Complete Guide to Radiology Information Systems (RIS)

The letter “k” works as a suffix with “401” but as a one on your radiology information system…not so good. It takes RIS to RISK, and no one is looking for more of that.

You can’t put your radiology/imaging operation at risk with a weak RIS, especially at a time when capturing every insurance and copayment dollar for every visit is critical, and with patients becoming responsible for more and more of what’s owed.

Besides that, the need for efficiency and tight workflow has also never been more urgently needed for radiology. With super-expensive diagnostic equipment that needs to be generating revenue, and with human assets (e.g., radiologists and technicians) who need to be fully occupied, not idle because patients aren’t showing up as scheduled.

A solid RIS helps with all of that, and so much more.

But what exactly is a RIS? We know it means “radiology information system” but that’s really a misnomer since it provides - or should provide - a lot more than information. In fact, a more complete acronym for a RIS that’s on the ball is: RISRPPPPRTGPKDFBPRPCSRTCDMPSAMCRSKPITIEHRITRCMAT.

Totally absurd so let’s leave it at “RIS” and see how the others letters apply.

A Radiology Information System is a sophisticated database system that radiology medical professionals use to keep track of patient data and the enormous image files typically generated in the course of diagnosis and treatment. A RIS is a special kind of electronic health record or EHR system designed specifically for use in radiology. You use it to manipulate as well as distribute patient data.

Want more specifics on what an RIS is capable of? Check out an article that goes deeper!

Almost assuredly, your radiology practice, group or network severely depends on one group of people in particular: your referring physicians. That’s because no doubt the vast majority of patients coming through your doors have been directed to you by your referrers / their physicians. (You might get patients through marketing and advertising but that comes later. Yes, the RIS is involved in that as well.)

That’s why you need to be sure your referrers are happy, and that they continue to refer. In fact, you’d be thrilled to expand your referring network if possible. It actually is possible if you’re using a RIS with specific capabilities as you’re about to see.

One great way to keep referrers referring is by making it easy for them to get their orders to you in a novel way, and for you to get finalized reports back to them in an equally novel way, with links to the patient’s images embedded in your reports, assuming your PACS supports that.

We’re talking about orders in and reports out with four elements:

• no expensive HL7 interfaces which can also cost thousands of dollars annually to maintain, and
• where orders go directly to your RIS from the referrer’s electronic health records (EHR) system, and with your finalized reports going back into whatever EHR that referrer uses, and
• with links embedded taking the referrer to the patient’s images if the PACS supports it, and
• with an ability to track that finalized reports were transmitted back to the referrer if confirmations are ever needed.

If the RIS supports a no HL7, EHR-agnostic, bi-directional in / out circle of orders with links to the patients’ images that are trackable, that’s a powerful package of features designed to keep any referrer referring. More than that, it could also work to expand the referring network.

And of course, the electronic choreography taking place between you and your referrers work to the patient's advantage. They'd no doubt appreciate knowing it.

RIS-enabled physician and patient portals. These are also great for your other most important group of people: your patients. Let’s go through it.

For referrers, how helpful would it be if their practice could enter your physician portal (which could almost be called a “referrer’s portal”) and schedule the appointment for the patient while the patient is still at the referrer’s office?

If that’s doable, then the order been transmitted from the referrer’s EHR as just discussed, and the radiology appointment is also scheduled. Two thirds of what’s needed is already completed while the patient is still at the referrer’s office.

The last third comes from the RIS’ patient portal, assuming it has one. The RIS’ patient portal enables patients to complete any forms and questionnaires that may be needed in advance of their appointments.

Patients either register as new portal users, or login if they’ve already registered and complete that “paperwork” anytime 24 x 7 x 365 prior to arriving.

Now there’s really nothing left for the patient to do but actually show up for their appointment. The RIS should have its hand in that as well.

The referrer transmitted the order, and the appointment was scheduled. The patient completed forms and “paperwork” in advance. Everything is set to go, but where’s the patient?

According to a 2015 survey by amednews.com, most patients are no-shows simply because they forget about their appointments. Sure, life happens with last minute or unforeseen occurrences, but mostly, it’s because the appointments are forgotten.

That’s why the RIS scheduler must support interactive appointment Reminder Texts to patients’ cellphones a few days in advance of each appointment, where texts can contain directions to the appointment location and can be in multiple languages.

Being interactive, patients can reply that they’re confirming or canceling. Ideally, each type of response would land directly on the correct appointment on the scheduler. Patients who cancel can be called to reschedule while other patients with future appointments can be contacted to come in sooner in wait-list mode.

Filling gaps like that keeps the radiology practice humming without having very expensive assets (human and mechanical) not generating revenue.

Patients who don’t respond at all can be called to see about their status.

No-shows will never be completely eliminated, but texting reminders absolutely helps to dramatically reduce no-shows, and the RIS’ scheduler should support it.

We know we told you 'NO "K' in RIS, but like every rule, that one was meant to be broken. We'll allow a "k" as long as it stands for kiosk. 

For years, kiosks have been used at airports, train and bus stations, auto rental outlets, movie theaters, museums, fast food chains, and more as a way to register and enter information.

That same type of “I’m here” kiosk technology can be implemented at your radiology practice, assuming the RIS supports it.

On arrival, the patient is given a practice-supplied, kiosk-enabled iPad™ or Android™ tablet. In a semi-private type space in the reception area, the kiosk walks the patient through registering on screen. Then, any forms that may still be needed for that particular visit are displayed and completed electronically by the patient.

Clipboards with handwritten paperwork which needs to be deciphered and manually entered into the system by the intake team are eliminated.

The patient is now checked in and any forms not completed in advance using the patient portal now are. Note that some forms might arise after using the portal. Those would be included for completion using the kiosk.

Two kiosk security notes:

1. The list of patients who’ve already signed in manually, and which is often inadvertently visible to everyone else coming in after, is eliminated.
2. The kiosk should support an automatic shutdown if it’s left unattended for a period of time, generally 30 – 60 seconds.

Another on-arrival timesaver is for the RIS to support the scanning of drivers’ licenses and / or insurance ID cards. It eliminates the time consuming manual entry of the patient’s data, and it’s basically 100% accurate every time. It should simultaneously capture an image of the scanned item and attach it to the patient’s record.

The RIS has been involved in so much long before the patient goes in for his or her test. Now it’s almost time for that and for you to get paid, but ensuring you get paid also begins before the patient arrives.

A number of things must happen in the risk management system in order to ensure guarantee Getting Paid, starting again with the scheduler:

1. When scheduling the appointment whether it’s (1) through the referring physician’s portal, or (2) by the patient using the RIS’ patient portal to schedule, or (3) by the patient calling in to schedule, the RIS’ scheduler should be configurable to provide an on-the-spot alert when the radiologist doesn't participate in the patient’s insurance.
   
   From the outset, this helps avoid unpleasant situation later where you’ll almost assuredly have to do collections work in getting payments which no doubt went to the patients instead of you.
   
   
2. Also at the time of scheduling, how great would it be if the system had a way for your scheduling associate to let the patient know what his or her approximate responsibility amount will be once insurance has finished reimbursing, and what the patient’s copayment amount will be on arrival?
   
   If the appointment is scheduled through a portal, you’d be able to advise as to what they’ll approximately owe and what their copayment amounts are when confirming their appointments.
   
   Whichever way the appointment is scheduled, this RIS safeguard is ideal for avoiding surprises about copayments on arrival, and surprises when their statements arrive.
   
   
3. Now that the appointment has passed the “radiologist insurance approval test” and the patient knows approximately what they’ll owe, the next thing the RIS scheduler must support is batch pre-appointment eligibility verifications and “pre-certs” enough time in advance to alert patients who have red flag coverage issues.
   
   In fact, red flags - literally - must appear next to each patient’s name on the scheduler if there are eligibility / pre-cert problems. You’d be able to alert each patient about them before they arrive, giving enough time for the patient to help correct any coverage issues.
   
   Note: the RIS should support on-the-spot verifications for those arriving on shorter notice, or for same day appointments, or if you simply want to double check coverage is in effect.
   
   Pre-alerts on radiologists being approved by patients’ insurance, pre-appointment batch verification eligibility, and alerts on copayments and patient responsibility amounts are three major steps in guaranteeing as much as possible that you’ll be paid by insurance and by patients.

Now the appointment has been completed and the RIS should be ready to submit the claim.

There are a few approaches on this which the RIS should accommodate, but a basic radiology data-for-billing scenario is when the radiologist’s report is finalized, the RIS automatically transmits the billing data for the professional and technical components for that visit to the system’s billing side.

We’ll discuss the billing detail shortly but right now, let's follow as the patient leaves.

On exiting, the patient can be shown on screen and/or by printout how the approximate responsibility amount is calculated. Remember, you could’ve explained that when the appointment was made, but now they can actually see it.

This gives you a chance to get a partial patient responsibility payment on that amount while the patient is right there, or maybe even a full payment. Either can be suggested.

You can obtain a signed acknowledgement from the patient as to what they’ll owe so when their statement arrives, it can’t be a surprise.

We have to take a quick detour at this point in the billing sequence to talk about the finalized report.

Once it’s finalized, the RIS should support transmitting it back to the referring physician’s EHR in similar fashion as to how the referrer transmitted the order to you. The report would go directly into the patient’s record in the EHR regardless of which one is used, and do so without an expensive HL7 interface. Presumably the EHR would alert the referrer that the report has been received, but that’s part of the EHR and would have nothing to do with you.

What you would be able to do is track that your outgoing reports have been sent.

Reminder that the RIS should enable links to the patient’s images be embedded into the report, assuming your PACS supports it.

That now cleanly completes the orders in / reports out exchange.

Now for the actual billing. As mentioned, there are a few different radiology-specific scenarios as to when claim data is generated, and the risk management system should accommodate all of them. But let’s assume here that the claim is created as soon as the report is finalized in the RIS. That claim is now automatically transmitted for claim submission and for you to be reimbursed.

Because we know the radiologist is "good to go" insurance-wise, and there are no issues as to eligibility or benefits since that was batch verified through the RIS scheduler a few days in advance, the RIS should produce a nearly 99% success rate on first attempt radiology clearinghouse claims including HCFA, UB, workers compensation and no-fault.

If the patient has more than one insurance, the RIS should automatically submit a claim to payer #2 as soon as the reimbursement from payer #1 is applied, and continue to do the same for any ensuing payers. This type of cascade billing needs to be automatic and hands-off.

A word on reimbursements: the RIS must support automated EOB reconciliations through electronic remittance advices (ERAs) which are virtually instantaneous and error proof. Manually posting of payments to EOBs is eliminated with a RIS that’s ERA-friendly. And, cascade billing in the RIS must also be ERA friendly.

Overall, the RIS should get billing info to the billing side immediately, and the submissions and reconciliations process should be hands off and virtually self-running.

You don’t want to submit your claims then wonder how they’re doing. You’ll want to know exactly how they’re doing right now.

Claim tracking is the answer, and the RIS should support it in real time. You’d be able to view exactly how your claims are progressing much the same way you’d track an overnight shipment. If you see claims lingering or idle, you’d be able to question the payer about them. Real time claim tracking is an essential RIS component.

A nearly 99% success rate on claims is about as ideal as it gets, because there will always be at least some denials. That’s why the RIS must also support an on-the-fly denial manager.

With it, you’d be able to view any denials and their reasons for being denied. Then, you can quickly make the necessary edits and resubmit - ideally all from one window - effortlessly turning denials into revenue.

If the RIS is on a higher level, it might even support pre-denial alerts by predicting the likelihood of claims being denied based on the denial history with that particular payer. You’d be able to re-code before submitting them and avoid what would doubtless be guaranteed denials resulting in less and less need to use the denial manager.

So…claims are being tracked, reimbursements are coming in and EOBs are being automatically reconciled through ERAs. At the same time any denials are being edited and resubmitted.

A word on smart collections: Similar to how it should predict denials, the RIS must have some intelligence on the average length of time it takes individual payers to make their reimbursements.

For example, if a certain payer never pays before 39 days, red flags shouldn’t appear on their receivables reports until day 40. It wouldn’t make sense to waste time trying to collect on day 28, but it would make sense on day 41 for that payer.

The RIS should have a myriad of time saving efficiency tools such as this built into it including workflow, which is addressed a little later.

Now, the radiology information system must know to produce patient statements as soon as balances become their responsibility. The RIS should support patient statements in one of two ways depending on how you want to handle them:

1. The RIS itself creates the statements which you’d print, fold, insert into envelopes, seal, affix postage, and mail.
   
   This is a cumbersome, six step process for just one statement. Multiply it by hundreds and maybe thousands of statements and that becomes a lot of steps. Statement paper and envelopes are needed (the original and a return envelope), and the wear and tear on printers and toner cartridges. But if you want to do it, the RIS should support it.
   
   
2. It should also support offsite production of statements whereby you’d download statement data to the offsite resource. They’d produce mailers with your information and logo as though it was coming from you, and a return envelope that goes to you.
   
   Offsite statements typically cost just pennies more each than the cost of the postage. This is obviously a better way to go, but the RIS should support either or both.

Regardless of how you choose to handle your patient statements, the RIS should know to create them immediately as the patient’s final (or only) insurance reimbursement has been applied. And regardless of how long it took to be reimbursed by the patient’s insurance(s), the patient’s first statement must show their amount due as current.

If you’re using a portal with a secure online way for patients to make payments, so much the better. Patients can be directed to your portal for this and make their payments which go directly to you.

Intelligent, “no hands / no thinking” sequencing of reimbursement reconciliations-to-patient statement-creation is invaluable in helping to ensure as much as possible that your patient receivables are in good shape. This is bolstered by having been able to advise the patient in advance as to his or her approximate responsibility amount.

Radiology practices and groups almost invariably have to track an entirely separate group of people besides referrers, patients, and insurance payers. We’re talking about patients’ attorneys.

That’s why the RIS should have a built-in, no extra cost database capability to handle attorney management by case since it’s not beyond the realm that over time, one patient might have different attorneys for different cases. You probably already know that.

Having an integrated way to manage patients’ attorneys is an invaluable feature, assuming the RIS has it.

By the way, the RIS should be able to clearly define a patient’s cases for patients who have more than one case. This would be especially applicable to workers compensation and no-fault patients. You’d want to be able to view a patient’s specific case in the RIS, or selected cases, or all of the patient’s cases.

As mentioned earlier, radiology is highly competitive. That’s why it’s not unusual for radiology practices and groups to do marketing as well.

Radiology marketing has actually become sophisticated to the point of using digital reality viewers to give potentially new patients a way to virtually experience your imaging center.

But more down to earth, there’s local print and media advertising, mailers, billboards, “back of the bus” advertising, etc. There’s also digital outreach with social media, emails, and the radiology practice’s own website which might attract potential new patients organically through search engine optimization (SEO). You might even belong to an online radiology network.

All of this falls under the “marketing” category, and if you’re doing any of it, you’ll need a way to track the success of those efforts. For that, a CRM (customer relationship management) system is needed.

A stand-alone CRM can cost tens and even hundreds of thousands of dollars depending on the system size and features selected. Then, it would need to be integrated (another cost) with the RIS for optimal use, and it would typically incur an annual maintenance cost to keep the interface going.

If the RIS has CRM features built-in at no additional cost, that’s a powerful system advantage. And if you ever want to implement a stand-alone CRM, the RIS should be amenable to that through an interface.

Even if you’re not doing any marketing right now, chances are you will at some point, even minimally. The RIS should be ready for it when you’re ready for it.

We mentioned at the beginning that what started out decades ago as a “radiology information system” has morphed into software that handles way more than information as you’ve seen by reading to this point. Now we go back to the roots of RIS with KPIs.

Perhaps it's not a coincidence that KPIs falls under Chapter 13 in this paper. Financial and management key performance indicators are what every business relies on to operate successfully. KPIs, reports, and analytics provide a picture as to how things are going, what’s doing well and what needs to be improved.

Your radiology practice or group is no exception. As such, the RIS should have very comprehensive reporting capabilities built-in without requiring expensive, add-on report writing utilities that often require hours of training, if not programming time as well.

The RIS’ ability to support wide ranging, user-defined reports that are easily created and compiled is of paramount importance. System operators should be able to save their report parameters eliminating the need to create them “from scratch” every time.

More than that, the RIS should enable automatic compiling of saved reports on specific days and at specified times, at certain intervals, etc. Reports must be exportable to Excel® and be able to be drilled-into for details on a specific element. Displays ideally are user defined with standard report views, graphical views, dashboards, etc.

Reports should be possible in roll-up fashion across the enterprise, or by specified locations or location. On a security note, administrators must be able to put limits on the types of reports operators can generate, often in a role-based approach by login.

The question “How are we doing?” as it applies to any of your radiology practice’s financial and operational matters shouldn’t be answered by conjecture or shoulder shrugging. It should be answered by being able to quickly compile the data needed through the radiology information system.

Tax IDs and the number of them needed by your radiology group shouldn’t be taxing on the RIS. The RIS must be able to handle as many tax IDs as needed, or just a single tax ID if that’s how you’re setup.

The key to successfully navigating multiple tax IDs is an ability to “flip” between them without having to continually logout of one and login to another which is incredibly tedious for system operators having authorized access to more than one.

Another timesaving tax ID feature is being able to copy and paste the patient’s data from one tax ID into another when needed without having to manually reenter the patient’s data.

Similar to tax IDs are directories which radiology groups sometimes find to be useful. Directories are used if the group wants to more solidly segregate different segments of the business either by location, or perhaps by diagnostics vs. interventional, or if different segments have different corporate names, etc. Directories should be able to handle an unlimited number of tax IDs in each.

Data views would be by directory across the enterprise or by specific directories, and then by any / all tax ID(s). Likewise, system reports should have tax IDs and directories as part of their parameters enabling users to compile them based on whatever data is needed.

Tax IDs and directories work to keep things neatly compartmentalized and orderly. They’re RIS essentials.

As in “implementation type.”

For example, the RIS may be cloud-based if you’d prefer not to have it implemented on your own server(s). Your system operators would access the RIS securely in the cloud without having to worry about buying and maintaining servers and performing backups.

If cloud, make sure the offsite hosting is secure and is handled by a very reputable resource with all malware, intrusion, firewall, and physical protections in place.

The RIS should also be deployable on your server(s) if a privately hosted (client server) configuration is preferred.

The RIS and the RIS vendor should be versatile enough for whatever implementation scenario works best for you, not them. And if you implement one way and decide to redo it at some future point, they should be versatile in that way as well!

There’s actually a third implementation type in the form of outsourced revenue cycle management (RCM).

In this scenario, the RCM team of radiology specialists handles the EDI (pre-appointment eligibility verifications, claims, claim tracking, denial management, EOB reconciliations), patient statements with patients directed to call the RCM team if there are statement questions, and KPIs / reports with reviews of them with the radiology group’s team.

A really good RCM resource will provide its clients with transparent, 24 x 7 x 365 access to all of their data, and training on using the system. Clients would be able to compile their own reports at any time in addition to the reports provided by the RCM team.

The RCM resource would probably have tools to increase revenue by maximizing the value of claims without over-coding, for predictive denial analysis enabling re-coding, and more.

If the RIS vendor has its own RCM resource, that’s something you might want to consider. They should be able to provide a no-cost assessment on exactly how they can increase your radiology group’s revenue.

Regardless of how the RIS is implemented, you’ll want to know that a reliable audit trail is in the background continually monitoring system use by operator with administrators and any other authorized users able to view system use at any time.

As a side note, it’s good for system operators to know their activity in the RIS is being “watched” but doing so is the administrator’s decision.

A few separate items of importance specifically regarding the RIS vendor and its resources:

1. You’ll want to make sure they have a solid track record of stability and reliability in in the industry. Several decades of proven RIS experience would obviously seem to be an advantage.
   
   
2. Do they provide implementation, training ongoing support with updates, and IT (here we mean “information technology” / hardware / networking) services, or do any of these involve second or third party entities?
   
   
3. Has the vendor’s programming team performed successful data conversions from and interfaces to other systems, including PACS? The vendor’s RIS should essentially be PACS-agnostic, but the vendor should also have a few recommended PACS resources if one is needed.

To read more about what you should look for in a RCM vendor; read this article! 

A RIS needs to have its hand in virtually every aspect of your radiology group’s financial, operational, and clinical sides, and provide automation solutions that positively impact your payers, your referring base, and your patients.

If it does, it’ll have a positive effect on something else: the wellbeing of your radiology group!