happening are you seeing these trends affecting not just your department but the community hospital? Bill Algee: I think so far for us we've been pretty lucky. We have not had to cancel procedures or roll back our schedules to not be able to provide patient care. We have to look at it from a community perspective overall. We are the only hospital in the community. We have a community of 45,000 people. We are the one stop shop. WE have to keep the doors open and we have to figure out ways to do that. Bill Algee: The things that we are doing we have our own xray school. It is a small program. We only have four students. As of July, we are going to expand this back to six. WE had six for years then we had a couple of years in the late 80s early 90s... maybe it was a little later than that, man, I am aging myself for sure, probably in the late 90s, early 2000s then, we had students that were graduating and couldn't find a job. The market had totally flipped the other way. We cut our program back to four. Now we are going to have to expand it because our last class graduated four students, and we didn't get to keep any of them because they all wanted to specialize or one of them wanted to be part-time and work in an office. We didn't get to keep any of them. That's a challenge. Lisa: All right. Well that was the last of our questions. Again, we certainly appreciate the conversation today and discussion. It has been very interesting to hear your perspective. Again, for those who joined today we will be sending out an archive here in the next couple of weeks. If you could, please complete the survey that will launch immediately following the webinar once we hit close. We would really love to hear your feedback. If you have any additional questions, you can certainly ask us during that survey. Russ, is there anything that you would like to say before we close? Russ Cardwell: I would just like to thank Bill. Thank you for your leadership and your friendship all of these years. I do appreciate your sharing your perspective today. Thank you so much. Bill Algee: Thanks I appreciate it. Lisa: Absolutely. Thank you Bill and thank you Russ for today. Russ Cardwell: All right. Goodbye everybody. Lisa: Take care.