In this episode of After the Chaos, Angela and Kandice reflect on their conversation with David Facchini, Director of Radiology at Yale, and someone who has lived every phase of building a follow-up program from the ground up. Before purpose-built technology existed, David and his team built a completely manual system, investing 10 FTEs and four years to operationalize actionable findings follow-up at scale. The program improved care, but it came with a cost few health systems can absorb.
Angela and Kandice use David’s experience to explore a central question health systems face today: Should we buy technology or build it ourselves? While EHR-first strategies feel practical, leaders often underestimate the true scope of work—designing workflows, building governance, maintaining data models, supporting connectors, and continuously iterating on performance. And with only “a partial FTE” available in many radiology departments, the math rarely adds up.
The discussion also highlights a second overlooked factor: selecting technology means selecting a long-term partner. Stability, customer success, vision, and values influence the effectiveness of a solution just as much as the code behind it.
As radiology programs sit at the intersection of rising volumes, shrinking resources, and increasing complexity, this episode offers a clear takeaway: actionable incidental findings are one of the most strategic and highest-ROI places to start. But choosing how to scale requires a realistic assessment of resources, long-term goals, and the pace of technology change.
Full Transcript
AI-generated transcript. Accuracy may vary; please excuse any transcription errors.
Kandice Garcia, RN
Here we are again—one of my favorite parts of the show—where we get to reflect on the conversations we just had with our guests. We just spoke with David Facchini, the Administrative Director at Yale and a dear friend of mine in quality.
Angela Adams, RN
I love David’s story. He started as a transporter and worked his way up to essentially running radiology at Yale. And beyond that, what stands out is how he built a manual follow-up process before technology in this space really existed. That kind of experience gives you a deep understanding of workflows—what works, what doesn’t—and allows a team to evaluate technology with clarity.
Kandice
Exactly. He approached it like a true quality leader—building, testing, PDSA cycles—before hardwiring anything into an electronic system. But what really struck me was the sheer level of resources it required. This is Yale, an academic medical center. He still had to develop a business case, secure funding, request FTEs, and manage the entire build. Many organizations could never take that on. And even with all of that support, he said that knowing what he knows now, he wouldn’t build it again.
Angela
That point is huge. I talk with leaders every week who think they can “just turn something on in Epic” or create a worklist and staff around it. But the reality is far more complicated. The human cost, technology cost, time cost, and quality implications add up fast. And often, when I ask how many FTEs they have to manage follow-up for hundreds of thousands of studies, the answer is: maybe one. Maybe half of one.
Kandice
Right. And technology is just one part of the development. You also have to build roles, responsibilities, communication workflows, and culture around it. Even when using a vendor, you still need resources from your IT or TDS team to integrate, connect feeds, authorize interfaces, and maintain infrastructure. Every organization has different technical constraints, approval processes, and queues. It’s incredibly hard to manage.
If you take on building the program and building the technology, you’re underwater in a few years—and the tech landscape has already changed.
Angela
And that’s what people underestimate. Even if you build the identification piece, that’s only a fraction of what’s required. Behind the scenes, our data science team iterates models every month to increase efficiency. Nothing stays static. Being a learning organization means constantly updating, optimizing, and improving. You can’t build once and expect it to last.
Kandice
Exactly. Selecting technology is really selecting a long-term relationship with the company. You’re not buying a product—you’re choosing partners. Their vision, their implementation approach, their support structure, their values—all of it matters. I can usually tell from meeting a team how their product is working in the field. If the interactions feel off, the solution usually is too.
Angela
Well said. My nugget of the week is this: hospitals often don’t realize that the “Epic-first” mindset unintentionally pushes more burden onto staff without giving them the tools to succeed. And with limited FTEs, that’s not sustainable.
Kandice
And mine is this: leaders must understand their vision for technology—when to build, when to buy, and where to place resources—especially in areas like incidental findings, lung screening, and population health. These are high-value, high-ROI programs that directly support patient care and operations.
Angela
As always, so good to talk through these insights. And thanks to our listeners—find us anywhere you get your podcasts.
