Thus far during the coronavirus crisis, many practices have experienced a sudden drop in imaging exams, which has resulted in dramatic changes in operations and impacts on revenue. But the crisis also provides an opportunity to emerge even stronger in the post COVID-19 era, if the present is used wisely to prepare for the upcoming post-pandemic surge in volumes.
In this article, we review findings of some of the latest research together with interviews on the impact of the COVID-19 pandemic for radiology, and how to deal with the aftermath.
Nobody can deny that the COVID-19 pandemic is having a significant impact on radiology. For example, this is described in detail in a report[1] published on April 15 in the Journal of the American College of Radiology by Dr. Howard Forman and Dr. Joseph Cavallo from the Yale School of Management. They describe how emergency policies have been put in place across the US to keep people safe and to expand hospital crisis capacity, which has impacted radiology practices, among other specialist areas.
Since mid-March, radiology has experienced postponements in scanning, and patients are being deterred from seeking non-emergency medical services. The extent to which radiology practices are being affected varies significantly between geographic regions based on the severity of the coronavirus outbreak. The report concludes that outpatient imaging has been hit the hardest, with a decline of more than 70% in volumes, compared to 50% among emergent and inpatient scanning. Outpatient imaging is also expected to suffer the greatest revenue losses.
Another report[2], published on April 23 by the market research firm Quinsite (mentioned in an article on AuntMinnie.com[3]), describes a scenario where healthcare providers are cancelling or postponing elective care nationwide, which has led to radiology imaging volume in the US falling by 50–55% as an effect of the pandemic.
Promisingly, its findings also show that the decline seems to have stabilized. Quinsite found in its research that the daily volumes at the surveyed practices in their latest measurement were down 52.9% on average in week six of the COVID-19 outbreak, compared with the figures recorded on March 16. An intermediate recording made on April 13 showed that volumes were down 60%. Hence, there has been a slight recovery in volume, albeit very slow.
Quinsite estimates the average lost revenue from the outbreak to be USD 37,700 per full-time equivalent (FTE) employee during the latest period it measured in the US—a figure that would cause severe financial issues for most radiology departments and clinics. As a result, many radiology departments have already adjusted the way their staff work and how imaging is performed to cope with the decline in revenue, such as shortening working hours and laying off staff.[4]
According to Dr. Forman and Dr. Cavallo, the situation is very unique, and they conclude the following[5]:
“While economic recessions generally tend to result in decreased health care expenditures, radiology groups have never experienced an economic shock that is simultaneously exacerbated by the need to restrict the availability of imaging.”
Looking at Europe, the situation is similar in many countries, with declining volumes for most radiology subspecialties. From interviews performed with radiologists in Sweden[6], it is reported that many radiologists now have to work from home, and more time is spent on internal training and to keep the backlog as short as possible to prepare for a potential scenario in which many colleagues fall ill. Furthermore, it would appear as though many departments have significantly decreased their utilization of services from privately held telemedicine companies.
Although the prerequisites for radiology practices to adapt to the declining volumes vary considerably between the US and Europe, radiology has indeed suffered. This recession will be like no other, due to the combination of economic instability and the need to restrict the amount of imaging services available, resulting in short-term as well as permanent changes to the profession.
Looking at the impact of the COVID-19 pandemic by imaging modality, the hardest hit has been mammography with a decline of 77.8% compared with the start of the pandemic; probably because it is non-acute in its nature. Next is MRI with volumes down 46%, ultrasound down 43.3%, and x-ray down 41.8%.[7]
As the aforementioned survey shows, there is some light at the end of the tunnel and volumes are slowly recovering, and radiology departments therefore need to consider how to cope with the aftermath. There is a risk that volumes and workloads will increase rapidly when all the postponed elective exams need to be performed. It will force radiology practices to quickly adjust operations as the pendulum swings in the opposite direction.
In the article “The crisis after the crisis: the time is now to prepare your radiology department”[8], published on April 14, the author Dr. Thomas Kwee, PhD, of University Medical Center Groningen in the Netherlands, says that it is inevitable that a large reservoir of radiologic procedures will accumulate. Dr. Kwee and his group write:
“The backlog of imaging exams that has been put off amid the COVID-19 pandemic will be the ‘crisis after the crisis’.”
They also explain that although there is literature on how to prepare a radiology department for operation during the COVID-19 crisis, the post-crisis situation has not yet been addressed. He is of course looking at it from a Dutch perspective, but most likely the lack of preparation will be similar for practices in many other countries.
The length of time it will take before volumes are back to, and probably above, normal levels, is still not certain. Dr. Forman and Dr. Cavallo mention in their report[9] that radiology departments will see reductions in imaging volumes over a period of least 3–4 months. This will allow time for preparation.
So, how can radiology prepare given a current situation with overcapacity, to a sudden post-coronavirus surge in volumes?
Dr. Forman and Dr. Cavallo advise radiology groups (again, a US perspective) not yet deeply impacted by the pandemic to consider reducing working hours, temporary salary cuts, bonus suspensions, furloughs, and if necessary, layoffs to offset temporary reductions in revenue.[10] Basically, the recommendation is to create a contingency budget.
In addition, they advise practices that are already affected to ensure they make appropriate modifications to their workflows. They should also establish additional hygienic precautions that will allow radiology staff to operate under semi-restrictive conditions that could follow the lifting of total lockdowns. This may require longer hours and reduced staff at any given time.
Furthermore, they mention that one of the most important things is taking care of employees. Cavallo says that any first step in recovery should be to empower staff:
“Furloughs, cut hours and reduced wages have affected many. The first priority for any practice should be to make sure that their workers feel valued and reassured.”
From their US perspective, creating an organizational flexibility to handle both the sudden decline and surge in volumes comes down to being able to more effectively adjust working hours and costs to volumes.
Kwee and colleagues[11] suggest in their report a set of clinical ways to cope with the upcoming imaging backlog when COVID-19 restrictions lift. One example they mention is to use abbreviated MRI protocols:
“MRI represents a large proportion of the total volume of procedures in our department, and is relatively time-consuming. Therefore, current MRI protocols will be replaced with abbreviated MRI protocols when possible.”
They also mention a redistribution of the workload. Some radiology subspecialties will experience higher peak workloads once non-urgent imaging exams resume, so the department could evaluate the reassignment of its staff to those subspecialties, such as x-ray, chest CT, oncologic CT, and abdominal ultrasound.
“Now is the time for radiology to consider how to prepare for further stress on its departments.”
Workload balancing is also mentioned among the Swedish providers[12], highlighting the need to utilize the workflow orchestration functionality featured in their PACS to even out workloads. One radiologist said:
… the chat functionality is great. And it is also really convenient to work with shared worklists driven from the PACS, where I can see which cases other radiologists are working on and we have the possibility to easily share the workload. [13]
The Swedish radiologists interviewed also mention the increased utilization of chat functionality integrated with the PACS to allow for quick and easy consultations or asking questions. Another example that was brought up was lesion tracking tools to save time, or teaching files to tag COVID-19 cases and make them searchable.
Although the preparations may vary among countries due to different regulations and healthcare systems, all radiology departments should raise awareness and encourage discussions on how to prepare for “the crisis after the crisis” based on their prerequisites.
In Chinese, the word crisis is composed of two Chinese characters representing ‘danger’ and ‘opportunity’, respectively. The dangers of the COVID-19 crisis for radiology are the financial and the clinical effect due to surging post-crisis workloads. Also, physician burnout might be a problem—or an even bigger problem than before—once workloads surge. But as the Chinese wording says, a crisis seldom comes without opportunities, and that also goes for the coronavirus situation.
Dr. Forman and Dr. Cavallo write that while it has entailed mainly negative effects, the pandemic has produced growth in a few areas, including the greater use of distributed workflows. For example, the pandemic has forced radiologists to work from home to a much greater extent than before. This has quickly increased the adoption of new technologies and will change the way radiology groups work also in the long term.
They also conclude that practices in the US are trying to capture more revenue to make up for losses incurred during the height of the pandemic:
“Responsibilities that were previously outsourced to teleradiology services could ultimately be brought back ‘in-house.’”
In addition, they mention that the merger and acquisition activity among healthcare providers may also increase, due to historically low interest rates and the need to access capital:
“Even prior to the current crisis, the prevailing trends were toward consolidation. Larger groups are more likely to have balance sheets that can better weather the uncertainty ahead. Smaller practices may have more difficulty competing, and this could speed up the pace of mergers and acquisitions.”
The Swedish radiologists interviewed highlight the benefit of being forced to adopt new technologies to become efficient in the new working situation. As one radiologist stated:
I am more productive working from home, as I don’t experience the same level of disturbance, big or small. [...] I encourage everyone to really utilize the technology, to embrace it and turn it into an advantage. [13]
Recovery for any practice will take time, and at the very least will require temporary changes in their operations. In tougher business climates, such as in the US, newcomers to the field can expect a tougher job market, while senior radiologists may be required to potentially delay retirement and staff may incur pay cuts, furloughs and, potentially, layoffs. In Sweden and other European countries, radiologists may face similar consequences to their counterparts in the US if they are privately employed, or, if working for public hospitals, be rescheduled to support the care of COVID-19-infected patients or to work from home.
The research outlined in this article urges radiology departments to start preparing for the post-crisis scenario to be able to handle the heavy workloads ahead. The dramatic shift from a 50–70% decrease in volumes to workloads even higher than before the crisis will require significant adaptions in workflows and for staff.
But with every crisis, there will be opportunities. Those practices acclimating to these new conditions will emerge even stronger post-crisis. The radiologists that adopt new technologies for remote reading and workload balancing—including functionalities that enable a more efficiently distributed workflow—will be armed with greater flexibility to adapt to changes in volumes and be able to cope with the COVID-19 aftermath much more efficiently.
