Imaging 3.0: Radiology Gets a Facelift | Diagnostic Imaging

Imaging 3.0: Radiology Gets a Facelift

Radiology is getting an upgrade. After incorporating and mastering the explosion of technologies that emerged on the market over the past 20 years, many industry leaders say it’s time to take practice and patient care to the next level.

This revamp comes in the form of a new initiative from the American College of Radiology (ACR) called Imaging 3.0. It’s a national campaign to guide practitioners and facilities from being focused on volume-based service to concentrating on value-based practice.

“It’s now time for radiology to build the value into our service,” said Bibb Allen, MD, vice chair of the ACR Board of Chancellors and a practicing radiologist in Birmingham, Ala. “The value on the front end of radiology means being involved in identifying the most appropriate test. It’s the value of managing and helping the patient understand the risk of exposure. It’s all sorts of things.”

Reaching this goal, though, will require radiologists to work more closely with referring physicians and to take on more leadership and consultation responsibilities, he said.

What Is Imaging 3.0?

Launched earlier this year, Imaging 3.0 is a campaign that brings radiologists and their referring physicians together with the cutting-edge technologies that can foster more appropriateness in imaging and improve patient care. It’s also a tool designed to create a paradigm shift within radiology.

“All the incentives are there to keep doing more and more. We’re not giving up on fee-for-service, but we have to prepare our membership for the time when doing more of the same old thing isn’t the way healthcare works,” Allen said. “We have to make policymakers aware of the great things radiology can do beyond interpretation. We can’t just say we’re part of the solution, we have to show it.”

The structure of Imaging 3.0 is actually fairly simple, and it changes the current practice of radiologists having little input into study selection and having to conduct only the scans ordered by referring physicians. Within Imaging 3.0, when referring physicians determine the need for a diagnostic study, they can consult a clinical decision support (CDS) system at the point of care. By entering patient data, physicians get an immediate recommendation for the most appropriate study even before contacting a radiologist. If the best choice is unclear or if referring physicians have questions, however, they can reach out to the radiologist for further guidance.

This system is designed with a single goal in mind — to identify the best study for individual patients at the beginning of their care. That choice sets the trajectory for the patient’s ultimate outcome, said Bob Cooke, vice president for marketing for National Decision Support Company, the manufacturer of the point-of-order CDS system ACRSelect, the ACR’s official conduit for access to appropriateness criteria.

“We believe that selecting the right test has impact throughout the entire care cycle — getting the appropriate result is a great first start,” Cooke said. “Selecting the right imaging procedure can have an impact economically, and can improve the healthcare cycle, and it can potentially reduce the patient length of stay.”

What’s Happening Now?

Although Imaging 3.0 is a hot topic of conversation for many radiology leaders, this practice model is far from being the new standard, Allen said. The pull to practice under the fee-for-service model is still strong enough to dampen the industry’s enthusiasm for this approach.

However, there are things that practices and departments can do to begin the shift toward focusing more on value services, particularly in light healthcare reform’s call to control image utilization.

For example, Allen said, providers should participate in the Physician Quality Reporting System (PQRS), maintain their certification, and participate in the Dose Index Registry. They should also encourage their facilities to implement a CDS that works within the electronic health record (EHR) system. Each measure is a step toward a new patient-centric care model.

“This isn’t a campaign to go say hello to three patients a day, and all will be well,” Allen said. “We want to use the tools that are available to make preemptive strikes — to use the data collected to help radiologists intervene at the point of care, when necessary, to make sure what’s done is the most appropriate and that patients get what they need.”

He also recommended radiologists develop a standardized follow-up program and participate in image-sharing programs so they have access to patient reports.

Ultimately, according to Geraldine McGinty, MD, chair of the ACR Commission on Economics, each of these measures will likely have a direct impact on future radiology reimbursement. And, as image utilization is more tightly controlled, radiologists will need to actively demonstrate and deliver their value to justify those payments.

“Radiologists need to identify other ways to contribute, such as patient consultation and educating referring physicians,” she said. “This is the crux of Imaging 3.0 — to ensure providers continue to receive appropriate reimbursement based on the value they show.”

The Importance of CDS

In many ways the linchpin for the success of Imaging 3.0 and the makeover of radiology’s commodity image is CDS, Allen said. Having it added to PQRS or meaningful use would be an enormous benefit to this initiative’s effort.

Whether it becomes a mandate, giving referring physicians finger-tip access to diagnostic scan guidance at the point of order can save both time and money, said ACRSelect’s Cooke. Presenting appropriateness criteria guidance in an easily consumable electronic format is more efficient than relying on referring physicians to consult paper documents.

“Today’s order entry relies heavily on the ordering physician selecting an exam based on his or her knowledge of the patient’s condition. It’s largely driven by physician understanding of imaging,” he said. “We remove the subjectivity. We use a point-of-order set of structured indicators that can help the ordering physician make the right selection.”

CDS systems, including ACRSelect, work best when they’re embedded within the facility’s EHR, he said. That way, physicians can add specificity to their order by selecting various clinical indicators without exiting the EHR platform. Based on the entered parameters, ACRSelect returns a ranked list of possible imaging studies, based on the ACR Appropriateness Criteria, that will meet provider and patient needs.

So far, facilities using ACRSelect have seen a 10 percent to 12 percent drop in imaging utilization, Cooke said. Demonstrating appropriateness and controlling utilization are indelibly linked, he said, and when used correctly, it’s easier for radiologists to showcase their value.

“The basic issue is that radiologists are the experts in terms of what procedures are appropriate and what their impact will be,” he said. “By enabling this collaboration and guidance with the referring physician, radiologists will be able to make more of an impact on the care cycle and continue to do what they do best.”

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Radiology Partnership Agreements: Achieving Better Alignment Without Hiring the Physicians


Radiology Partnership Agreements: Achieving Better Alignment Without Hiring the Physicians



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While hospital employment of radiologists is less common than in other specialties, there is increasing reliance on this strategy to better align radiologists with health system priorities. Under an employed model, hospital leaders clearly have the leverage they seek to improve care coordination, drive performance improvement or eliminate competitive activities such as imaging center ownership by their radiology group. These potential benefits come at a significant cost though, with financial losses likely in the early years due productivity declines and expenses related to the acquisition and technical integration of the practice. Given the potential negative economic impact of physician employment, it can be advantageous for hospital leaders to focus instead on improving the terms of the existing professional services agreement.

Determine what success will look like
When using the PSA as an instrument for change management, it is important to clearly establish the objectives of the negotiation. These should broadly include promotion of clinical practice that conforms to evidence, along with proactive performance measurement and improvement. Establishing a shared focus on competitive concerns should also be an important outcome. The first task in achieving these goals is to distill the needs into specific metrics that can be easily measured and reported. Once identified, the metrics can then be included in the agreement as a guide for minimum performance thresholds, to structure pay-for-performance incentives, or as a combination of both.

Important quality and operational metrics to include are:

  • Interpretive accuracy measured through peer review (error rate)
  • Compliance with critical findings reporting policies (reporting time or percent compliance with reporting the diagnoses defined in the policy)
  • Interventional radiology outcomes (complication and mortality rates)
  • Report turnaround times by location of service
  • Percentage of high-tech imaging studies interpreted by subspecialists

The requirements and/or goals for these areas may be formulated by evaluating past performance, benchmarking against external high performers and modeling the expected impact of quality improvement projects and technology upgrades scheduled to take place during the term of the agreement. For example, a hospital planning to eliminate transcription and implement voice recognition should factor in forecasted turnaround time improvements as a result of the change when defining the target in the agreement with its radiologists.

Expect radiologists to lead as well as read
Business development activities are of equal concern to hospitals and radiology groups, and this should be reinforced in the contract. While it is in the self-interest of radiologists to help the hospital gain market share (increased volume is the most effective way to offset declining reimbursement), they can be reluctant to invest significant time in practice-building activities. As accountable care organizations proliferate, the pressure to prevent referral leakage will mount, necessitating involvement by the radiology group in marketing activities. To encourage a high level of engagement in the hospital’s marketing programs, the PSA should incorporate performance standards around volume growth, physician satisfaction and patient satisfaction. Radiologists must own the relationship with referrers, and incentives should promote good habits in this arena.

It should also be the purview of radiologists to educate and evaluate the performance of technologists, define safety policies and assist the department director in improving daily workflow. Similar to practice-building, these activities provide mutual benefit to the hospital and radiology group because improved operational efficiency boosts revenues for everyone. Likewise, increased focus on safety also reduces malpractice liability for both parties. Incorporating key operational and safety oversight requirements in the formal position description for the chairman of radiology is one way to address this contractually with the group.

Use inclusion to achieve buy-in
To increase radiologist commitment to the achievement of hospital objectives, it is essential to give the radiologists a “seat at the table,” enabling them to truly understand and buy into the overall business goals. This may be accomplished through inclusion in hospital committees and participation in discussions about strategic planning, system performance and payer strategy. The challenge is that many radiologists won’t participate willingly in non-revenue producing activities, expecting compensation for time spent on administrative tasks and projects. This stance, while counter-productive, is understandable given recent declines in radiologist income. The problem may be resolved by simply requiring committee participation in the PSA, or in some circumstances it may behoove the hospital to meet the group halfway and provide compensation for time spent on non-clinical activities. While rankling to some administrators, the investment may be worth it, considering how unlikely a disenfranchised doctor is to fully support the mission.

Address health IT needs in the negotiation
Making it easy to do things right serves all parties to the relationship well. The hospital and radiology group should collaborate to select and deploy technology that promotes efficiency and quality, evaluating potential solutions such as voice recognition, radiation dose monitoring or decision support software. It is not enough for the hospital to consult with the radiology group about what to buy; when making technology investments there must also be shared accountability for successful implementation. Decision support software is a case in point. Designed to provide feedback to referrers at the point of order, decision support software in its native form relies on a relatively static matrix of ordering scenarios created by the American College of Radiology in its ACR Appropriateness Criteria®.

While this represents an excellent starting place, some hospitals have concluded that decision support technology isn’t optimal when deployed in a plug-and-play fashion. To get the most out of the system — and avoid backlash from frustrated referring physicians — the content can be  configured further (“localized”) to work differently for specialists addressing clinical scenarios not accounted for in the ACR criteria. These types of content changes are necessarily driven by the collaboration between radiologists and hospital clinicians, and implementation of decision support should only be undertaken with commitment from the radiologists to develop the right protocols, educate referrers about the system and manage any referrer concerns. Expectations for participation in any large technology projects should be defined in the PSA to ensure everyone is on the same page about what will be required from the group.

Tie compensation to performance
Determining whether the hospital will continue to supplement the compensation of the group beyond what they bill insurers is another challenging element of the negotiation. Radiology groups have traditionally enjoyed supplemental financial support in the form of stipends, office space, transcription and PACS/RIS, all paid for the hospital. Many contracts have also included hospital payment for preliminary reads during off-hours. Attempts to eliminate stipends and transfer operational costs back to the group will invariably be met with resistance given the downward trajectory of radiologist salaries, although large-scale national radiology groups that eliminate these fees have provided hospitals with more leverage to tackle this issue. Another solution is to re-allocate these dollars to fund the incentive components in the contract; in this approach the group can “earn it back,” but only by delivering the targeted level of performance. The resulting boost in efficiency and volume may ultimately be more lucrative for the hospital than elimination of fees and stipends.

Carrots are one way to change performance, but sticks may also be necessary. For example, what if the hospital agrees to tie incentive compensation to successful implementation of voice recognition but members of the group nearing retirement decide the learning curve is not worth it and simply choose not to do it? Losing incentive compensation may not be enough motivation in a case like this, so the hospital could include a contract provision stipulating that failure to implement voice recognition will obligate the group to employ its own transcriptionists, alleviating the expense for the hospital.

This example highlights an important final principle, which is that in the contracting process, the hospital should always include viable options to deal with non-performance besides the ultimate penalty, non-renewal of the contract. If failure to perform is pervasive, there is ample opportunity to change groups. When considering this solution, leaders must be realistic about the costs involved in terminating the group’s contract, particularly when working it out is an option within reach. In addition to any implementation fees charged by the new group, hospital leaders should also count on costs for IT integration, personnel to manage the project and marketing expenses to promote the new group. When contracting with a large national radiology group, it will be necessary to credential 15-30 radiologists to support a distributed reading model; the resources needed for this should also be factored in. Many hospital leaders find that it is ultimately less disruptive and far more cost-effective to assign some financial penalties to the existing group and then focus together on how to achieve the desired level of performance.

There is no question that negotiation of a comprehensive and highly effective professional services agreement for radiology is both time-consuming and challenging. Given the complexity of issues involved, leaders on both sides must approach the process with equal measures of determination and patience. There will inevitably be areas of disagreement, and those involved in mediating these conflicts should recognize and factor in the value that a strong, mutually beneficial radiology partnership creates in terms of market competitiveness. When done correctly, the rewards of the final agreement are tangible for both sides, enabling the hospital to achieve excellent alignment with their physicians and the radiology group to retain its independence.

Ms. Yates is the founder of Accountable Radiology Advisors, a consulting practice that specializes in advancing the delivery of radiology services.  n her previous role she served as the chief quality and risk officer for a national radiology group of more than 150 physicians. Ms. Yates is one of the country’s leading experts on radiology peer review and is a frequent presenter on standardized performance assessment and the transformation from volume-based to value-based reimbursement in radiology. She can be reached via email

More Articles on Radiology Agreements:

Assessing the Value of Radiologist Services with an Imaging Center Acquisition


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Aunt Minnie: Doctors who own MRI scanners order more negative tests


By Kate Madden Yee, staff writer
August 29, 2013

Physician groups that own their own MRI scanners order more studies — but the scans are more often negative when compared with physician groups that don’t own a scanner. The finding could be a sign of overutilization, according to a new study published in the September issue of theAmerican Journal of Roentgenology.

The findings illuminate how self-referral affects imaging use, and how self-referral is a key factor to consider in the ongoing debate on how to best reduce healthcare costs, according to lead author Dr. Timothy Amrhein, from the Medical University of South Carolina, and colleagues.

“Self-referral of imaging studies has been singled out as a potentially important factor contributing to rising healthcare costs because, critics assert, financial interest can lead to overutilization,” Amrhein’s group wrote (AJR, September 2013, Vol. 201:3, pp. 605-610).

Assessing appropriateness

Studies on self-referral’s effects on imaging use have been criticized for their inability to assess the appropriateness of the exams ordered — a task confounded by factors such as clinical setting, disease prevalence, referral biases, and terminology differences between interpreting radiologists. That’s why Amrhein’s team wanted to assess the rate of normal exams (i.e., negative studies) as well as compare the prevalence and severity of disease within the subject population.

“We set out to test the null hypothesis that no difference in utilization exists between physician groups with self-referred imaging practices and physician groups that do not engage in self-referred imaging,” the team wrote. “To do this, we tested two subordinate hypotheses: There is no difference in the rate of negative MRI scans between self-referred and non-self-referred groups, and there is no difference, among positive scans, in individual lesion prevalence in the two groups.”

For the study, Amrhein’s team reviewed 1,140 consecutive shoulder MRI scans ordered between January and September 2009 by two referring orthopedic groups serving the same geographic community (kept anonymous to protect the identities of the physician groups).

The first group owned the scanners used and received technical fees for their use. The second group did not own the scanners used and had no direct financial interest. The shoulder scans were performed with identical protocols and were interpreted by a single radiologist group without financial interest in the imaging equipment used.

The researchers found that 255 of the 1,140 shoulder MRI scans were negative. The group that owned the scanners had 25.6% more negative scans (142 scans, compared with 113 for the group that did not own the scanners). This result was statistically significant (p = 0.047).

“[Our] data suggest that there may be a lower threshold for shoulder MRI referral in the financially incentivized group compared with physicians with no financial incentive in MRI equipment,” the team wrote.

There was no statistically significant difference in the average number of lesions per positive scan (1.67 for the financially incentivized group and 1.71 for the nonfinancially incentivized group), and there was no statistically significant difference in the frequency of 19 of 20 lesion subtypes.

The fact that there was little difference in the frequency of these lesions is informative, as physicians who self-refer argue their patients are sicker and thus need the immediate access to imaging they provide with their office units, according to study co-author Dr. Ramsey Kilani of Duke University.

“There are probably some scenarios in which that’s true, but it didn’t prove to be so in this study,” Kilani told “The positive scans showed us that the patient groups were almost identical in their disease — rebutting the argument that the patients that physicians who have MRI scanners see are sicker.”

Although the study does suggest a bias toward increased utilization of shoulder MRI by physicians with a financial interest in the MRI equipment used, it doesn’t prove intended overutilization for profit, Kilani said.

“Doctors that own MRI scanners order significantly more negative scans,” he said. “We’re not making accusations that this is overt, but it is something to investigate.”

The practice of self-referral needs to be examined, according to Kilani.


“Washington has passed across-the-board cuts to curb imaging overuse rather than going after self-referral,” he said. “It’s gotten to the point that outpatient centers are going out of business, and access to imaging is being threatened. The pendulum is swinging too far.” – The self-referral, appropriate use, and pay for quality conundrum

Brian Baker

The self-referral, appropriate use, and pay for quality conundrum

By Brian Baker

The noise level around health care related to cost seems to be increasing of late, while initiatives to drive interoperability and quality are missing the mark and losing their leaders. Meanwhile, individual hospitals are facing millions in cuts while enduring increasingly invasive payment or RAC audits. The bottom line here was expressed recently by a physician at the AHRA Physician Leadership Day: “Medicine isn’t the problem, it’s the business of medicine.”

We have identified the enemy and it is us

Back before DRGs (Diagnosis-Related Groups) were implemented, around 1982, payments in health care were based on cost reporting and were paid on a “cost plus” methodology. Critical Access Hospitals (“CAH”) still operate this way today, getting paid 101 percent of reasonable costs. Other reimbursement options exist for CAHs, but that’s another article. The DRG system unified the payments based on groupings of services provided. Come in to the ER with a possible heart attack? Medicare has a code that pays one amount, regardless of how many aspirin are consumed. As a result of this payment grouping, providers haven’t paid as close attention to the cost reports any longer. They are still filed, as it’s a requirement, but may not have the same level of attention to accuracy paid to them. As an organization that consults for hospitals, we rarely see an accurate expression of procedural costs.

Fast forward to today. Cost reports are used by Medicare under advice by groups such as theRUC (Specialty Society Relative Value Scale Update Committee) to adjust Medicare reimbursement. To be fair, that description is a gross oversimplification of the effort and information utilized. But what is important to know is this: The cost reports, as explained recently by one member of the RUC, while variable between submitter, indicate a low cost to deliver things like medical imaging that is not representative of true costs.

So if Medicare and its advisers are using the cost reports, among other things, to help determine reimbursement, and the reports show a steady or declining cost, it might make sense then that Medicare is reducing reimbursement. Have we missed something along the way?

Your credit line has been exceeded

The sustainable growth rate (SGR) originally created in 1997 to help limit spending from Medicare for physician services has been exceeded every year since 2002. The fix was intended to be what are called “negative updates”, which means reduced reimbursement. But for the last ten years Congress has passed a series of short term fixes (kicking the can down the road) to prevent these cuts from happening. So today the estimated cost to fix the disparity between the original SGR formula from 2002 and where Medicare spending is now is estimated by the Congressional Budget Office to be significantly more than $140 billion. Yes that is a “B”. While the House Energy and Commerce committee voted 51-0 to repeal or fix the SGR on July 31, 2013, no plan has been developed to pay for this fix…yet. If a fix is not in place by the end of 2013, physicians who treat Medicare beneficiaries will see cuts estimated at 25 percent. If history is any indication, expect the can to be kicked again. What we really need is a solution. Most physicians today don’t have a profit margin of 25 percent. Without a fix or a kick of the can, this is unsustainable.

Free beer tomorrow…

…said the sign in the restaurant. Sound familiar when you think about health reform and the changes since it passed in 2010? Transparency cried the masses! We need transparency through access to data to determine what is really going on! Yet, call a Medicare Administrative Contractor (“MAC”) and ask for de-identified utilization data. Click… buzz is what you will hear. Call Medicare directly and ask the same. After several hoops you can get a 5 percent file. That is one in 20 claims; hardly representative and impossible to determine who is referring what to whom with statistical certainty. HIPAA rules aren’t making it any easier. The problem is, in order to get to real automated clinical decision support, we need access to the linear patient records, including outcomes. Another way to think about “pre-encounter” clinical decision support is predictive healthcare. Using the scads of data already available in the hundreds of millions of patient records to analyze treatment and outcome patterns would clearly reveal what works and what does not.

Solving the riddle

Self-referral (of diagnostic testing services) is a complex issue and is driven by several factors. Some legitimate, like proximity to the testing services; other self-referral excuses perhaps not so legitimate. Self-referral, the growing use of diagnostic testing services in general and the increasing cost to payers, including Medicare, are the primary engines behind the cry for appropriate use. Then, in no small part due to the efforts of some clever statisticians who quantified broad gaps in patient outcomes compared to costs in several markets across the country, the light came on flashing “Pay for Performance” (“P4P”) not just for doing the work. Quality in other words. Perhaps you see now how wise the statement was in our first paragraph: “Medicine is not the problem, it the business of Medicine”. Any business with a poor quality product (Inappropriate use, poor outcomes, high cost) will not last long. Not everyone is on board with pay for performance as a recent study by the JAMA published by Diagnostic Imaging found 70 percent of 2556 respondents not in support of eliminating fee-for-service. However, that same study revealed 89 percent believe they need to take a more prominent role in limiting the use of unnecessary tests.

To get to appropriate use, which drives quality and keeps cost down, we must first completely understand our current care models and outcomes, to determine what changes must be made to improve. The caveat is: you cannot improve what you cannot measure. The HITECH Act is paying providers (Meaningful Use) to report on key measures while no structure or incentive exists to capitalize on and learn from the data now being collected. Providers are being paid to simply report on collecting basic data. It’s a wonderful start but there is no process or plan that we know of, to actually learn from the data. Larger than that is the lack of interoperability between information systems in health care which, by the way, is driving some of the duplication of services, waste, and cost through a lack of access to complete patient histories between providers.

Without a standard for collecting and communicating longitudinal patient records for analysis, learning and feedback, it’s going to be tough to learn from the data. Compounding the problem is a lack of a national patient identifier and a well-founded concern for protecting health information.

To drive pre-encounter clinical decision support based on actual patient outcomes, to propel appropriate use; to minimize cost and maximize positive patient outcomes, we need to connect patient data nationally and learn from it to make decisions. It’s a simple concept, a feedback loop.

Feedback loops, sometimes thought of as Artificial Intelligence, by design, learn from themselves by constantly evolving and adjusting, using historical and new data, as defined by the analytics design, to deliver actionable measures. This technology is no longer Star Trek fiction – it exists today. These approaches can allow the bi-directional connection of health IT systems and deliver the advanced automated analytics clinicians can use to make decisions based on accepted criteria. The result is appropriate tests (bring down cost) that reveal the answers to the clinical questions (based on past and current results) that direct clinicians to treat for the best (proven through data) outcomes. The new outcomes feed back into the data because health care data are standardized and connected. Sound like a circular reference?

Boldly go where no one has gone before; (to) live long and prosper 

Disruptive innovation, we are told, is innovation that creates new markets and value networks. Do the goals of the Affordable Care Act (“ACA”) represent a corollary? If the ACA is promoting P4P, the fundamental problem of measuring our performance today must first be solved. To get there the measurement capability must be able to quantify the thousands of elements needed to determine quality and performance through the measurement of thousands of outcomes, not simply attesting that the data is being collected. It’s time health care boldly solves its own issues following in the footsteps of other dominant industries to demand standardization and communication of health care-related data. Then we must make ourselves and our vendors accountable.

Based in Franklin, Tennessee, Regents Health Resources is a national consulting firm focused on the complexities of medical imaging. As President of Regents, Brian concentrates on business strategy and development focused on industry challenges.

The engaging radiologist | mHealthNews

The engaging radiologist

In the tireless effort to enhance patient-physician communication, collect more (and better quality) data and improve cost-effective care, there has been very little discussion regarding enhancing the role of the radiologist in patient care. In fact, most articles about radiologists in mainstream media refer to the diminishing job market, the amount of unnecessary imaging and the growing practice of teleradiology. In a field that is facing increasing commoditization, a small-but-growing number of physicians are arguing for increased patient interaction in a historically isolated field.

Take for instance two recent studies in the prestigious American Journal of Roentgenology (the classic term for radiology) and Journal of American College of Radiology. The first evaluated the significance and impact of direct consultation between patients and radiologists following CT scans or ultrasounds of the body and pelvis. Of the 86 patients included in the study 84 (98 percent) found that reviewing the findings directly with the radiologist was very helpful and 99 percent reported that they will always want to review future examinations directly with a radiologist. While this may be alarming for those who argue that patients need a physician who knows the patient well and can provide the results within a broader context, it goes against not only recent research but my own experience as well.

I recently awoke one morning with a fever, an increasingly difficult time swallowing and voice changes. Lucky for me, my wife is also a physician, and based on a cursory brief examination and the clinical finding of a hot-potato voice, I was whisked off to the emergency room for further testing and observation in case the airway became more difficult to manage. A CT scan was deemed unremarkable by the emergency radiologist, and I was discharged after an observation period with a course of oral antibiotics and steroids. Later that day, however, I received an anxious call from an emergency physician. The ED doc had received a call from a neuroradiologist (who was referred to for finalization during normal business hours) who had noticed something. I was directed to come back to the ED that afternoon for further testing and an emergent otolaryngology consultation. By that time, however, I had begun to feel slightly better, and based on my developing symptoms did not consider them to warrant a repeat trip to the emergency room nor a surgical consultation in the coming hours. Lucky for me, I happened to know the neuroradiologist who read the study and called him directly. He was kind enough to explain his concerns in detail and offer a differential diagnosis (none of which demanded a same-day or emergency visit), and I scheduled a close follow-up with my primary care physician on an outpatient basis.

Now, I understand my experience is unlike 99.9 percent of all other patients. I had the privilege of speaking directly to my radiologist (rather than through a third-party middle man) and had an understanding of the differential and the relative acuities. However, what should be noted is that the emergency physician (even when speaking to another physician) did not feel comfortable offering a more thorough interpretation of the significance of the neuroradiologist’s addendum to the radiology report (nor do I think they should be tasked with that responsibility).

Is this not a perfect opportunity for mobile technology to empower patients and radiologists alike to cut costs, reduce patient anxiety and more fully create patient-centered care? While I think so, the vast majority of primary care physicians do not.

The second study examined perspectives of primary care physicians on the growing practice of radiologist-delivered results. What percent of primary care physicians felt that radiologists should deliver results directly to the patient? Zero. That’s right, 0 percent. However, 94 percent of the docs felt medico-legally obligated by recommendations made by radiologists within their reports. So, even though the radiologist should not deliver the results to the patient, the PCP is obligated to medico-legally make his or her recommendations.

Call me crazy, but if I was a patient and my PCP or referring physician was providing a recommendation, I would want to know full well the reasoning beyond medico-legal justification. I do not mean this as a slight to any primary care physicians (I come from a family of primary care physicians, so I need to watch my words) or referring providers in general, but I see this as a perfect opportunity for mobile technology to empower patients by directly connecting them with their results and to reinvigorate the field of radiology.

Share your experience or your thoughts on this growing practice below!

Zachary Landman, MD, is the chief medical officer for Doctorbase, a developer of scalable mobile health solutions, patient portals and patient engagement software. He earned his medical degree from UCSF School of Medicine. As a resident surgeon at Harvard Orthopaedics, he covered Massachusetts General Hospital, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center.

Single educational lecture not enough to stem inappropriate imaging | Health Imaging

Single educational lecture not enough to stem inappropriate imaging

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More robust educational interventions may be necessary to encourage appropriate imaging, as a single lecture and Q & A session failed to deliver results in one institution’s efforts to limit unnecessary CT pulmonary angiography (CTPA) tests in the emergency department (ED), according to a study published in the September issue ofAcademic Radiology .

“In this small single-center study, we found that clinicians employ a very low threshold to test for PE [pulmonary embolism], resulting in a very high rate of negative testing and a low rate of PE diagnosis,” wrote Yassine Kanaan, MD, of Texas Scottish Rite Hospital for Children, Dallas, and colleagues from the University of Michigan, Ann Arbor.

Prevalence rates for PE at CTPA have been shown by prior studies to be in the 10 percent to 23 percent range; however, at the authors’ institution, positive rates were 5 percent or less. This could mean unnecessary use of imaging, which in turn increases radiation dose and false-positive rates.

Clinical diagnosis of PE can be unreliable as asymptomatic patients do not have clinical signs, explained Kanaan and colleagues. Clinical probability can be estimated in the emergency setting using the Wells score, with guidelines suggesting this probability be determined before imaging is ordered. D-dimer testing is recommended for patients with low and intermediate pretest probability for PE before imaging.

These recommendations regarding ED imaging use for suspected PE were relayed to ED faculty at the University of Michigan through a lecture, and Kanaan and colleagues tested this intervention’s impact by looking at records for 100 consecutive CTPA studies before the lecture and another 100 after the lecture.

Pre-intervention, 1 percent of patients suspected of PE had Wells scores performed and 40 percent of patients who underwent CTPA had D-dimer testing. Of these patients, 15 percent had a negative D-dimer test, 17 percent had an alternative explanation for chest pain and 76 percent had low or intermediate pretest probability, reported the authors. The overall appropriateness rate for CTPA was 7 percent, with 8 percent of the tests resulting in positive findings.

The intervention failed to achieve significant improvements, as the appropriateness rate for CTPA post-intervention was 6 percent, according to Kanaan and colleagues. The positive CTPA rate was 10 percent. Fewer patients had D-dimer testing after the lecture and 84 percent had low or intermediate pretest probability.

The authors speculated that a number of factors besides knowledge play into the decision to order CTPA in the ED. Residents may request the study for a lesser indication because they know the attending physician will want CTPA imaging subsequently anyway. Also, since CTPA has a high negative predictive value, the authors suggested clinicians may get sufficient reassurance from a negative CTPA exam to discharge patients from the ED sooner. This may reduce costs in the long run, but no formal comparative effectiveness analysis has been conducted.

Kanaan and colleagues called for repeated and sustained educational interventions to improve imaging ordering, and also suggested incorporating decision support could increase effectiveness.

CT scans rise fourfold in EDs, but hospitalizations fall by half –

CT scans rise fourfold in EDs, but hospitalizations fall by half

 A new look at a decade’s worth of emergency visits suggests increased use of CTs may help physicians send patients home sooner.

By KEVIN B. O’REILLY amednews staff — Posted Aug. 19, 2011

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Computed tomography use in U.S. emergency departments more than quadrupled between 1996 and 2007, but newly published data from more than 350,000 patient visits show that hospital admissions after a scan in the ED fell by more than half.

In light of concerns about potential cumulative radiation dose due to the skyrocketing use of medical imaging, the information sheds light on how CT scans may benefit patients, said Keith E. Kocher, MD, MPH, lead author of the study published online Aug. 12 in Annals of Emergency Medicine (link).

“There are a lot of questions to ask about the exploding use of CT scans in the ED, and one of the things you want to know is whether this is changing patient outcomes,” said Dr. Kocher, clinical instructor of emergency medicine at the University of Michigan Medical School. “It appears there’s an association between the rate of CT scans going up and physicians being more likely to discharge patients home than [there] used to be.”

So, for example, a patient with abdominal pain might previously have been hospitalized for observation due to fears of appendicitis, Dr. Kocher said.

“Now, after a couple of hours of getting the CT scan done and read, you’d know whether or not the patient has appendicitis,” he said. “Instead of having to admit the patient at the end of that visit you can say, ‘Hey, you’re OK. There are no signs of appendicitis. Maybe this is a stomach flu. Why don’t you go home and get better?’ “

Sandra Schneider, MD, president of the American College of Emergency Physicians, echoed the point.

“CT scanning is used by emergency physicians because it often makes the diagnosis,” she said, adding that doctors’ medical liability concerns play a role.

“A recent survey of emergency physicians showed that more than half stated that the fear of lawsuits was the main reason that emergency physicians order the number of tests that they do,” said Dr. Schneider, an emergency physician at Strong Memorial Hospital in Rochester, N.Y. “If we provided reasonable protection for emergency physicians who follow endorsed guidelines — perhaps with compensation for that one-in-a-thousand victim — then we might see some real cost reduction in health care.”

Reassessing habits

Congressional legislation to add medical liability protections for emergency physicians has been stymied repeatedly. The Physician Consortium for Performance Improvement, convened by the American Medical Association, is considering a set of 11 quality metrics aimed at discouraging inappropriate use of CTs to reduce unnecessary patient exposure to medical radiation.

In 1996, 3.2% of ED visits involved a CT scan, said the Annals study. By 2007, CT scans were ordered in 13.9% of trips to the emergency department.

But the rate of hospitalization after a CT fell from 26% in 1996 to 12.1% in 2007. The overall rate of hospitalization of ED patients rose during this period, suggesting that patients who were scanned saw a benefit in avoiding admission to a hospital.

The study does highlight questionable imaging practices, Dr. Kocher said. For example, 43% of ED patients with flank pain underwent CT scans by 2007. These scans probably were ordered to diagnose kidney stones, but there are other ways of diagnosing the condition without CTs, he said.

“Ultimately, the growth in CT scans is unsustainable,” Dr. Kocher said. “Studies like the one we did call attention to the fact that you should reassess your habits as a physician when it comes to ordering CT scans.”

The Road to Quality for Radiologists Part II

Slide1If Radiology is accountable for quality imaging, then the provider should be equally accountable to follow the radiologist’s recommendations. Assume for a moment that Radiology is black box. There’s the ‘order’ and the ‘result’.

In an ACR Select enabled imaging world, consultations are performed when it matters. Radiologists and ordering physicians regularly communicate.  Imaging shares in the reward of creating impact in the continuum of care for selecting the right order and disseminating an actionable, track-able report such that all parties are held accountable to the guidance.

Accountability matters, and, it’s a two way street. A few simple additions to the reporting workflow bring quality alive.

Actionable Reporting is an important next step in the implementation of Appropriate Imaging. The concept is simple. Close the loop! Make your findings and recommendations measurable.

Make your reports “actionable”.  One way is include a structured finding and recommendation code with each report.  For example:

  • Is the finding consistent with the reason the exam was ordered?
  • Is the recommendation for more imaging a result of the wrong exam being ordered?
  • Is there an incidentialoma (sic)? If so, what’s the severity?  Is it critical?

Ensure the provider is held equally accountable:

  • Was the exam really the right one opposite the selected reasons for exam?
  • Were the reasons for exam “right”?
  •  It’s also possible that there was a better exam opposite the conditions, and that’s worth knowing, recording and acting on.
  • Was there a prior exam that would have dis-intermediated this exam?
  • Are your recommendations, (which was requested as a result of the ordered exam) being followed? If not, why?

Often, radiologists work with no clinical correlation for the advice they are giving.  Producing an actionable, track-able report is the starting point for demonstrating the radiologist’s value in the care continuum.

Follow up.

Jeffrey Singer: The Man Who Was Treated for $17,000 Less –

  • The Wall Street Journal

Jeffrey Singer: The Man Who Was Treated for $17,000 Less

Bypassing his third-party payer, my patient avoided a high hospital ‘list price.’



Every so often I have an extraordinary and surprising experience with a patient—the kind that makes us both say, “Wow, we’ve learned something from this.” One such moment occurred recently.

A gentleman in his early 60s came in with a rather routine hernia in his lower abdomen, one that is easily repaired with a simple outpatient surgical procedure. We scheduled the surgery at a nearby hospital.


Getty Images

My patient is self-employed and owns a low-cost “indemnity” type of health insurance policy. It has no provider-network requirements or preferred-hospital requirements. The patient can go anywhere. The policy pays up to a fixed amount for doctor and hospital bills based upon the diagnosis. This affordable health-insurance policy made a lot of sense to this man, based on his health and financial situation.

When the man arrived at the hospital for surgery, the admitting clerk reviewed the terms of his policy and estimated the amount of his bill that would be paid by insurance. She asked him to pay his estimated portion in advance. (More hospitals are doing that now because too often patients don’t pay their portions of the bills after insurance has paid.)

The insurance policy, the clerk said, would pay up to $2,500 for the surgeon—more than enough—and up to $2,500 for the hospital’s charges for the operating room, nursing, recovery room, etc. The estimated hospital charge was $23,000. She asked him to pay roughly $20,000 upfront to cover the estimated balance.

My patient was stunned. I received a call from the admitting clerk informing me that he wanted to cancel the surgery, and explaining why. After speaking to the man alone and learning the nature of his insurance policy, I realized I was not bound by any “preferred provider” contractual arrangements and knew we had a solution.

I explained that just because he had health insurance didn’t mean he had to use it in every situation. After all, when people have a minor fender-bender, they often settle it privately rather than file an insurance claim. Because of the nature of this man’s policy, he could do the same thing for his medical procedure. However, had I been bound by a preferred-provider contract or by Medicare, I wouldn’t have been able to enlighten him.

Hospitals and other providers make their “list” prices as high as possible when negotiating contracts with health plans and Medicare regulators. No one is ever expected to pay the list price. Anybody who has seen an “Explanation of Benefits” statement from a health plan will note a very high charge from the provider, and an “adjusted charge” based upon the contracted fee schedule, which usually leaves the patient with little or nothing in out-of-pocket expenses. The only people routinely faced with list prices are those few people who have insurance like my patient’s—that doesn’t include a pre-negotiated fee schedule with contracted providers—or those who have no insurance.

Most people are unaware that if they don’t use insurance, they can negotiate upfront cash prices with hospitals and providers substantially below the “list” price. Doctors are happy to do this. We get paid promptly, without paying office staff to wade through the insurance-payment morass.

So we canceled the surgery and started the scheduling process all over again, this time classifying my patient as a “self-pay” (or uninsured) patient. I quoted him a reasonable upfront cash price, as did the anesthesiologist. We contacted a different hospital and they quoted him a reasonable upfront cash price for the outpatient surgical/nursing services. He underwent his operation the very next day, with a total bill of just a little over $3,000, including doctor and hospital fees. He ended up saving $17,000 by not using insurance

This process taught us a few things. First, most people these days don’t have health “insurance.” They have prepaid health plans. They pay premiums to take advantage of a pre-negotiated fee schedule arranged for and administered by a third party. My patient, on the other hand, had insurance.

Second, even with the markdown for upfront “cash-pay” patients, none of the providers was losing money on my patient. Otherwise they wouldn’t have agreed to the prices. With the third-party payer taken out of the picture, we got a better idea of the market prices for the services. It is the third-party payment system that interferes with true price competition, so “market clearing prices” can’t develop.

Take the examples of Lasik eye surgery or cosmetic surgery. These services are not covered by insurance. Providers compete on the basis of quality, outcomes and price. And prices have continually dropped as quality and services have improved—unlike the rest of health care.

When my patient returned for his post-op visit we discussed the experience. It was clear to both of us that the only way to make health care more affordable is to diminish the role of third-party payers. Let consumers and providers interact through market forces to drive down prices and drive up quality, like we do when we buy groceries, clothing, cars, computers, etc. Drop the focus on prepaid health plans and return to the days of real health insurance—that covers major, unforeseen events, leaving the everyday expenses to the consumer—just like auto and homeowners’ insurance.

Sadly, we are heading in the exact opposite direction. ObamaCare expands the role of the third party and practically eliminates the role—and the say—of the patient in the delivery of health care. Will they ever learn?

Dr. Singer practices general surgery in Phoenix, Ariz., and is an adjunct scholar at the Cato Institute.

A version of this article appeared August 22, 2013, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: The Man Who Was Treated for $17,000 Less.

Radiology’s drive to Quality


Road to quality

The entire payment model for healthcare services is transforming towards rewarding the value of care and Radiology is not immune.

In today’s payment models the net unit value of imaging is dropping. Although Imaging has unquestionable value in the delivery of healthcare, the amount providers and payers are willing to pay for imaging is most certainly being questioned.

The Radiologist role in the care cycle for patients is well beyond the reading room. But how can Radiologists be held accountable for inappropriate utilization of value imaging resources without a seat in the vehicle.

ACR Select is an integral part of Radiology’s roadmap to value based care. A National Standard, maintained by the American College of Radiology. Key word: Radiology.

Structured indications at the point of order ensure that orders are based on valid and defensible medical reasons.

Every order is scored; every order gets a unique Decision Support Number. This data is the basis for a true understanding of the pain points that are creating inappropriate utilization and the positive impact of quality imaging.

Appropriateness Scoring during order entry drives consultation for questionable orders, prevent in appropriate exams and foster real time learning and interaction with the ordering physician. Helping to increase visibility and relevance.

With ACR Select, Radiology has the opportunity to manage towards value based payment contracting for Imaging Services, by ensuring quality/compliance, and, sharing in the subsequent total savings.

With ACR Select, Radiology can reposition the value of imaging in the value chain and highlight the system wide impact of imaging:

  • Cognitive, consultative
  • Impact on the entire care continuum
  • Imaging saves cost

Re-establish the obvious. Appropriate Imaging improves patient care and saves costs.

  • Proper consultation and the resulting appropriate exam and properly communicated result reduces length of stay and readmission rate
  • Managing authorizations through third parties creates overhead and complexity. ACR Select creates simplicity and transparency. Allowing physicians to focus on paient care vs. navigating authorization workflows.
  • ACR Select creates a transparent platform for all stakeholders in the process to share data and align on outcomes

Get on the road. Take the steering wheel. ACR Select creates a platform for new models for Radiology Service delivery where the impact of quality Radiology service has on the patient care cycle is quantified, and obvious. Radiologists can get paid for value by sharing in the total impact and helping it’s customers manage outcomes in risk bearing models.