Managing the U+liza+on of CT and MR Studies in an Era of Precer+fica+on

Transcription

1 Managing the U+liza+on of CT and MR Studies in an Era of Precer+fica+on Steven E. Seltzer, M.D. Department of Radiology Brigham and Women s Hospital Harvard Medical School Boston, MA

2 COI Disclosure - Partners HealthCare is an equity holder in Medicalis Corpora9on, a manufacturer of medical decision support so=ware tools. Dr Seltzer has no personal equity in Medicalis Corpora9on. Dr Seltzer is a recipient of research grants from Siemens and GE Health Care Dr Seltzer serves on the following Boards: GE- AUR Radiology Research Academic Fellowship Program (receives travel reimbursement) Academy of Radiology Research (no compensa9on)

3 Overview Radiology Medical Management- Current state Opportuni9es for Improvement Examples of CDS systems US Government Ini9a9ves A new impera9ve

4 Overview Radiology Medical Management- Current state Opportuni9es for Improvement Examples of CDS systems US Government Ini9a9ves A new impera9ve

5 Analog Era

6 Error Prone -Copying error -Illegibility Is Dr Roentgen the ordering physician?????

7 Error Prone -Inconsistent terminology -No quality control -No connection to CPT or ICD-9/10

8 Current State Runaway costs for medical imaging perceived as budget busters for insurers Precer9fica9on viewed as a crude, but effec9ve tool to manage (reduce) u9liza9on Radiology Benefit Management (RBM) companies capitalizing on this opportunity <but at great cost to pa9ents and providers> - Federal government now taking interest via PAMA

9 Overview Radiology Medical Management- Current state Opportuni9es for Improvement Examples of CDS systems US Government Ini9a9ves A new impera9ve

10 Opportuni9es Opportuni9es Future State Use informa9on technology, esp CPOE Deliver knowledge at the point of care Provide opportuni9es for improvement Well integrated with billing systems Case Example: CPOE and Decision support for ordering CT and MRI

11 Overview Radiology Medical Management- Current state Opportuni9es for Improvement Examples of CDS systems US Government Ini9a9ves A new impera9ve

12 Case Examples CPOE and Decision support for ordering CT and MRI

13 Radiology Information Flow Test Selection/ Scheduling Image Generation Referring MD Image Interpretation Radiologist Image/Report Distribution

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15 Radiology Information Flow Test Selection/ Scheduling Image Generation Referring MD Image Interpretation Radiologist Image/Report Distribution

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18 Duplicate Order Advice

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29 Appropriateness Values Another excellent CPOE system At MGH Courtesy: Dan Rosenthal, MD 1-3 Low Utility 4-6 Intermediate 7-9 High Utility

30 Add indica9ons

31 Impact of CDS at BWH: High quality condition-specific evidence Choosing Wisely MRI for low back pain: (ACP) Outpa9ents: MRI use 30% on day of PCP visit; 12.3% within 30 days of index PCP visit CT for minor trauma+c brain injury (ACEP) 13.4% in use of CT in ED CT for? pulmonary embolism: (ACEP/ NQF) ED use 20%; yield up 69% over 2 years Inpa9ent use 13% over one month, then stable All above now published in peer reviewed journals

32 Impact of CDS at BWH Outpatients ( 05-09): 12% high cost imaging / 1000 sustained over 4 years in a commercial payer population ED ( 07-12): 33% in CT; 21% in MRI/1000 visits Inpatients ( 09-12): 21% in CT/1000 admissions; adjusted for severity of disease All care settings: 7.5% in repeat CTs (Approx. 22% of all CTs are repeated within 90 days) All above now published in peer reviewed journals

33 Decision Support/ Quality Improvement Op9ons Reduce unnecessary exams on evidence- based criteria Possible by- pass of RBMs! Eliminate duplicate test ordering Avoid adverse events

34 CDS Summary Terminology, Concepts and Keys to Acceptance 1. Evidence library; the medicine 2. Evidence delivery IT tools; the syringe

35 CDS Evidence Library: the medicine Evidence available in CDS library is agnostic to publisher Various Professional Society guidelines: e.g. ACR AC, ACC; ACP, NQF, ACEP (Choosing Wisely), etc. Provider Groups (internally assembled) from: Peer reviewed literature Local best practices; evidence created from data mining QPLE is federal parlance Quality/Strength of Evidence transparently scored Oxford EBM Strength of Evidence US preventative task Grade of Recommendation

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37 CDS IT: the syringe Evidence delivery tool embedded in CPOE/EHR Key functionality: Each piece of evidence can be configurable by: Source of evidence, care setting, ordering specialty, ordering practice, individual physician; payer plan Configuration determined by multi-disciplinary clinical steering committee

38 Overview Radiology Medical Management- Current state Opportuni9es for Improvement Examples of CDS systems US Government Ini9a9ves A new impera9ve

39 U.S. Government Ini9a9ves PAMA of 2014 Sec9on 218(b) of the PAMA amended Title XVIII of the Act to add sec9on 1834(q) direc9ng CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnos9c imaging services.

40 Opportuni9es and Challenges Federal mandate for CDS use for advanced imaging beginning in 2017 Medicare pa9ents (more than 20M eligible procedures per year) Rule making now in progress Follows meaningful use of EHR incen9ves Could improve evidence- based prac9ce Logis9cs of na9on- wide implementa9on are daun9ng Access to AUC Real 9me knowledge delivery Documenta9on

41 CMS Comments 2015 Sec9on 1834(q) of the Act includes rapid 9melines for establishing a new Medicare AUC program for advanced imaging services. The number of clinicians impacted by the scope of this program is massive as it will apply to every physician and prac99oner who orders applicable diagnos9c imaging services. This crosses almost every medical specialty and could have a par9cular impact on primary care physicians since their scope of prac9ce can be quite vast.

42 Conclusions Use of knowledge- based informa9on system tools is an important new fron9er for Radiology Departments Expected benefits could include: Improved quality Improved efficiency Ra9onal resource u9liza9on Compliance with payor and governmental rules