“Have it your way” was the marketing slogan of Burger King until the plastic headed “King” of social media stormed the scene. Traditionally, veterinarians believe that their practice can have everything “their way” and have applied the Burger King ethos to digital radiography. Because it is essentially impossible for digital modality vendors, practice management software vendors (PIMS), and teleradiology providers to create customized solutions for every veterinary practice, veterinarians will need to do way with this Burger King business, give up some of their independence, and allow the vendors to dictate aspects of their practice workflow before widespread integration is possible in the veterinary practice.
If veterinarians are willing to cede a modicum of control and the vendor community1 is willing to put aside their differences and work together, automated digital radiography and teleradiology integration will be possible.
Step 1: Veterinarians need to allow some aspects of their practice workflow to be dictated by their practice management vendor
In human medicine, insurance companies help define items like billing and procedure codes0.5. Veterinary medicine lacks this standardization so vendors are unable to build robust integration platforms that require standardization. 
Before the Internet and efforts at integration, each veterinary practice could do things their own way because each practice was a self-contained unit. In the days of the Internet and information exchange between practices, the flexibility and customization that practice management software vendors have afforded their clients, and the independence that veterinarians have become accustomed is a heavy weight that is suffocating2 efforts at automated digital and teleradiology integration.
Veterinarians must, as an industry, give up some flexibility and allow practice management software vendors and modality vendors to dictate some aspects of their practice workflow before we will see widespread integration in veterinary medicine.
Step 2: The veterinary industry must come together and define the different imaging study types (for example thorax, cervical spine, abdomen) we perform at veterinary practices.
Currently, each veterinary practice defines a digital radiographic study differently. Some practices hold on to antiquated solutions such as charging by the image (e.g. one view setup plus additional view). Some practices call a “thoracic study” a “thorax” and others call it a “chest.” Some call a “3 view thorax” a “3 view thorax” and others call it a “met check.” The problem with having different names for these studies is that for integration to occur different computers systems must speak a common language. With regard to digital radiography integration and automated billing the basic building block of that language is the digital radiographic study.
Step 2 in this plan, therefore, is for the industry to develop a list of studies that we perform in veterinary medicine. Once this study list is defined, PIMS, modality, and teleradiology vendors can start to talk with one another and digital radiography integration can move forward in veterinary medicine.
Step 3: Digital modality vendors define the relationship between an image and a study.
GEEK ALERT: if you are a normal human being you can probably skip to step 4. If, however, you are a software developer or are just interested in the intricacies of DICOM you are permitted to read about step 4.
DICOM allows modality vendors to define a digital radiographic study in 2 ways. First, each image can be given a series designation and a study is defined as a collection of series. Second, each image can be given an image designation and a study is can be composed of a single series with multiple images in the series3.
It really does not matter how the different designations within DICOM are used but we all need to do it the same way. This will allow PIMS vendors to automate billing because it will take out the ambiguity in determining if each series is an image or if each series should initiate a new billing event4.
Step 4. These new definitions of a study must be made sacred in the imaging device.
Modality vendors must implement systems that will prevent users from adding images of a different body part (e.g. adding images of a tarsus when radiographs of the thorax are ordered) to an existing study while allowing users to add images of the same body part (e.g. a Great Dane thorax that requires 7 images even if the study only really calls for 2 images).
If users are allowed to add images of a different body part that were not ordered, there will be missed charges because PIMS has no way to account for them Similarly, users must be allowed to add images of the same body part without creating a new study or PIMS will over charge for these images.
Finally, vendors must encourage users to “close out” a study when a pet leaves the radiology room (e.g. a patient comes into radiology at 10AM and has thoracic radiographs but comes back at 11PM on the same day for recheck images. This should initiate 2 billing events. Leaving the study open and allowing users to add images to an existing study will result in lost charges because PIMS will have no way to account for them).
Step 5: Veterinarians must accept that by allowing vendors to dictate the types of studies that are available in their PIMS and digital radiography system they are giving up a small bit of independence but they gain the satisfaction of not losing money on lost charges.
In our experience, lost charges are common in veterinary medicine. In every practice that we audited (as well as the data put out by the PIMS vendors selling integration) every practice missed charges and the amount of lost charges can be significant. In the days of veterinary medicine 3.0 where selling items such as flea products are out the window, vaccination revenues happen every 3 years, and we are trying to build our practices on wellness exams, capturing as many charges as possible will become increasingly important over time.
Veterinarians must accept that automated billing will slightly impact their workflow. Automated billing means that studies must be ordered in PIMS. Automated billing means that if your technician is in the radiology room and you yell at them that to add a stifle to the thorax study you previously ordered will require you to first order the stifle study in your practice management software because the digital radiography system will not allow them to take the images without first ordering them5.
Bottom line: the time has come for veterinarians to give up some independence and for the modality vendors and PIMS vendors to define a digital radiographic study so we can all see the day when automated billing and digital radiography integration is the rule rather than the exception. Automated billing just might make up the lost revenues from the flea products and medications that you no longer able to sell at your practice.
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0.5: Insurance companies, however, are not the answer. They are still having issues on the human side and we can do better. Here is a recent article discussing the topic: http://www.radiologytoday.net/archive/rt0311p8.shtml
1. Remember this article (click here for article) yeah…well…time to eat a bit of mud. I am more than inclined to believe that Butler is doing, and will continue to do, the right thing. Don’t be surprised if Butler along with the Veterinary Radiology Reporting Group (VRRG) kick start the process by developing a list of studies modality vendors can use. While we are discussing the topic, the VRRG has been making strides in developing a universal format for the radiology report that looks like it will stick. Kudos boys. Keep up the good work. Especially you Mr. Ballance.
2. I am told Hungarian women write the names of men who spurn them on flat rocks and bury the rocks. Apparently, the weight of the ground causes the person whose name is written on the rock to feel like they are suffocating. Now I know why I always feel like I am suffocating. Damn all of you doctors who filled my head with all of this asthma, allergy, and dust mite nonsense. Liars. Every one of you.
3. There should probably be a little chart showing what this means since I know it made absolutely no sense. Then again, if it did not make sense you did not heed my geek alert. If you are still confused but interested, contact me and we can go through it. It is very important.
4. I just killed you with geek speak. Just trust me. This is important. Please do not hold it against me or write my name on a flat rock and bury it. See footnote 2 if that does not make sense.
5. Although there should be an “emergency” setting on the digital system for emergency cases. When the emergency setting is used, automated billing will go out the window and you will need to remember to bill for them.