10/11/2017. AGENDA What you should expect. Complete Service. Structured Reporting: Reducing Failure to Observe TECHNOLOGY ENABLED RADIOLOGY SERVICES

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Samuel McDonald
5 years ago
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Web-based survey of 41 ED physicians Level 1 trauma center 38 responses (93%) Average years in practice 14.

3, scale 1-5 Diagnostic accuracy most important component (47%) Turn-around time 29% Too many recommendations 18% Radiology

National Medical Director Envision Radisphere Division Journal of Radiology & Radiation October 23, 2013 Atlantic City

Communication & Consultation Complete Service All Modalities Including X-rays Final interpretations 24 x 7 x 365 Optimized

ENABLED RADIOLOGY SERVICES We optimize physician schedules to meet demands of the practice Structured Reporting: Reducing

goals Configure rules to route cases based on final schedules Structured reporting functions as a checklist, risk management

1 Web-based survey of 41 ED physicians Level 1 trauma center 38 responses (93%) Average years in practice 14.4 (range 2-35 years) Collectively group orders 100,000 exams / year 79% very satisfied or somewhat satisfied Mean 4.3, scale 1-5 Diagnostic accuracy most important component (47%) Turn-around time 29% Too many recommendations 18% Radiology Best Practices in Emergency Medicine and Hospital Medicine Frank E. Seidelmann, D.O. National Medical Director Envision Radisphere Division Journal of Radiology & Radiation October 23, 2013 Atlantic City September 14, AGENDA What you should expect Complete Service Accuracy Quality Assurance Turn-around time -TAT Communication & Consultation Complete Service All Modalities Including X-rays Final interpretations 24 x 7 x 365 Optimized Scheduling & Routing of cases Standardized, structured reports Appropriate Utilization (CDS) Analytics 3 4 TECHNOLOGY ENABLED RADIOLOGY SERVICES We optimize physician schedules to meet demands of the practice Structured Reporting: Reducing Failure to Observe Forecast future demand based on historical Match demand against goals Suggest physician schedules to meet goals Configure rules to route cases based on final schedules Structured reporting functions as a checklist, risk management tool, reducing the likelihood of missed findings by the radiologist. Atul Gwande: Checklist Manifesto (Failure of Ineptitude) Consistency, clarity and completeness. No two line or rambling two page reports

2 Accuracy - Quality Assurance (QA) Most experienced anesthesia group WORKING in the U.S. COLLABORATIVELY with first WILL IMPROVE OUTCOMES practice in Focus of Medicine Is Reduction of Errors Eight Goals for improvement outlined to reduce errors 5% of US adults who seek outpatient care experience a diagnostic error Postmortem examinations research spanning decades has shown that diagnostic errors contribute to 10% of patient deaths Goal #3: Ensure that health information technologies support patients and health care professionals in the diagnostic process. Medical records reviews suggest that diagnostic errors account for 6-17% of hospital adverse deaths Improving the diagnostic process is a moral, professional and public health imperative. 7 - National Academy of Medicine (formerly Institute of Medicine) 2015 Causes of Diagnostic Errors Include Inadequate collaboration Inadequate communication among Clinicians Patients Families Health Care work system not well designed to support the diagnostic process Limited feedback to clinicians about diagnostic performance Culture that discourages transparency and disclosure of errors, which impedes learning Candescent Health Technology Lays on top of all PAC s Systems to allow for Enterprise Diagnostic Integration 9 10 Subspecialists are underutilized Subspecialist Re-Interpretation Discrepancy Literature Example: 5 health systems (for profit and not-for-profit) with 34 total hospitals, 2.5 million annual radiology exams, and 24 radiology groups Pediatric Eakins 21.7% major 41% overall Studies read by an appropriate subspecialist 1 Percent of cases Women's 60% Subspecialists on rosters Number of FTE 49 Share of subspecialists capacity 21% Neuroradiology Loevner Briggs Zan Eakins 41% major 13% major 7.7% major 12.6% major Neuro MSK Body Pediatrics 12% 19% 35% 49% % 4% 1% 7% Body Imager Gollub 17% major 37% overall Wibmer 30% major Loughrey 34% major Vincent 20.2% major 53.3% overall Eakins 32.6% major 0% 25% 50% 75% Subspecialist qualification Fellowship or Certification 1 based on training and/ of Added Qualification (CAQ). Pediatrics requires any appropriate fellowship training (i.e., MSK study on a 2-year old, read by a fellowship trained MSK radiologist) Represents percent of studies a subspecialist reads in her/ his area of expertise; Pediatrics percentage includes 2 any fellowship trained radiologist treating a pediatric case. Musculoskeletal Heck 46% unacceptable reports (tumors) Radisphere 14% errors 12 2

RIGHT RADIOLOGIST, AT THE RIGHT TIME, FOR EVERY STUDY ACR RadPeer

privileged with the necessary expertise and sub-specialization.

rapid TAT Smart worklist prioritizes case for each radiologist

of most practices Under-reports errors 2010 ~ 3.

4% errors 13 14 Candescent QA Tools Robust Program Goal 5% Review

Reviews (workstation-integrated peer reviews) Assigned

Management Double Blind Reviews (DBR) External Reviews:

Bad, Ugly Focused Reviews: New Radiologists New Privileges for

QA Daily, Real-time Workflow Quality Assurance becomes an

done at the end of the month to fulfill Joint Commission

from greater data 15 16 Work-station & Over-Read Error Recovery

reviewed in < 12 hours Misdiagnosis detected before harm to the

3 RIGHT RADIOLOGIST, AT THE RIGHT TIME, FOR EVERY STUDY ACR RadPeer Review Processes Studies are routed to the radiologist who are privileged with the necessary expertise and sub-specialization. Workload is balanced across all available radiologist assuring rapid TAT Smart worklist prioritizes case for each radiologist Technology maximizes radiologist efficiencies, facilitates collaboration and communication. ACR Scoring System 16,000 Radiologists Participate Sole program of most practices Under-reports errors 2010 ~ 3.0% Literature reports ~4.4% errors Candescent QA Tools Robust Program Goal 5% Review of All Radiologists Internal Reviews: Optional Concurrence Reviews (workstation-integrated peer reviews) Assigned Concurrence Reviews (aka over-read, error recovery )- Risk Management Double Blind Reviews (DBR) External Reviews: Healthcare Provider submitted reviews Addendum Reviews: Good, Bad, Ugly Focused Reviews: New Radiologists New Privileges for existing radiologists Professional Quality Improvement projects QA Daily, Real-time Workflow Quality Assurance becomes an integral part of everyday activities of radiologist and is not done at the end of the month to fulfill Joint Commission requirements DBR Case Assigned Integrated into workflow Learning from greater data Work-station & Over-Read Error Recovery Double Blind Reviews High Risk cases Selected radiologists Cases reviewed in < 12 hours Misdiagnosis detected before harm to the patient Considered the gold standard for Quality Improvement > 2% double blind reviews Error recovery process Receives all the original clinical history Blinded to who originally interpreted the study Blinded to the original report

Assesses the accuracy of the original and double blind reader

Adjudication Module QA Committee Adjudication Explanation and

ways to avoid future errors and learning objectives Directs continuous

measures of value Eliminates not wrong, but not helpful reports

notification of errors to radiologists Allows for review and

2011-2015 Garland, 1959 Radiologists miss 30% of positive findings

radiologists, Seven year period Double blind reviews, 3-4%, 11,000

2% Soffa & associates, ACR, Yale 2% Double Blind review, general

Reporting Subspecialty Reads Overall Errors 2s, 3s, 4s Overall Major

4 Assesses the accuracy of the original and double blind reader Simulation training module Evaluates the value/quality of the report Adjudication Module QA Committee Adjudication Explanation and recommendations are provided from the committee members suggesting ways to avoid future errors and learning objectives Directs continuous learning Value of Report Assessment Module Client defined measures of value Eliminates not wrong, but not helpful reports Real-Time Alerts to Radiologists When an Error Identified Electronic notification of errors to radiologists Allows for review and acceptance and/or appealing review Case Study of QA Program Garland, 1959 Radiologists miss 30% of positive findings Seigle, et al, University of Texas Six Community Hospitals, 35 radiologists, Seven year period Double blind reviews, 3-4%, 11,000 cases Mean error rate of 4.4%, variance of 0.8% - 9.2% Soffa & associates, ACR, Yale 2% Double Blind review, general radiology, excluding CT & MRI 3.48% (x-ray 3.03%; mammography 5.79%; ultrasound 4.07%) ACR- RadPeer Reporting 2s, 3s, 4s Literature on Discrepancy Reporting Subspecialty Reads Overall Errors 2s, 3s, 4s Overall Major 2b, 3b, 4b Overall Minor - 2a, 3a, 4a Hospital Reported Errors 3s, 4s ACR RadPeer 2004 report: 3.5% ACR RadPeer 2009 report 2.9% Platts-Mills, et al: Journal of Emergency Medicine % major discrepancy in ED interpretations

of error rates between radiologists 25 26 Rolling Six Month Error Trend

5 Overall 86% Reduction in Errors Shifting the Curve Lowering Error Rates Lowering the number of radiologists with errors Decreasing the variability of error rates between radiologists Rolling Six Month Error Trend Performance KPI s ED Radiologist Ranking Turn-around Time (TAT)

I 5x variation exists in turnaround time for final radiology reports in the ED Example: 4 health systems (for profit and not-for-profit) with 34 total hospitals, 2.

100 90 80 70 60 50 Turnaround Time (TAT) Compliance to TAT: Hospital Specifications vs.

9% (18 minutes) Inpatient expedited < 4 hours 95.9% (1 hour, 24 minutes) Inpatient routine < 6 hours 97.

5% (18 minutes) Subspecialist Reads MRI 100% 96.8% PET 100% 100% Diagnostic Accuracy 31 Clinically significant error rate < 1% 0.

Support Communication s Assists radiologists in obtaining complete clinical histories, missing prior reports and images.

imaging study that suggest conditions that are lifethreatening or would require an immediate change in patient management.

finding, that could result in mortality or significant morbidity, if not appropriately treated urgently (within 2-3 days).

communication? Assures 100% verbal communication!

6 I 5x variation exists in turnaround time for final radiology reports in the ED Example: 4 health systems (for profit and not-for-profit) with 34 total hospitals, 2.3 million annual radiology exams, and 16 radiology groups Final Report Radiology TAT in the ED for Hi-Tech Modalities Active Hours 1 Minutes from exam complete until final report available Turnaround Time (TAT) Compliance to TAT: Hospital Specifications vs. Actuals Performance Category Hospital Our Compliance to the Specification Specification Turnaround Time ED stroke < 20 minutes 92.2% (10 minutes) ED/inpatientSTAT < 30 minutes 97.9% (18 minutes) Inpatient expedited < 4 hours 95.9% (1 hour, 24 minutes) Inpatient routine < 6 hours 97.3% (5 hours, 48 minutes) A C E G K M O Q S U W Y AA AC AE AG Best quartile 22 minutes Communication New/unexpected finding communicated < 60 minutes 97.5% (18 minutes) Subspecialist Reads MRI 100% 96.8% PET 100% 100% Diagnostic Accuracy 31 Clinically significant error rate < 1% 0.28% Our 24 X 7 X 365 team constantly monitors cases and workflow, providing critical support to radiologists Communication and Consultation Exception Management Practice Support Physician Support Communication s Assists radiologists in obtaining complete clinical histories, missing prior reports and images. Facilitates and documents Rad-Rad; Rad-Tech; Rad-Clinician Communication Monitors workflow NON-STANDARD COMMUNICATIONS: Joint Commission Level 1: New or unexpected findings on an imaging study that suggest conditions that are lifethreatening or would require an immediate change in patient management. REQUIRES DIRECT CONTACT between the radiologist and the requesting or responding clinician Must occur in minutes and must be documented Mandated and audited Level 2: New or unexpected finding, that could result in mortality or significant morbidity, if not appropriately treated urgently (within 2-3 days). REQUIRES COMMUNICATION within 6-12 hours Radiologist might call directly or might request a call service or associate to call on his behalf Critical Result Communication: How do you confirm communication? Assures 100% verbal communication! Service support tracks the appropriate healthcare worker until communication is completed Case never leaves the radiologists worklist until verbal communication completed to the physician providing care at the time of communication Documents compliance with Critical Results communication. Required on all addendum reports which change the original diagnosis Level 3: New or unexpected finding on imaging study that could result in significant morbidity, if NOT appropriately treated, BUT ARE NOT immediate life threatening. NOT time sensitive Report contains an important or potentially important finding that should NOT be overlooked May report electronically Track s and assure that they are successfully sent When answers are needed FAST! Enable timely and efficient communications Supplement with phone calls or faxes

ACR recommends that radiologists contact ordering physician directly for urgent findings.

utilization: ED CT utilization varies across facilities Example: 1 health system (for-profit) with 8 hospitals (1 excluded from analysis), 750,000 annual radiology exams, and 8 radiology groups 40%

CT Brain = 100 Chest x-rays CT Chest = 350 Chest x-rays CT Abdomen = 400 Chest s-rays Dosage varies from pt. pt. Actual dose could be 2-3X larger or smaller 33.1 28.1 23.

This range is not much less than the lowest doses of 5 to 20 msv estimated to have been received by some of the Japanese survivors of the atomic bombs.

7 ACR recommends that radiologists contact ordering physician directly for urgent findings. Survey DID NOT include subarachnoid hemorrhage, brain herniation or tension pneumothorax, which must be communicated verbally Appropriate Utilization Radiology does not appear to manage ED utilization: ED CT utilization varies across facilities Example: 1 health system (for-profit) with 8 hospitals (1 excluded from analysis), 750,000 annual radiology exams, and 8 radiology groups 40% 30% 20% 10% F G H J A K I Number of CTs per ED patient Percent Bottom quartile performers 1 What are the Radiation Risks from CT? CT Brain = 100 Chest x-rays CT Chest = 350 Chest x-rays CT Abdomen = 400 Chest s-rays Dosage varies from pt. pt. Actual dose could be 2-3X larger or smaller Top quartile performers The effective doses from diagnostic CT procedures are typically estimated to be in the range of 1 to 10 msv. This range is not much less than the lowest doses of 5 to 20 msv estimated to have been received by some of the Japanese survivors of the atomic bombs. These survivors, who are estimated to have experienced doses slightly larger than those encountered in CT, have demonstrated a small but increased radiation-related excess relative risk for cancer mortality. Hospitals 40 1 Benchmark quartiles based on scans ordered in the ED for physicians ordering >500 CTs What are the Radiation Risks from CT? The risk of developing cancer as a result of exposure to radiation depends: body part exposed age at exposure gender. For the purpose of radiation protection, a conservative approach that is generally used is to assume that the risk for adverse health effects from cancer is proportional to the amount of radiation dose absorbed and that there is no amount of radiation that is completely without risk. This conservative approach is called the linear non-threshold model. Biological Effects of Ionizing Radiation (BEIR) Committee, National Academy of Science (BEIR VII Report) 2005 Lifetime risk of 100mSv one (1) in 100 develop solid cancer or leukemia STUDY Prospective four-center study MGH Johns Hopkins Univ. of Washington, Seatle Duke Emergency CT studies Abdominal pain Chest pain and / or dyspnea Headache Pre & Post CT Surveys Primary measures Leading diagnosis Admission decision changed Median changes in diagnostic confidence Secondary measures Alternative diagnoses Return-to-care (ED) about 0.4% cancers in US attributable to CT studies Current estimate is % CT scans account for 17% of all radiology imaging procedures but contribute 49% RESULTS 1280 patients / 245 physicians Radiology Vol 278: Number 3 March 2016 Leading diagnosis changed: Abdominal (235/460) 51% Chest Pain (163/387) 42% Headache (103/433) 24% Median change in Confidence: Abdominal + 25%; Chest Pain + 20%; Headache + 13% Post-CT Confidence: 95% (all) Admission decision changed: Abdominal (116 /457) 25% Chest Pain (72/387) 19% Headache (81/426) 19% Follow-up scans for same indication: Abdominal (70/450) 15% Chest Pain (53/387) 14% Headache (49/433) 11% CT help confirm or excluded 95% alternative diagnoses Conclusion ED physicians diagnoses, diagnostic confidence and management are likely to change after CT. Broadly applied physician-targeted incentives to decrease the number of CT examinations should be viewed with caution. Nevertheless, CT carries risks and costs, and efforts to safely eliminate low-yield CT examinations should be an ongoing goal. 42 7

WHAT IS R-SCAN? https://rscan.org/ R-Scan Topics https://rscan.

Choosing Wisely topics Delivers immediate access to Web-based tools and clinical decision support (CDS) Lower the cost of care Optimize imaging care & reduce unnecessary imaging No cost to

8 WHAT IS R-SCAN? R-Scan Topics Radiology Support, Communication and Alignment Network Clinical practice improvement activity Brings radiologists and referring clinicians together to improve imaging appropriateness based Choosing Wisely topics Delivers immediate access to Web-based tools and clinical decision support (CDS) Lower the cost of care Optimize imaging care & reduce unnecessary imaging No cost to participate Radiologists and referring clinicians fulfill "Improvement Activity" credits under MIPS PECARN Head injury Prediction Rules Pediatric Emergency Care Applied Research Network Between , CT use in children more than doubled ~20-60% of children assessed for head trauma in North American emergency departments undergo CT Great variability in practice among ED departments < 10% of CT scans in children with minor head trauma (defined by GCS score of 14-15) show traumatic brain injury (TBI) Only % of injuries need neurosurgery in children with GCS Pilot Project Dr. Gittleman & Dr. Doan Department of Radiology Dr. Whitman & Dr. Font Department of Emergency Medicine Northwest Medical Center, Margate, FL A collaborative team of ED physicians and Radiologists To improve image ordering Use R-SCAN Several Choosing Wisely topics on the R-SCAN website were reviewed Participants included members of the Radiology and Emergency Medicine Departments Migliorett et al. JAMA Pediatr Mannix et al. J Pediatr Palchak et al. Ann Emerg Med NWMC Demonstration Project Minor head injuries occur commonly in children CT scans are performed in ~ 50% of children who present to the ED with a head injury Cal ACEP/ Choosing Wisely Collaboration Pediatric Head Trauma CT Decision Guide Children younger than 2 years GCS < 15 High Risk--4.4% risk Palpable skull fracture of ci-tbi* AMS (agitation, somnolence, slow response, repetitive Yes to any questioning) CT No Many of these may be unnecessary Radiation exposure poses a danger to children Undue costs on the health care system Scalp hematoma (excluding frontal) LOC >5 seconds Not acting normally per parent Severe mechanism of injury -Fall >3 ft -MVA w/ ejection, rollover, or fatality -Bike/ped vs. vehicle w/o helmet -Struck by high-impact object Yes to any Intermediate Risk--0.9% Observation vs. CT using shared decision-making Clinical factors used to guide decision-making: - Multiple vs. isolated factors - Worsening findings during observation (AMS, headache, vomiting) - Physician experience - Parental preference - <3 months old No Low risk-- < 0.02% CT not indicated, Observe *ci-tbi: risk of clinically important TBI needing acute intervention, based on PECARN validated prediction rules 47 8

9 Cal ACEP/ Choosing Wisely Collaboration Pediatric Head Trauma CT Decision Guide Children 2 years and older No Vomiting LOC Severe headache Severe mechanism of injury -Fall >5 ft -MVA w/ ejection, rollover, or fatality -Bike/ped vs. vehicle w/o helmet -struck by high-impact object GCS < 15 Signs of basilar skull fracture AMS (agitation, somnolence, slow response, repetitive questions) Yes to any Intermediate Risk--0.8% Yes to any Observation vs. CT using shared decision-making High Risk--4.3% risk of ci-tbi* CT Clinical factors used to guide decision-making: - Multiple vs. isolated factors - Worsening findings during observation (AMS, headache, vomiting) - Physician experience - Parental preference Shared Decision Making Based on: Physician experience Parental preference Multiple vs. isolated findings Age < 3 months Worsening signs or symptoms after initial period of observation is an indication for CT scan No Low risk-- < 0.05% CT not indicated, Observe *ci-tbi: risk of clinically important TBI needing acute intervention, based on PECARN validated prediction rules 50 Explaining the Rationale Low risk = Concussion Concussion is a clinical dx based on symptoms Risks of CT outweigh benefits Intermediate risk Intermediate risk symptoms warrant observation before deciding whether to perform head CT No increase in adverse outcome with this strategy WEIGHING THE RISKS IN INTERMEDIATE PATIENTS Give more consideration to CT scan if: Child is < 3 months of age Home observation is unreliable Child has more than one intermediate risk factor, for example: Vomiting AND headache Headache AND LOC High-risk mechanism AND parietal hematoma WEIGHING THE RISK FACTORS - If patient has worsening signs and symptoms during observation get CT - Experts recommend observation period of: - ~2 hours post-injury in low-risk patients - ~4 hours post-injury in intermediate-risk patients - Some of observation period can happen at home if there is a reliable observer NWMC R-Scan Pilot Project Results Over 55 CT Brain studies performed in the ED over the past 6 months were retrospectively reviewed Dr. Whitman reviewed the ED provider s documentation Determine why necessary to perform CT Identify if PECARN criteria were utilized The team classified studies based on the following criteria: Either met PECARN criteria, then CT necessary If didn t meet PECARN criteria, then CT unnecessary

R-SCAN REPORT BASELINE DATA RESULTS Total CTs for Pediatric Head

Appropriateness criteria >=7 N = 25 (45%) CTs Deemed

CONDUCT EDUCATIONAL ACTIVITIES CONDUCT EDUCATIONAL ACTIVITIES

physicians and staff To guide improved image ordering Begin with

and examples Consisting of presentation of the study results

Educational Materials ACR Appropriateness Criteria 57 58

10 R-SCAN REPORT BASELINE DATA RESULTS Total CTs for Pediatric Head Trauma During 6 months N = 55 CTs Deemed Appropriate Appropriateness criteria >=7 N = 25 (45%) CTs Deemed Inappropriate Appropriateness criteria <=3 N = 30 (55%) CONDUCT EDUCATIONAL ACTIVITIES CONDUCT EDUCATIONAL ACTIVITIES Hold collaborative educational programs With ER and Radiology physicians and staff To guide improved image ordering Begin with overview of the pilot project Followed by discussion of cases and examples Consisting of presentation of the study results Presentation of the Choosing Wisely campaign Educational tools Educational Materials ACR Appropriateness Criteria Analytics Measuring Our Performance We regularly provide summaries to radiologists to track our performance

11 Measuring Our Performance We also regularly provide deep analytics to facility administration. Summary: What you should expect Complete Service Accuracy Quality Assurance Turn-around time -TAT Communication & Consultation Appropriate Utilization (CDS) Turnaround times by priority, place of service, and for new/ unexpected findings Analytics Outpatient growth focused on high-tech modalities Top referring physicians with specialty Cost/RVU, QA, productivity, utilization, and more 62 Questions & Discussion 63 11

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