European Society of Radiology – Update on the ESR Clinical Decision Support Project

Update on the ESR Clinical Decision Support Project

At ECR 2014, the ESR announced an ambitious project to introduce a Clinical Decision Support (CDS) system for imaging referral guidelines – a software tool to aid referring physicians in recommending the most appropriate radiological examination for patients – on the European market. After evaluating different possibilities to address the lack of use of imaging referral guidelines and concomitant inadequacies in the use of imaging procedures, as well as to ensure the availability of guidelines throughout Europe, the ESR decided to look across the pond and learn from the implementation of ACR Select in the United States.

ACR Select is a CDS system developed jointly by the American College of Radiology (ACR) with the health IT firm National Decision Support Company (NDSC). Since its launch two years ago, ACR Select boasts an impressive track record of enabling radiologists and referring physicians to utilise imaging technologies in a more targeted way, thereby reducing unnecessary exposure to radiation and improving diagnosis and treatment for patients, to say nothing of additional benefits such as greater clinical workflow and cost efficiency. The ESR has partnered with ACR and NDSC to replicate this success in Europe.

The partnership with ACR and NDSC allows the ESR to build on their work and experience. Rather than reinventing the wheel, ESR experts will ‘Europeanise’ the ACR Appropriateness Criteria, i.e. adapting them into imaging referral guidelines tailored to the European setting. Nine organ-based expert groups will conduct a scientific review of the American guidelines overseen by a dedicated methodologist, and ensure that European standards of practice and scientific literature are duly taken into account. Further to this Europeanisation, localisation of the recommendations is possible for end users based on regional or institutional requirements such as the availability of imaging equipment, while the software can be integrated into hospitals’ existing IT infrastructure.

Presentation of a prototype of the ‘ESR iGuide’ is planned for the next European Congress of Radiology in March 2015, with rollout of the final product to start from summer 2015. In addition to this European project, the ACR and the ESR have concluded a Memorandum of Understanding that includes a commitment to work towards a global solution to make CDS and evidence-based imaging referral guidelines available in all parts of the world. Cooperation on establishing a common terminology and standards will start during the ESR’s European review.

CDS has the potential to revolutionise the way medical imaging is used in Europe, especially at a time where healthcare costs are on the rise and concerns about the effects of exposure to ionising radiation are increasing. Successfully introducing a CDS system in a market that includes dozens of distinct healthcare systems seems a daunting challenge – but the promise of achieving better healthcare for less money certainly makes it worth the effort.

Providing reads of outside images slashes rate of repeat scans | Health Imaging

Providing reads of outside images slashes rate of repeat scans

 - Brainscan CT

A recent study has shown that providing a formal report for outside images does more than simply offer a second opinion, it leads to a significantly lower chance of repeat imaging.

“Reducing repeat imaging spares patients from unnecessary cost and radiation dose,” wrote Michael T. Lu, MD, of the University of California, San Francisco, and colleagues. “Institutions, payers, and policy makers should consider supporting this practice.”

The results were published in the July issue of American Journal of Roentgenology .

Lu and colleagues explained that, according to some estimates, review of outside imaging accounts for up to 22 percent of radiologist workload at some tertiary care centers, but most research has focused on discrepancies between initial and subsequent interpretation of outside images. “If the value of providing formal reports for outside imaging is not proven, reimbursement and radiology’s ability to provide this service are in jeopardy,” wrote the authors.

To assess the impact of providing outside reads, Lu and colleagues considered cases where a patient had an outside abdominal CT imported to the authors’PACS from Jan. 1, 2006, through Dec. 31, 2011. This included more than 10,000 patients, with 3,719 receiving a formal report on these outside images.

Patients whose outside images got a formal report were 32 percent less likely than others to undergo repeat imaging. After controlling for variables such as the age of the outside study, the odds of repeat imaging remained significantly lower for patients who received a formal report.

Lu and colleagues suggested that providing a formal review of outside images could be a way of cutting into the rate of repeat testing after patients are transferred between institutions. “Further studies are necessary to establish the cost-effectiveness of formal reports for outside imaging. Cost-effectiveness analyses should incorporate the cost and radiation dose savings from reduced repeat imaging, the cost of interpretation, reduced delay to treatment, and changes in diagnosis and management.”

Clinical decision support’s role in radiology – FierceMedicalImaging

Clinical decision support’s role in radiology

By Mike Bassett

Concerns about overutilization of imaging, its appropriateness in all cases, and its costs in terms of healthcare dollars and exposure to ionizing radiation has led to an increasing emphasis on clinical decision support.

And the extent to which policymakers have latched onto the concept of CDS as a tool to address overutilization and rising costs is demonstrated by the fact that the “Protecting Access to Medicare Act of 2014”–the Sustainable Growth Rate “patch” legislation–contains language requiring that physicians consult appropriateness criteria before prescribing advanced imaging procedures for Medicare patients.

“There’s obviously a growing interest around clinical decision support,” said Anthony DeFrance, M.D., a clinical associate professor at the Stanford University School of Medicine. “And as we try to wring out waste and improve quality, and move towards metrics that are more quality-based, these clinical decision support systems are becoming more relevant to the practice of radiology and imaging.”

In this special report, FierceMedicalImaging explores the importance of CDS in radiology. We talk with healthcare professionals about what’s necessary to increase physician adoption and how such tools can be improved.

Click on any of the links below to learn more.

Imaging Utilization Trends and Reimbursement | Diagnostic Imaging

Imaging Utilization Trends and Reimbursement

Concern over the steady drop in diagnostic imaging utilization rates has been a conversation topic at nearly every radiology meeting for the past decade. While this trend does cause worry, the trick, experts say, is to remember utilization rates haven’t shrunk to pre-2000 levels – it’s the growth rate that’s slowing down.

So, what’s causing the impact? What factors are reining in utilization, and which ones continue to move the needle forward? And, what does this all mean for reimbursement?

According to a November 2013 study published in BMC Medical Imaging, utilization rates grew significantly between 2000 and 2005, but curbed through the next four years. For example, MRI/CT rates expanded by 15 percent during the first five years analyzed. However, these modalities experienced no increase in the latter half of the decade.

A July 2013 Journal of the American College of Radiology (JACR) study supports the existence of a slowing trend. Conducted by the ACR’s Harvey L. Neiman Health Policy Institute, the report examined physician decision and patient visit data from the Medical Expenditure Panel Survey and found that imaging used in patients over age 65 fell from 12.8 percent in 2003 to 10.6 percent in 2011.

“This study should prompt a re-thinking of the assumption that diagnostic imaging is a leading contributor to the nation’s health spending challenges,” said Danny Hughes, PhD, study author and research director for the Neiman Policy Institute. “When you look at the available evidence in a truly patient-centered way, understanding what occurs on a patient visit to the doctor, then you see that physicians are calling for less, not more, imaging tests.”

Yet, data from ACR Select, the College’s clinical decision support tool, showed that diagnostic imaging accounts for 10 percent – $100 billion – of total annual healthcare costs. So, what are the factors in play that keep the diagnostic imaging wheels turning?

What’s Driving Utilization?
Even though the ACR continues to report that up to 10 percent of all imaging services are unnecessary or duplicative, there’s little evidence that providers are turning away from these tools en masse. In fact, imaging utilization is feeling a push from several different directions, according to David Levin, MD, radiology professor at Jefferson Medical College and Thomas Jefferson University Hospital.

• Aging population: Based on National Institutes of Health data, patients age 65 and older undergo diagnostic imaging at two or more times the rate of younger people. Women also tend to use slightly higher rates of imaging than men.

• Affordable Care Act (ACA): With the U.S. Supreme Court’s 2012 decision to uphold the ACA, the healthcare system has been bracing to accept and serve a much larger pool of insured patients. This greater population base, Levin said, will play a significant role in imaging utilization in the near future.

• Defensive medicine: While providers order diagnostic studies to improve patient health, many also order the scans to protect themselves from potential litigation, Levin said. Ordering an exam leaves an electronic trail that the radiologist practiced due diligence in giving the patient the best possible care. Defensive medicine will continue to be a steady contributor to imaging utilization, he said, until the industry sees some type of tort reform.

• Patient sophistication: Coupled with the need for defensive medicine, providers also face a far more savvy patient population than they did just a decade ago. A myriad of Internet sites offer information about imaging modalities and when they might be useful in healthcare. Consequently, Levin said, many patients come to providers, proactively requesting imaging studies that might be unnecessary.

• Added clinical pressure: As the patient population increases, so does the pressure placed on primary care and emergency room providers. To handle the growing patient load, many doctors might find it easier to order an imaging study in place of a face-to-face, physical exam. For example, conducting a physical exam might be of little value with a patient who has either a lung or abdominal problem, he said. Instead, a CT scan or chest X-ray would give faster, more definitive results.

• ACR Appropriateness Criteria: Although the American College of Radiology’s (ACR) Appropriateness Criteria have been around for nearly two decades, there are some providers who are still unfamiliar with the guidelines for imaging utilization. In some cases, Levin said, their lack of knowledge leads them to order unnecessary or duplicative exams.

• Self-referral: A 2011 Journal of the American College of Radiology study reported that self-referrals – referrals by non-radiologist physicians of patients to imaging facilities in which the provider has a financial interest – accounted for 59.7 percent of imaging. The study’s lead author, Ramsey K. Kilani, MD, an Arizona-based diagnostic radiologist, said non-radiologist self-referrers were nearly 2.5 times more likely to order imaging than clinicians with no financial interest in doing so.

What’s Paring Back Utilization?
But, while diagnostic imaging services clearly remain an integral part of healthcare, there are several factors that have begun to slowly dial back the yearly utilization rate.

“Imaging is consistently shown to be one of the most efficacious and quick tests to figure out what’s wrong with someone,” said Jonathan Berlin, MD, associate radiology professor at NorthShore University Health System. “There’s tremendous value in terms of what a diagnosis could be – even in negative exams. But along with value, there has to come cost.”

And, overall, these hindrances to utilization hinge on controlling or limiting access in some way.

• Increased cost sharing: In effect, increased cost sharing in healthcare means patients are now paying a higher proportion of their health insurance. Larger deductibles paired with a smaller amount of covered services have pushed many patients to forego diagnostic imaging to reduce their own out-of-pocket expenses, Berlin said.

• Pre-authorization: Many health insurance companies now rely heavily on radiology benefit management companies (RBMs) to determine whether an imaging service is appropriate and necessary. Without approval – or pre-authorization – from an RBM, it is unlikely that a patient will undergo the study. However, the growing push toward using clinical decision support systems, such as the ACR Appropriateness Criteria, is designed to retain decision-making control over imaging studies within the radiology department.

• Narrow health insurance exchanges: As the ACA continues to roll out, companies could opt to provide a subsidy, giving employees an option to purchase their own health insurance, Berlin said. But no one knows, to date, what the rates will be. To keep them low, companies could contract with narrow health insurance exchange networks, choosing to work with providers who offer imaging services at the lowest costs. The impetus, he said, would be to funnel patients to the less-expensive providers.

Non-Radiologist Provided Imaging
But it isn’t just insurance changes and cost-shifting ratcheting down the utilization numbers, Levin said. There’s also a significant population of non-radiologist providers, known as self-referrers, who now offer imaging services linked to their own practices.

“I think it’s a pretty substantial group. If you look at the number of MRI and CT scans being done in the offices of non-radiologists, it’s pretty high,” he said. “In 2012 – the last year that we have Medicare data for – there were 461,000 MRI scans done by non-radiologists. It’s probably close to a million if you factor in commercially-insured patients.”

And, if you talk to radiologists nationwide, he said, they’re feeling the pinch. Across the country, practices and departments are seeing their utilization rates drop.

But, while self-referrers frequently order imaging studies that flout the ACR Appropriateness Criteria, there are many who offer effective, necessary imaging services that usually fall outside of a radiologist’s purview, Berlin said. For example, radiologists do not often provide cardiac or obstetric imaging.

Impact on Reimbursement
At the peak in 2006, according to a 2008 Government Accounting Office report, Medicare spent $14.1 billion on diagnostic imaging. Since then, annual spending has steadily dropped, falling by 21 percent by 2010, based on a Neiman Policy Institute report. To date, this trend has not reversed, Levin said.

“There’s no question that reimbursement is going down when you look at the Medicare dollars paid for non-invasive diagnostic imaging,” he said. “It’s been a big hit.”

The advent of code bundling, the continuation of the multiple procedure payment reduction (MPPR), and providers’ re-evaluations of their practice expenses have also altered imaging utilization and its associated reimbursement, he said.

Berlin agrees, but he also pointed to the influence insurance companies hold over imaging services. Ultimately, he said, payers control cost and utilization in two ways: they pay less for each service or they decrease the number of covered services overall.

“This makes patients more discerning about where they get their studies. If one practice charges $10 per imaging test, but another asks you to spend $5, then you can double your imaging by spending the same amount,” he said. “These aren’t mutually exclusive – it either decreases the amount spent on imaging, or it will slow the rate of growth.”

What Could The Future Hold?
Predicting how the market, federal legislation or patient influx could affect the industry and imaging utilization isn’t possible because the healthcare system is complex. However, Berlin said, there are several potential changes.

If the healthcare system shifts from fee-for-service to a bundled or capitated payment model, providers and facilities will be compelled to work together to both optimize care and control costs. The thought, he said, is that such cooperation could eliminate duplicative imaging.

Such a paradigm shift could impact technological innovation, as well. Rather than only aiming to produce the most advanced equipment, vendors could be asked to produce machines for which there is a distinct use or unmet need that would also cut costs downstream, he said. It’s unknown whether that type of change would slow imaging equipment use or cause facilities and practices to postpone new purchases.

“In general, the theory is that imaging that is unnecessary or duplicative will go down,” Berlin said. “It comes from the idea that when people share information and cooperate, that healthcare expenditures overall will decrease.”

– See more at:

Why Your MRI or CT Scan Costs An Arm and a Leg | The Fiscal Times

Why Your MRI or CT Scan Costs An Arm and a Leg

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The Fiscal Times

July 21, 2014

Medical imaging is one of the most common and overused diagnostic techniques used today, and by far the costliest. While cancer caused by radiation from medical imaging can be a long-term concern, the more immediate worry for someone facing a new diagnosis is usually cost.

The good news is that there are at least a few tools that can help patients curb spending on medical imaging, which is employed to diagnose everything from broken bones to multiple sclerosis to cancer.

Related: The New Luxury for the Super Rich: Health-Centric Homes

At $2,600 on average for an MRI and $1,100 on average for an ultrasound, even one unnecessary test is too many for folks on a budget, unless your insurance or Medicare covers the test. If you were unfortunate enough to find yourself in one of the nation’s top charging hospitals, those fees could jump to over $13,300 for an MRI and $7,600 for an ultrasound. (These prices are total amounts billed to patients and don’t reflect insurance payments.)

Health Care Cost Increases Expected To Accelerate In…
TIME Magazine

Health care costs are expected to pick up in 2015 — increasing even faster than they did this year, according to a new study by PricewaterhouseCoopers.

Paying a portion of these charges is unavoidable, as imaging technology costs a lot to develop and maintain; but that only explains a fraction of the actual costs to patients.

Here’s why medical imaging costs so much:

Doctors err on the side of too many tests. From your doctor’s point of view, it’s best to cover all bases and have any test done that might be helpful. This is supposedly done in the interest of the patient, although over-ordering may also be done to safeguard against malpractice accusations and lawsuits. That practice is called defensive medicine. It’s hard to quantify, but research suggests that it may account for anywhere from 5 percent to 25 percent of total imaging costs, according to the Massachusetts Medical Society.

Related: The Government’s Next Big Health Care Experiment

Doctors may also be ordering tests because they benefit financially. Most health systems run on a fee-for-service plan, where each test and visit is ordered and billed separately. Since doctors get paid more when they order more services, they may be inclined to over-order imaging exams.

Imaging machines are costly. Each type of imaging device comes in a range of prices, and hospitals recoup those expenditures through imaging charges. For example, the cost of a CT scanner can be as low as $65,000 for a refurbished one that produces only small images quickly. A larger and brand new CT scanner can run as high as $2.5 million. Prices are slightly higher for MRI machines, running up to about $3 million for a new machine. Ultrasound machines are much cheaper at $10,000-$200,000, depending on brand and type.

For hospitals and imaging centers, the base price for machines is just the beginning. CT and MRI imaging machines usually cost about $100,000 per year to maintain, since they get very hot and must have an internal cooling source, which also requires a lot of energy. Additionally, MRI machines must be placed in suites that protect patients and staff from magnetic waves that can cause problems with pacemakers and other devices. Installation of machines in these suites can run the hospital $4 million to $6 million.

Providers can charge what they want. Whether it’s a large hospital or a private imaging center, health centers set their own prices, just like retail stores. Unlike retail, however, medical centers and practices rarely advertise their prices up front, which can result in wildly different charges for the same service, even between nearby locations.

For example, at Good Samaritan Hospital of Suffern, New York, you could be charged$7,000 or more for an MRI, but if you drive an hour south to the Bronx-Lebanon Hospital Center in New York City, the MRI would cost about $500, according to 2012 Medicare data. Some hospitals charge 10 times or more than what others do for the same service.

Related: 6 Ways to Lower a Massive Medical Bill

Those wide ranges haven’t gone unnoticed by health care experts and regulators. The Food and Drug Administration launched an initiative a few years ago to reduce unnecessary radiation exposure and plans to reach out to providers earlier this month to make sure fewer tests are ordered. For instance, the FDA will provide education for physicians on responsible test ordering.

Increasing price transparency in health care would help consumers choose lower-cost providers. An Obamacare provision requiring hospitals to publish standard charges hasn’t yet been implemented, but it may help by putting more information in health care consumers’ hands.

Much of the increased transparency so far is due to the recent release of Medicare data shedding light on vast price inconsistencies. Thanks to this new data, price comparison tools are popping up online to help patients make smart health care decisions and get quality health care at more affordable prices.

So before you get your next scan, you may want to scan the Internet for pricing information on providers in your area.

Lacie Glover writes for NerdWallet Health, a website that empowers consumers to find high quality, affordable health care and insurance.

– See more at:

French MRI waiting times are ‘worst in a decade’

French MRI waiting times are ‘worst in a decade’

By Philip Ward, staff writer

July 16, 2014In France, an oncologic patient in need of an emergent MRI lumbar scan must wait an average of 37.7 days, 7.2 days more than last year. The figures, posted on the website of the French Society of Radiology (Société Française de Radiologie, SFR) on 7 July, represent the worst outcome since Cemka-Eval started its annual assessment 11 years ago and are a serious threat to France’s newest Cancer Plan, which aims to reduce waiting times to 20 days by 2019. The delays continue to be very worrying, the authors noted.

“This report points out a disaster,” said Dr. Philippe Soyer, PhD, the general secretary of the Syndicate of Radiologists of Public Hospitals (Syndicat des Radiologues Hospitaliers). “The worst thing is that the delay in question may reach up to two months for a patient with a suspicion of liver cancer … it is almost criminal to let a patient wait so long to confirm the diagnosis and start further treatment. Waiting two months is a lost chance for the patient.”

The problem is that many MRI units are used for musculoskeletal indications, he explained. Also, the growth of cardiac MRI was anticipated by the government, so there has been a dramatic increase in the potential indications, and these emerging indications have not been anticipated.

“One solution to manage the paucity of equipment would be to select indications and patients according to the suspected diagnosis,” Soyer continued. “It is not normal that a patient with a liver metastasis has the same delay for an appointment as a patient with a mild pain in the knee. But some radiologists are reluctant to do this. The major problem in France is that we are still underequipped and one of the worst countries in Europe. This is the actual problem.”

The results of the study come as another blow to the under-siege French MRI sector, which already lags behind its neighbors. While Western Europe as a whole has an average of 20 MRI machines per million citizens, France has only 10.7 machines per million, prompting less than flattering comparisons from the radiological community. France has fewer machines than Slovenia and Croatia, and three times fewer than Germany, whose average hovers around 30 per million.

As most countries continue to expand their equipment, the 38 French machines added in 2013 do little to fill the gap. In fact, experts say that 50 new scanners per year are needed to meet the objectives defined by the various public health plans and good practice guidelines.

Unfortunately, the planned growth of MRI in France may add to the problems and is incompatible with the objectives defined by the healthcare organization regional schemes (les schémas régionaux d’organisation des soins, SROS), according to Imagerie Santé Avenir (ISA), an association of medical imaging and healthcare professionals, which commissioned the study.

Nearly 60 systems are due to be introduced by the end of 2014, and 100 osteoarticular MR examinations have already been planned for the next two years, straining the examination authorization potential to its limits in most regions. A rapid and substantial revision of MRI objectives is needed to face the demands of the various government plans, ISA recommended.

MRI indications continue to increase by 5% to 10% each year and are in line with radiation protection demands from health and nuclear safety authorities. But there seems to be a persistent misunderstanding as to the urgency of the situation. Recent comments from the National Health Insurance Fund for Salaried Workers (Caisse Nationale d’Assurance Maladie des Travailleurs Salariés, CNAMTS) added fuel to the fire by alleging that rapid growth in MRI risks is encouraging an increase in unnecessary exams. The SFR vigorously reacted to the comments and released a strong statement, calling for a halt to the confusion over MRI caused by the CNAMTS’ position.

“[MRI] meets a concrete need for quality and appropriate care as specified in the Good Practice Guidelines for Imaging (GBU) developed by the SFR and the French Society for Nuclear Medicine,” the SFR stated. “The catch-up plan in MRI, sought for many years by imaging professionals, is more pertinent than ever if we wish to respond to issues in public health, with regard to quality and emergency care, and also equality in access to innovation across the country.”

The previous, more ambitious Cancer Plan had set the limit to 15 days nationwide and 10 days in regions with high cancer mortality. This year, however, none of these regions are able to offer examinations within less than 30 days, except Nord-Pas de Calais(26.3 days). In Brittany, Alsace, and Lorraine, patients have to wait up to 50 days, and up to 64 days in Lower Normandy.

Waiting times have increased across the country, except in Midi-Pyrénées, Languedoc Roussillon, and Provence-Alpes-Côte d’Azur (PACA). Regional discrepancies are on the rise, in spite of a political discourse permanently stressing the need to fight against social and geographical inequalities, according to ISA.

Commenting on this latest report from Cemka-Eval, another senior French radiologist said there is a strong industrial lobby behind this recurrent study and there are some pitfalls in it, particularly the clinical case used for appointment seeking, which is far from real life.

“Regional agencies (ARS) have their own policies and may not give their support for MRI in some parts of the country, as is the case in Paris/greater Paris,” the source stated. “Another point is that there is not much funding for hospitals (private practice is taking its own risks) and some hospitals cannot afford such expenses.”

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Last Updated hh 7/16/2014 2:49:44 PM

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The Clinical Decision-support Mandate: Now What? | Radiology Business