2014 Patient-centric Imaging Awards | Health Imaging

Radiology Order Entry Clinical Decision Support

Mount Sinai Medical Center, New York City


Radiology orders on inpatients are entered through our EHR. Previously, providers could enter the clinical indication from a structured list or via free text, but there was a desire for clinical decision support at the time of order entry to diminish inappropriate utilization of radiology services.


We deployed a radiology order entry clinical decision support system, targeted at CT and MRI, to implement ACR appropriateness guidelines within our EHR environment. A structured list of “clinical Indications” provided by the decision support system replaced our homegrown list. Providers were presented with this list.

Implementing such a program has several steps.  We are midway through the overall process. The first part of the process involved change management principles.  Along with our EHR team, we educated our provider staff to changes in the Radiology Ordering interface that were needed to implement this system.  We made some modifications to our user interface to address initial concerns.

For nine months, we ran the system in the background—that is the system provided an appropriateness score of 1-9, 9 being the strongest indication of an exam being appropriate. This was a data collection phase to understand the ordering practices and patterns of our providers.  We did not show the providers the decision support scores during that phase.


We learned that on a weekly basis, approximately 10 percent the exams ordered received a low score between 1-3. Just over 2 months ago, we turned on display of the decision support score, showing providers the score when it is between 1-4 and suggesting alternative exams through the automated interface. We are just beginning to analyze the data to look for change in ordering patterns.

We have anecdotal comments that this has been helpful. After 4 to 6 months, we will analyze the data to determine if there is a change in overall performance

Healthcare Reform Update: Doctors order unnecessary tests without even realizing it | Modern Healthcare

Reform Update: Doctors order unnecessary tests without even realizing it

By Sabriya Rice 

Posted: September 15, 2014 – 4:30 pm ET


Physicians order unnecessary tests and procedures to inoculate themselves from legal liability more than they realize, according to a new survey of physicians at several hospitals in one Massachusetts health system.

Nearly a third of the orders that the surveyed physicians placed were defensive on some level. The researchers argue that clear communication about evidence-based guidelines and tort reform that would protect clinicians when they follow those guidelines would help reduce providers’ fear and improve patient care.

Fear of frivolous lawsuits may be so pervasive that it has changed what is considered an acceptable diagnostic approach, said Dr. Michael Rothberg, vice chair for research in the Medicine Institute of the Cleveland Clinic and lead author of a summary of the findings published in JAMA Internal Medicine.

“Some people might say it’s defensive, and other people might think it’s the standard of care,” Rothberg said. “There’s really more of a culture about how people treat a particular problem, and many may not recognize it as being defensive.”

The study found 28% of orders and 13% of costs were judged to be at least partially defensive among the hospital medicine services at three institutions within one Massachusetts health system. About 2.9% of costs were considered to be completely defensive, meaning the only reason a test was ordered was fear of a lawsuit. Most costs were associated with the hospitalists prolonging a patient’s hospital stay.

Thirty-six physicians from Baystate Health System’s Medical Center in Springfield, Mass., Franklin Medical Center in Greenfield, Mass., and Mary Lane Hospital in Ware, Mass., rated 4,215 orders for 769 hospital inpatients.

The results suggested that physicians aren’t reliable judges of what’s driving their own decisions. Physicians who were most inclined to describe orders as influenced by liability fears did not actually drive more costs or order more tests than their colleagues who said they “practiced in a very nondefensive way,” Rothberg said.

Republicans have argued that the Obama administration and congressional Democrats missed an opportunity to tackle tort reform in the Patient Protection and Affordable Care Act, which conservative policy experts and many physicians say would do more to improve the efficiency of the U.S. healthcare system than any of the law’s payment and delivery reforms.

The reform law did authorize $50 million to fund grants to states to develop and test alternatives to medical liability litigation.

The Agency for Healthcare Research and Quality has said in a report (PDF) that one demonstration program achieved a 40% decline in the number of malpractice claims, an 80% reduction in the time it took to settle cases and a 20% decrease in defensive medicine services.

Still, when the American College of Surgeons hosted its third annual leadership and advocacy summit in Washington this past spring, medical liability reform was a primary topic.

Attendees called on lawmakers to support additional initiatives that lawmakers have introduced to curb frivolous lawsuits. For example, the Saving Lives Saving Costs Act (PDF) would give legal cover to providers who adhere to physician developed best-practice and appropriate-use guidelines from groundless lawsuits. The Health Care Safety Net Enhancement Act protects emergency on-call specialists. The Good Samaritan Health Professionals Act protects health professionals who provide voluntary care in response to federally declared disasters.

Follow Sabriya Rice on Twitter: @sabriyarice

The Rewards of Risk: Radiology Takes The Leap | Radiology Business

CDS increasingly important in struggle to manage imaging utilization – FierceMedicalImaging

CDS increasingly important in struggle to manage imaging utilization

The use of computerized physician order entry (CPOE) software supplemented by real-time clinical decision support (CDS) is becoming an increasingly important tool in efforts to manage imaging utilization, according to an article in RSNA News.

Radiology Benefit Management companies had been an important player in efforts to manage imaging utilization, but that’s changing.

“Traditionally, insurance companies have outsourced imaging utilization management to RBMcompanies,” Richard Duszak, chief medical officer of the Harvey L. Neiman Health Policy Institute and vice-chair for health policy and practice at the Emory University School of Medicine in Atlanta, said; Duszak also serves on FierceHealthIT‘s Editorial Advisory Board. “But the technology for CPOE with decision support has improved and the software has become more easily embedded into EHRs, which is spurring a shift away from using RBMs.”

The emphasis now being placed on CDS by the federal government suggests how important a tool CDS has become. Beginning in January 2017 ordering physicians will have to consult appropriateness guidelines when ordering procedures for Medicare patients using qualified CDS systems as identified by the U.S. Department of Health and Human Services.

Several recent studies have demonstrated the role CDS can play in reducing inappropriate imaging tests. For instance, as reported by FierceMedicalImaging in June 2013, use of a CDS tool based on American College of Cardiology Appropriate Use Criteria resulted in a reduction of inappropriate cardiac imaging tests from 22 percent to 6 percent.

What’s more, this past June, FierceMedicalImaging reported on a survey of emergency room physicians in which they said that overimaging with CT in their departments was a problem and that they would welcome the introduction of CDS tools in their departments in order to reduced inappropriate CT imaging.

“There’s obviously a growing interest around clinical decision support,” Anthony DeFrance, M.D., a clinical associate professor at the Stanford University School of Medicine,told FierceMedicalImaging in July. “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.”

To learn more:
– see the article in RSNA News

Related Articles:
Clinical Decision Support’s role in radiology
ED docs want imaging clinical decision support
CDS tool cuts inappropriate heart imaging tests
EHR tool helps to reduce ED imaging overuse

Why Defensive Medicine Will Continue | Diagnostic Imaging

Why Defensive Medicine Will Continue

Defensive medicine is prevalent in all specialties of medicine. Physicians may not even consciously realize they are practicing defensive medicine since it has been engrained in our thought process early on in our careers, especially over the past few decades. From my experience, physicians-in-training are usually not exposed to defensive medicine until residency, since medical schools usually shelter us from the “real life” thought process.

Defensive medicine is usually the result of two issues, one is the fear of being sued and the other is the continued decrease in time spent taking care of a patient. Both result in the increased utilization of additional consultation and testing. The increased utilization of mid-level providers such as physician assistants and nurse practitioners have also attributed to increasing costs, given their lower level of training, which likely ultimately leads to overutilization of services.

 I recently came across an article in Forbes Magazine – Defensive Medicine: A Curse Worse Than The Disease. This article discusses the issue of defensive medicine and how it is engrained in our health care system. One in four health care dollars is attributed to defensive medicine which amounts to about $650 million annually. The article also addresses the likely worsening of the problem due to the Affordable Care Act creating more insured patients, as well as the decreasing physician workforce due to retirement of baby boomers.

From my personal experiences, I see the practice of defensive medicine in all specialties including my own specialty of radiology. In my daily radiology reading grind, I can think of many situations where I may recommend an additional study, or my non-radiology physician colleague ordered a follow-up of a benign nodule. For instance, one case I read today was a renal ultrasound that demonstrated a likely renal cyst but given the slight debris within it (likely artifact), I recommended a CT abdomen. Since I practice in a litigious state, I recommended the study mainly for the fear of a malpractice lawsuit that this likely cyst may turn out to be cancer in a rare instance. Another example is seeing likely cysts within the kidney on lumbar spine MRIs which usually get an ultrasound or CT scan next to verify that they are cysts. I am sure most of you can come up with examples on a daily basis as well.

Another article I recently came across was in the Journal of American College of Radiology – Are Chargemaster Rates for Imaging Studies Lower in States That Cap Noneconomic Damages (Tort Reform)?  The article caught my attention since it seemed to evaluate the effect of tort reform on health care spending.  However, after reading the article, I realized that the authors may have missed the underlying issue of defensive medicine as the real issue is overutilization of health services not increasing charges of individual tests.

The article addressed the significance of whether tort reform (cap awards for noneconomic damages (NED) influences the chargemaster rates by hospitals and diagnostic testing centers for certain imaging studies. The authors concluded that chargemaster rates for select imaging services were not lower in states that have capped NED and were higher in some cases. One of the states that had tort reform, but had higher chargemaster rates was California. I am not surprised by this, given the high cost of living in California, which would likely increase costs for all business sectors within the state.  Hopefully, future studies will address the correlation between defensive medicine and overutilization of services.

The solution to combating defensive medicine is not an easy one, especially in a system that rewards physicians for doing more. Decreasing the risk of a malpractice lawsuit for physicians and limiting damages paid to patients while maintaining the right for patients is a difficult balance. The article in Forbes points out that the practice of defensive medicine did not significantly change in Massachusetts after legislatures enacted “Disclosure, Apologize, and Early Offer” as well as in Texas despite a cap on damages related to pain and suffering. Georgia and Florida legislatures are considering “Patients’ Compensation System,” which would eliminate the possibility of any physician or hospital ever being sued again. This system would replace our current system and would have a panel of experts to hear the medical claims of patients.

Although there has been much attention on curbing defensive medicine, I am not sure we will reach the “Patients’ Compensation System,” given the lobbying efforts of trial lawyers in this country. Even if we enact such as system, I don’t think the behaviors of physicians will change much in the short term. It may take decades to reverse the defensive medicine behavior in physicians, including myself. Parallel reform of physician compensation from fee-for-service to outcomes-based may also help align the goals of high quality and efficient care.

– See more at: http://www.diagnosticimaging.com/practice-management/why-defensive-medicine-will-continue?GUID=36E51150-DB8F-46B9-B290-23063C085678&rememberme=1&ts=05092014#sthash.eCLsF7vx.dpuf

Decision Support Software Aids Imaging Utilization Management

Decision Support Software Aids Imaging Utilization Management

September 01, 2014

Computerized physician order entry with clinical decision support can decrease the frequency of inappropriate imaging at a rate similar to that of radiology benefit management companies.


While radiology benefit management (RBM) companies continue to play a major role in managing the utilization of advanced diagnostic imaging, computerized physician order entry (CPOE) software, enhanced by real-time clinical decision support (CDS) is quickly gaining ground as an effective imaging utilization management tool.

RBM companies emerged in the 1990s and quickly became the dominant player in the radiology utilization management market. Today, approximately 90 million Americans are covered by RBMs and payers have credited these companies with reducing costs associated with imaging. But as healthcare continues to move toward the widespread adoption of electronic healthcare records (EHRs), the industry is increasingly turning to evidence-based CDS tools, which can be easily integrated with computerized ordering and EHRs.

“Traditionally, insurance companies have outsourced imaging utilization management to RBM companies,” said Richard Duszak Jr., M.D., chief medical officer of the Harvey L. Neiman Health Policy Institute and vice-chair for health policy and practice at the Emory University School of Medicine inAtlanta. “But the technology for CPOE with decision support has improved and the software has become more easily embedded into EHRs, which is spurring a shift away from using RBMs.”

The balance is shifting fairly quickly. When Dr. Duszak co-authored a two-part article about utilization management in the October 2012 issue of the Journal of the American College of Radiology (JACR), market penetration of CPOE with CDS was limited due to costs and software issues.

“At the time of the article, technological enablers weren’t there, and they weren’t embedded enough,” he recalled. “All of those pieces have improved, while challenges of RBMs have remained largely the same.”

Federal laws now back the use of CDS tools. Beginning January 2017, ordering physicians will be required to consult appropriateness criteria when ordering advanced imaging procedures for Medicare patients and the secretary of the U.S. Department of Health and Human Services must identify CDS tools to help physicians navigate appropriateness criteria. The American College of Radiology has long advocated for the use of CDS systems.

There is already mounting evidence suggesting that CPOE with CDS can decrease the frequency of inappropriate imaging at a rate similar to that of RBM companies, Dr. Duszak said. A January 2011 JACR study concluded that targeted use of imaging CDS is associated with large decreases in the inappropriate utilization of lumbar MR imaging for back pain, head MR imaging for headache and sinus CT for sinusitis. A study published in April 2009 in Radiology found substantial decreases in the growth of outpatient CT and ultrasound procedure volume coincident with CPOE implementation.

Radiologist Consultation Reduces Radiation Exposure

Nevertheless, RBMs will continue to play a significant role in imaging utilization management for millions of consumers for the foreseeable future. Radiologists who consult for RBMs can make a big difference in reducing unnecessary radiation exposure by providing guidance to other physicians, experts say.

In a study presented at RSNA 2013, Mark D. Hiatt, M.D., M.B.A., executive medical director for Regence BlueCross BlueShield of Utah in Salt Lake City, examined the impact radiologists had when consulting for RBMs. Dr. Hiatt examined records of 5 million subscribers to a national health plan from 2009 to 2010. In that time, radiologist consultations led to the cancellation of more than 19,000 CTs and the changing of more than 5,000 CT exams to other modalities including MR and ultrasound, sparing patients the radiation equivalent to more than 7 million posteroanterior chest X-ray equivalents.

Dr. Hiatt, who is also presenting an RSNA 2014 session on RBMs (See sidebar), named three key reasons for inappropriate imaging: wrong choice of modality; incorrect timing; and incorrect protocol, such as when contrast media is used when a non-contrast approach may be more appropriate.

The results of Dr. Hiatt’s research show the impact radiologists may have in reducing unnecessary imaging by providing expert guidance to other physicians. “It’s always better to get the right test the first time rather than the second or third time,” Dr. Hiatt said. “Encouraging adherence to guidelines saves millions of dollars while avoiding unneeded procedures and the negative consequences of false positives from those uncessary tests.”

Imaging Volume Shows Decrease

Overall, one recent study points to a reduction in imaging volume. A study in the July 2013 issue of JACR conducted by the Neiman Institute and co-authored by Dr. Duszak found that physicians are ordering diagnostic imaging exams as an increasingly lower percentage of their interactions with Medicare patients. The number of physician visits by patients 65 years of age or older resulting in an imaging exam dropped from 12.8 percent in 2003 to 10.6 percent in 2011, and Medicare spending per enrollee for imaging declined from $418 in 2006 to $390 in 2011.

While the numbers suggest that initiatives to reduce unnecessary imaging are paying off, there is concern within the specialty about the effects these efforts will have on access to necessary examinations. “There have been so many efforts in recent years to decrease the cost of imaging and raise the bar to receive imaging, but at what point do we curtail imaging so much that we decrease access?” Dr. Duszak asked. “The answer to this will take years to play out.”

In the meantime, radiologists will play an important role in ensuring that appropriate imaging remains accessible to patients, particularly through their interactions with referring physicians.

“Radiologists shouldn’t stay shut away in the dark room,” Dr. Duszak said. “They need to take ownership of their studies and be a part of the shared decision-making process.”

Richard S. Dargan is writer based in Albuquerque, N.M., specializing in healthcare issues.