What's Appropriate? The Promise, Mandate and Controversy Over Clinical Decision Support Software.

March 2015 | AXIS Imaging News

By Teri Yates, Accountable Radiology Advisors

There have been a variety of mechanisms employed by payors in recent years to control imaging utilization and costs, including prior authorization, radiology benefit management, and bundling payment for multiple examinations performed on the same day. In parallel with these payor-driven strategies, initiatives launched by professional medical societies also have been deployed to promote more appropriate use of diagnostic imaging. These include campaigns such as Image Gently to reduce unnecessary radiation exposure in children, or Choosing Wisely to encourage patients to question and avoid imaging procedures with no clear clinical benefit.

All imaging providers have been impacted to varying degrees by these programs, and there is more change on the horizon in the form of mandated use of clinical decision support (CDS) software. CDS is a tool to educate providers at the point-of-order about the clinical appropriateness of their proposed use of diagnostic imaging. The CDS software, which may be integrated with the electronic health record order entry system or accessed through a stand-alone web portal, analyzes details of the patient’s condition to determine if the radiology procedure ordered is indicated. This determination of appropriateness is based on the specific guidelines that are employed in the system; in circumstances where an order is not appropriate, the software also provides the ordering physician with recommendations about what alternatives are indicated given the clinical scenario.

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Smoke Screening

Published on September 19, 2014

Are the politics of smoking polluting public policy and the fight for low dose CT lung cancer screening? 

By Teri Yates, Accountable Radiology

The outlook for people living with lung cancer has always been exceptionally grim.  More than half of all patients do not even survive a year after diagnosis, primarily because nearly all lung cancers are detected after the disease has spread to other parts of the body. In its early stages, lung cancer is silent and symptomless, but like so many other cancers when caught in the early stages, it can be treated and in many circumstances it can be cured. The question is, how do we find lung cancer early?

In 1992, physicians at Cornell University Medical Center began looking for the answer to that question, forming the Early Lung Cancer Action Program (ELCAP) to determine if screening with low-dose CT could detect cancer at an earlier stage than chest radiography. ELCAP eventually became an international effort (I-ELCAP), and its promising findings prompted the National Lung Screening Trial (NLST), a randomized clinical trial that examined whether low-dose CT screening could prevent lung cancer deaths in high-risk patients.

Twenty-two years later, the collective work undertaken by these researchers has proven that annual screening with CT is effective at detecting early stage lung cancer, and more importantly that lung cancer screening can prevent 20% of lung cancer deaths. Armed with the necessary evidence demonstrating the effectiveness of screening, researchers and lung cancer advocacy groups have been working diligently to secure insurance coverage for this new and important preventive health service.

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Path to Compliance

Published on March 28, 2014

By Teri Yates

On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) finalized a number of changes to the Physician Quality Reporting System (PQRS). PQRS is one of several pay-for-performance models devised and implemented in recent years to facilitate the collection of quality information about the care provided to Medicare beneficiaries by physicians and other eligible professionals (EPs).

The earliest version of PQRS, known at the time as the Physician Quality Reporting Initiative, was first implemented in 2007 as a voluntary program that offered incentive payments in exchange for reporting.  Participation in the program was low at first despite the significant bonus payments offered, with physicians citing several reasons, including confusing program guidance from CMS, low confidence that the program actually improved quality, and limited success at actually achieving the bonus payments when reporting was attempted. Many of the physicians who did earn incentive payments early in the program concluded the costs outweighed the benefits of participating; those frustrating experiences did little to encourage expansion among other EPs. Despite its inauspicious start, continuation of the PQRS program was assured in 2010 by the Patient Protection and Affordable Care Act, and over time the program has been modified to incorporate both incentives and payment penalties to promote reporting.

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Strategic Radiology Establishes PSO to Improve Quality and Safety

Patient Safety & Quality Healthcare | December 2013

By Teri Yates, CHC

Early this year Strategic Radiology Patient Safety Organization LLC was announced as a component entity of Strategic Radiology LLC, an affiliation of 16 group practices representing more than 1,200 radiologists. The new patient safety organization (PSO) was listed by the secretary of the Department of Health and Human Services on June 19, 2013, signifying that its certifications have been accepted by the Agency for Healthcare Research & Quality (AHRQ) and making it the first radiology-specific PSO in the country.

PSOs improve healthcare quality by aggregating and analyzing data about adverse events; the PSO then helps its client healthcare organizations develop systems to identify risks and prevent patient harm based on what it learns from those analyses. To encourage participation, the adverse event data and analyses reported to or conducted by a listed PSO (called patient safety work product) are deemed privileged and confidential. Creation of a safe environment for transparent sharing and learning is one of the key reasons that Strategic Radiology (SR) formed its PSO. Randal Roat, chief operating officer for SR, explains: 

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Radiology Partnership Agreements: Achieving Better Alignment Without Hiring the Physicians

Becker's Hospital Review | August 28, 2013

By Teri Yates

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.

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Peer Review: Why Current Models Undermine Safety Culture

Patient Safety & Quality Healthcare | December 2012

By Teri Yates

The field of radiology is known for its rapid innovations in technology. We continually offer up exciting new ways to image the body, but when it comes to improving the accuracy of professional interpretations, little meaningful progress has been made in the last 50 years. This is true in part because current radiology peer review models are insufficient, and in some circumstances, even harmful to quality improvement efforts. To achieve our most important purpose—the provision of safe and high quality healthcare—radiologists must find a new and more effective way to conduct peer review.

Models for Peer Review
Despite the lack of substantive improvement in diagnostic accuracy, all radiology groups are under increasing pressure by hospitals, the Joint Commission and the payor community to participate in some form of peer review. Most commonly, radiologists conduct peer review utilizing the model developed by the American College of Radiology, known as RADPEER™. In the RADPEER model, radiologists evaluate each other’s work through the course of their normal reading activity, in which they compare prior studies to the current study being interpreted. Cases are self-selected, and the participants rate and document their level of agreement with the colleague’s interpretation of the prior study. The results of these reviews are then self-reported to the ACR for aggregation and analysis. 

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The Case for Standards-Based Performance Assessment

Patient Safety & Quality Healthcare | October 2012

By Teri Yates

Diagnostic radiology is a vital component of the healthcare system and is utilized in the diagnosis and management of nearly every hospital patient. Radiology services cost $175 billion annually in the United States, representing 7.5% of total healthcare expenditures.

Given the size of the annual spend, there can be little argument that aggressive utilization management is warranted to control front-end costs; however, evaluating the quality of service is equally important since radiology errors can lead to significant downstream costs. For perspective, a study by Radisphere estimated the cost of radiology error at $31B annually (Radisphere National Radiology Group, 2011).

Because radiologists play such a prominent role in the diagnostic process, it is critical that their interpretations are both definitive and accurate. Increasing focus by payers and accrediting organizations on the task of radiology performance measurement further supports the conclusion that both the administrative and clinical aspects of the service must be closely monitored by hospitals. Examples of these initiatives include:

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The Antidote for Radiology Errors

Imaging Technology News | June 2012

Better systems that improve quality, learning and safety are the key to real improvements

By Teri Yates

Most experts embrace the notion that the best way to prevent medical errors is to learn from them rather than punish the individuals involved. Despite this, the facts suggest there is still much work to be done in establishing a just culture in healthcare that acknowledges the inherent likelihood that humans will make mistakes. The Agency for Healthcare Research and Quality (AHRQ) has studied this particular issue for years, and its most recent findings point to the fact that the majority of physicians still feel their organizations employ a blame-oriented rather than solutions-oriented approach to error prevention. In AHRQ’s “Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report,” more than 500,000 staffers representing 1,128 hospitals were surveyed.1 The majority of respondents, including physicians, feel that their mistakes are held against them.

This is particularly interesting when considered against the backdrop of the recent Office of the Inspector General (OIG) report entitled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.” In it, the OIG concluded that based on its study of claims from 2008, 86 percent of incidents that harmed Medicare beneficiaries were not reported to the hospital’s incident reporting system.2 The report opined on a variety of potential causal factors for this, including:

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