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.

A prescription for success

I’m often asked, what impact can a tool like ACR Select have in a typical Hospital inpatient imaging environment?

I think the truth is that we all know that there is a LOT of wasteful use of inpatient (and generally unmanaged) imaging services.  I often chuckle when I recall many of my radiologist friends telling me that they can tell which exams are ‘normal’ just based on looking at their worklist and seeing the ordering clinician and reason for exam!

The easiest way to look at this is to simply compare this to the outpatient environment where a market goes to a pre-authorization or Clinical Decision Support (CDS) program. The typical reduction is about 10-12%.

I believe that at a minimum, CDS will replicate what happens in the outpatient environment.  There are however,  MANY variables that can affect this number.

I have a pretty ‘sobering’ belief as it relates to the impact we can create: 20-30% of all inpatient imaging should either probably have never been done, or was ordered incorrectly (i.e. wrong modality). Lets look at some the reasons why:

  1. Practice protocols and order sets; much of the inpatient imaging is done as a matter of ‘protocol’ or assumptions that are built into order sets that haven’t been reviewed or changed since inception.  This is a big problem and I believe that a review of these practices and order sets is an important first step. Using ACR Select to review these is a big first step.
  2. There is very little interaction between the ‘expert’ (the rad) and the ordering clinician. This has to change.  The radiologist needs to be incentivized to get involved in consults and the ordering clinician must know when a consult is necessary.  Getting feedback from ACR Select plays a big role in identifying cases that are ‘borderline’ and suggest that a radiologist consultation would help to improve the decision.
  3. Ordering clinicians get no feedback on the clinical efficacy for the exams they are ordering.  Most orderers order exams because “its what we always do”. Clearly, ACR Select solves this in an elegant way.
  4. Duplicate and repeat studies.  This is a no brainer and has nothing to do with ACR Select.  Having a proper ‘duplicate exam alert’  with report display and images in the CPOE is imperative to reduce over-utilization due to this.
  5. Self protection is a big issue too. Safe harbor for using guidelines/criteria will certainly impact what happens.  We are long way from getting this, but this WILL happen.  It has to!

The impact of ACR Select (and CDS in general) will be determined by how you implement.  There are a few options.  I’ll list in order of ‘boldness’:

  1. Disallow ALL orders that don’t reach a certain score threshold and require a consultation with Radiology. This will have the most impact.
  2. Display scores and ‘speed bump’ low scores by asking the orderer ‘why’ they are ordering a low scoring exam as well as offering a live consult with radiology. This is very effective and has been the most commonly used method.
  3. Display scores and offer no speed bumps. The doctors will see the low score and know data is being collected and this will affect behavior.  Nobody ‘wants to be wrong’.
  4. Display no scores, but require that they select reason for exam based on the indications provided by ACR Select so at a minumum we have ‘structured reasons’ that can be analyzed.

In ALL of the above scenarios, there should be reporting tools used to analyze ordering patterns that identify the outliers so they can be educated.  Keep in mind, our experience shows that inappropriate ordering is highly correlated to the ordering clinician, i.e.  if you have a 25% low score rate, the data will show that they come primarily from the same group of doctors that represent just 50 or 60% of the doctors. And in the case, it will be usually for a specific set of exams. So, educating that smaller population will go a long way towards reducing waste through unnecessary utilization.

Radiologist as Gatekeeper?

The New England Journal of Medicine just published a great piece comparing imaging service utilization in the U.K.’s National Health Service vs. the United States.

From Imaging Gatekeeper to Service Provider — A Transatlantic Journey by Saurabh Jha, M.B., B.S.

The article describes how in the National Health Service in the UK, Radiologists had to act as gatekeepers to preserve the relatively scarce resource of Imaging Services. The infamous “Dr. No” kept the the requestors at the top of their game and quality improved.

The article contemplates the choice between using Clinical Decision Support rules such as ACRSelect or the Radiologist to perform gatekeeping. The flaw in this thinking is that it is not an either/or choice. Decision Support (e.g. ACR Select) is the vehicle to improve and focus the dialog between ordering physician and radiologist. Its not a gate, its a collaborative tool. The notion of anyone in medicine performing gatekeeping in medicine is inconsistent with goal to improve care and outcomes.

The author throws the proverbial baby out with the bath water.  The proper way to improve quality and manage imaging resources is to do both CDS  AND consults.  The idea that EVERY request for an exam should involve a call with a radiologist is extremely inefficient and contrary to the goal of resource management. If healthcare providers invest in CDS to gather  feedback in the CPOE cycle, and remove the clearly inappropriate (the 1’s) and the appropriate (the 10’s) from a consult is a benefit to everyone.  CDS acts as first pass filter to further define and focus episodes whereby a consultation is required.

The author discusses educations process, but he ignores the fact that CDS  is also an educational tool. In fact, implemented correctly, its probably the best tool for education because it provides knowledge at the ‘point of practice’, learning on the fly and in ‘context’, which is arguably the best way to learn anything.

The most interesting points he makes is in the description of his interaction with “Dr. No” in the UK.  Of course with no CPOE, Clinical Decision Support wasn’t an option.  When Dr. No asked him “what the course of action was if the exam was negative?”, was interesting indeed!  It points to a fact that we already know… Asking MORE questions would get a better answer. Unfortunately, the entire principal behind today’s CDS system design is to provide value while causing as little ‘inconvenience’ to the ordering clinician as possible.  Even then, that the biggest hurdle to acceptance is to get a a clinician to simply enter a cogent reason for exam!  The problem isn’t what a radiologist is or isn’t willing to do as the author suggests. I know of no radiologist who is unwilling to take a call from a referring for guidance.  But rather, the problem may well be a culture whereby referring clinicians believe that their practices shouldn’t be questioned.  The irony is, it happens all the time with Radiology Benefits Managers and many others areas of medicine and the reason why it works is because payment is withheld and they have no choice, not because there is any perceived clinical value.