Radiologist Takes Appropriateness Message to the Community

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January 30, 2014

One radiologist is taking a proactive approach to encourage appropriate image ordering by educating his fellow referring physicians. Here’s why he’s doing it, and why other radiologists should, too.

As the campaign to encourage the right imaging tests at the right time continues to gather momentum in the medical community, one radiologist is taking an active approach to promoting appropriateness. Austin radiologist Robert M. Milman, MD, who has been giving presentations on imaging to primary care providers for many years, recently turned his attention to educating referring physicians on appropriate image ordering.

While it might appear at first glance that a radiologist instructing referring physicians to be more judicious about ordering imaging studies would be doing financial harm to himself and his group, Milman has the broader picture in mind. He embraces the ACR’s Imaging 3.0 initiative to provide better care at lower cost by helping providers determine the most appropriate tests to order.

Milman is with Austin Radiological Association, a 90-physicain private practice radiology group that provides services to almost all of the hospitals in the Austin area and operates 16 imaging centers. Diagnostic Imaging spoke with Milman about his efforts to ensure the appropriate use of imaging in his community, and how you might do the same where you practice.

Where are you giving these presentations, and to whom?

I go to different venues. I speak at meetings of state-wide organizations like the Texas Academy of Family Physicians when they meet in Austin and to local primary care groups. I also give the talks at the University of Texas School of Nursing for advanced nurse practitioner graduate students and at Texas A&M University to medical students.

What do you typically cover in your talk?

The main focus of the presentation is about appropriate imaging or “what to order when.” I go over what different types of studies can and can’t do and discuss the level of radiation exposure to patients — what’s involved in a CT scan versus a plain X-ray, for example, or that there is no radiation exposure at all with ultrasound or MRI. I also cover how to decide on appropriate follow-up studies and some of the lesser discussed risks involved with imaging like false positives and incidentalomas, both of which can cause patients unexpected anxiety.

What do you think draws primary care physician and nurse practitioners to these talks?

Imaging is now involved in the care of so many patients that our referring community really wants to learn about how to order the right study at the right time for the right reason. As radiologists, we can provide information to help doctors get the answers they need in the most efficient and most cost-effective way possible. They appreciate learning how to get from point A to point B when they’re trying to make the right diagnosis for a patient. The feedback has been positive. Also, my group has the ability to offer CME credit for some of the talks, so that helps.

What’s the level of engagement in the part of your audience members?

They’re very attentive and stay with me and stay on topic. For them it’s a picture show because radiology is so visual. No one is interested in dull material, but if you can provide something of worth, people will attend.

One issue that often comes up is related to patient demand. People have access to a lot of medical information today and if they have low back pain they know there is this thing called an MRI machine out there and they think they need that scan. Referring physicians spend a lot of time trying to help patients understand what’s appropriate when it comes to imaging, so I touch on that in my presentations.

What has surprised you since you’ve been offering these presentations?

Mostly that even though the American College of Radiology’s appropriateness criteria program has been out there for quite a while that many primary care physicians are still not aware of it. The traditional method of picking up the phone and calling a radiologist when they have a question is fine — and our group does a lot of that and is happy to do it — but primary care doctors could save a lot of time by using the information that the ACR has available. With a few clicks on the computer they can usually get an answer about what test to order.

How does the practice of so-called “defensive medicine” come into play related to appropriate imaging?

Some doctors order more than others or sooner than others because they don’t want to miss anything, and that’s understandable. But the appropriateness criteria are actually a benefit to physicians because if they follow the guidelines and document what they’re doing, they’re acting reasonably. That’s protective from a medical-legal standpoint.

What do you see as the future for radiology groups given the push for referring physicians to follow appropriateness guidelines?

Most radiologists are becoming aware that the world is changing from a volume driven, fee-for-service model to a value driven, patient-centered model. At the end of the day you want to do the most appropriate test and be as efficient as possible. It’s about making the right diagnosis and treating the patient appropriately. This is a culture change, but resources are not unlimited and costs need to be contained.

Is your group supportive of your efforts to educate healthcare providers?

Yes. There are about 90 radiologists in our group and many of us give CME presentations. I’m the primary one in the group doing talks on imaging appropriateness right now. I’m planning to branch out and start giving presentations about appropriateness specifically related to screening studies such as the latest in breast imaging, lung cancer screening, and the use of virtual colonoscopy.

What advice do you have for a radiologist who is reading this and thinking about offering similar presentations in their community?

Get energized about the topic and put effort into giving the talks. They could contact some of their local primary care groups and offer to come in and make a presentation or they could work through their local hospitals or medical society to get the ball rolling. Groups always appreciate having interesting speakers come in.

#RSNA13 @ACRSelect

NDSC Receives AuntMinnie's best new Radiology Vendor Award

NDSC Receives AuntMinnie’s best new Radiology Vendor Award

 RSNA 2013 was a busy time for the National Decision Support Company. Although the official theme of the show was “The Power of Partnership”, the unofficial theme of the show was clearly “Value-based Radiology”.

We had over 400 visitors to our booth, and tons of walk-in traffic. Our visitors spanned the gamut of the RSNA attendance, from clinical leadership in major healthcare providers to radiologist leadership from nearly every practice setting.  This level of traffic yielded some incredible dialog and perspective about how the imaging community is embracing partnership and delivering on the promise of value based radiology.

National Decision Support Company (NDSC) is the American College of Radiology’s commercial partner for delivering the integration ready, electronically consumable version of the ACR’s Appropriateness Criteria ® under the name ACR Select. The launch of ACR Select was part of the ACR’s Imaging 3.0™ initiative, which provides a framework and set of technology tools to enable radiologists to transform the delivery of their services in the new value driven healthcare economy. At its core, Imaging 3.0 ™ is simple:

  • Ensure the value of proper imaging
  • Ensure the right test, at the right time, is properly performed and interpreted
  • Create a platform and tools to promote the value of imaging
  • Confirm the role of the radiologist as a valued, cognitive, consultative member of the care delivery team.

Many of our visitors became aware of ACR Select through co-marketing between the ACR and NDSC related to the Imaging 3.0 ™ initiative. They wanted to know how the simple step of integration of the appropriateness criteria at the point of order could improve radiology services. It’s a simple step, and we had a simple answer:

Implementing ACRSelect at the point of order is the start of a powerful transformation process for delivering better care through imaging and enhancing the value proposition for Radiology services.

From the perspective of Radiology, ACR Select is an opportunity for Radiology to drive towards more appropriate utilization of valuable imaging resources by having its criteria guide the ordering physician. Where required, the platform enables direct consultation between the ordering physician and the radiologist.

By linking a structured reason for exam (vs. the typical free text), and tracking the appropriateness of an imaging procedure together with the entire patient record is an opportunity to quantitatively define what we’ve known all along:

Inappropriate use of Imaging is wasteful and the best imaging means better care.

This launched a range of interesting dialogs and perspectives about value based care and we thought we’d share some with you.

Several Radiologists initially pushed back on the idea of being available to consult on the best imaging procedures when ACR Select returns an indeterminate score, while others thought that the consult should be yet another paid transaction.

Part of our message at the show was to help radiologists understand how much money is being spent on imaging prior authorization in markets where payers already have adopted Radiology Benefits Managers (RBMs). In markets that have not, we discussed how providing this consultative service is a way to re-position the radiology practice directly in the value chain. When Radiology drives substantial savings for the healthcare provider, and embraces risk, a bigger slice of the imaging pie becomes available.

This is at the crux of radiology’s transformation from a volume-based service towards driving value-based care, and ACR Select is the cornerstone

 Now several Radiology practices are in the planning stages of embracing the consultative role in recognition of the opportunity to position imaging in the patient care cycle, engage the ordering physician and drive value-based care. Positioning their provider relationships and the order entry workflows to guide the ordering physician to consult with a Radiologist when needed, and using the ACR Select platform to manage and track the interaction.

Not only did we provide guidance, consultation and education to the market. We learned a few things of our own from radiologists already living the Imaging 3.0 philosophy.

Most notable was the interaction we had with a radiologist, who was presented with an ED ordering scenario that was a clear case of inappropriate imaging driven by the need to practice what can only be called defensive medicine. The radiologist offered to include a comment in the medical record that it was his professional opinion that the exam was not indicated. The ordering physician was more than grateful. The radiologist had added value. As such, this is now standard practice in his facility’s ED.  When this same physician learned that ACR Select is the ACR’s Appropriateness Criteria ®, he now had a defensible national standard to inform decisions, and a way to help provide this same value across the board by introducing ACR Select to the ordering physicians and the healthcare provider. The rest was easy.

Like we said, RSNA a busy conference. Our participation in RSNA 2013 only reinforced that we’re on the right track, and, with the support of the ACR membership we have solidified our role in driving value-based imaging. We value the partnerships we are creating with the healthcare community. More importantly, it is incredibly fulfilling to be providing a platform that can reinforce the partnership between radiology and the healthcare provider.

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.

SOAP Notes for Appropriate Imaging


Currently the ordering process for medical imaging provides no support for decision-making, which results in over utilization and inappropriate ordering of diagnostic imaging procedures.

This adds unnecessary overhead on the Healthcare delivery system and adds direct imaging related costs and wasted time for all those involved in the care continuum.  This is especially undesirable in risk bearing models such as inpatients and ACO’s.

Inappropriate and unnecessary imaging results in misdiagnosis and/or delayed diagnosis.  This creates less favorable patient outcomes and patients may be exposed to unnecessary radiation and contrast.

Existing CPOE platforms do not allow for adequate data analysis.


As medical imaging has advanced, the complexity and number of imaging studies has grown exponentially.

Computer Physician Order Entry (CPOE) and system automation has become commonplace.

Direct consultation with radiologists is not routinely performed, yet it is unreasonable to expect providers to be familiar with the correct indication for all imaging studies.  The American College of Radiology (ACR) has published “appropriateness criteria”.   Recently the appropriateness criteria information can be integrated into a CPOE in the form of ACR Select.

ACR Select offers a national standard, and integration, which offers real-time, decision support for providers when ordering imaging studies.


Providers need automated decision support when ordering imaging procedures.  Currently order entry decision support is non-existent in our CPOE.   Implementation of ACR Select decision support for imaging within CPOE improves patient outcome/quality of care, reduces unnecessary utilization, increases provider satisfaction, and creates analysis opportunities that are not possible with the current CPOE.


Enable ACR Select within the CPOE workflow. Include data capture and analytics to evaluate physician performance and effectiveness of point-of-order clinical decision support. Use this data to provide targeted intervention and counseling. Also, implement soft or hard stops for inappropriate orders to encourage or mandate consultation with radiology.

Aunt Minnie Healthcare IT Community – NDSC hires Cooke as marketing VP

Healthcare IT Community – Healthcare Informatics Systems, News, Vendors, and Links.


NDSC hires Cooke as marketing VP

By staff writers

July 24, 2013 — Clinical decision-support software firm National Decision Support Company (NDSC) has appointed two new vice presidents.

Bob Cooke will join the firm as vice president of marketing. He previously served at Agfa HealthCare and Fujifilm Medical Systems USA; most recently, Cooke founded ImagingElements, an organization focused on radiology meaningful use.

In addition, Mick Brown will join NDSC as vice president of business development. He formerly worked at Agfa, Siemens Healthcare, and Nuance Communications.


The appointments are part of NDSC’s effort to bring ACR Select, a national standard set of evidence-based guidelines that help healthcare providers choose appropriate medical imaging exams, to market, according to the firm.