Overuse of Imaging: Identifying Waste and Inefficiency
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1 Overuse of Imaging: Identifying Waste and Inefficiency Kimberly E. Applegate, MD, MS Emory University Atlanta, GA 1
2 Disclosures Book royalties; Evidence Based imaging: Optimizing Imaging for Patient Care, Springer Thank you to colleagues for slides and information: Drs. Craige Blackmore and Geraldine McGinty
3 Outline What is Waste? What is Lean? Lean Methods for Imaging Informatics Tools for Imaging in Healthcare 3
4 The system is designed perfectly to get the results it gets. - Paul Bataldin, MD 4
5 Geographic Variation Among Medicare Enrollees, Standardized Discharge Ratio (Log scale) Hip Fracture (14.3) Knee Replacement (53.6) Hip Replacement (69.5) Back Surgery (103.8) Source: Dartmouth Atlas Project.
6 Defining Radiology Quality IOM 2001 Crossing the Quality Chasm -Safe -Effective -Patient-centered -Timely -Efficient -Equitable 6
7 Worldwide Insatiable Appetite for Imaging 3.6 billion exams/year (UNSCEAR 2008)
8 Value of Imaging CT/MRI most important innovation in medicine in the 20 th century* *Fuchs V and Sox HC, Health Affairs 2001;20:30-42
9 Growth in Imaging Procedures Millions of Procedures Lee DW, Levy F. Health Aff 2012;31:1-9
10 Value of Imaging?
11 Value of Imaging?
12 Lean Healthcare Elimination of all tasks or items that do not add value Value is defined by the customer Patients, payers, employers Opposite of Lean is waste Tool to improve quality
13 Lean Objectives Framework for effectiveness of imaging in health care Using imaging for medical decision making Quality in imaging 13
14 Cultural History Lee Lusted,MD SMDM Society for Medical Decision Making SHSHR, now RASHR Radiology Alliance in Health Services Research SIDM: Society to Improve Diagnosis In Medicine 14
15 Hierarchy of Efficacy Technical: adequate image Accuracy: sensitivity, specificity Diagnostic certainty: disease probability Decision making: change in management Outcome: patient-centered outcome Societal value: cost-effectiveness Fryback, Thornbury. Med Dec Making 1991;11:88-94
16 Hierarchy of Efficacy Technical: adequate image Image without artifacts Signal to noise Accuracy: sensitivity, specificity Diagnostic certainty: disease probability Decision making: change in management Outcome: patient-centered outcome Societal value: cost-effectiveness
17 Hierarchy of Efficacy Technical: adequate image Accuracy: sensitivity, specificity Ability of test to identify normal and abnormal Diagnostic certainty: disease probability Decision making: change in management Outcome: patient-centered outcome Societal value: cost-effectiveness
18 Why Perform Diagnostic Test? Test results will change suspicion increase or decrease certainty change post-test probability Bayes Theorem
19 Hierarchy of Efficacy Technical: adequate image Accuracy: sensitivity, specificity Diagnostic certainty: disease probability Decision making: change in management Potential to change management Treatment threshold Outcome: patient-centered outcome Societal value: cost-effectiveness
20 Hierarchy of Efficacy Technical: adequate image Accuracy: sensitivity, specificity Diagnostic certainty: disease probability Decision making: change in management Outcome: patient-centered outcome Societal value: cost-effectiveness
21 Societal efficacy Cost-effectiveness Is CT for appendicitis worth expending societal resources? Efficiency Are the minimum resources expended to achieve a give aim 21
22 Societal Value Effectiveness (Does it work in the real world?) Efficiency (Does it work in the ideal world?) Equitability (Access and fairness) 22
23 Lean Thinking Processing Unnecessary processes and operations Traditionally accepted as necessary Time Waiting for people or services to be provided. Time when processes, people or equipment are idle. Defects Waste related to costs for inspection of defects in materials and processes, customer complaints and repairs Inventory Maintaining excessive amounts of supplies, materials, or information for any length of time. Having more on hand than what is needed and used. Waste Motion Unnecessary movement or movement that does not add value. Movement that is done too quickly or slowly. Overproduction Producing what is unnecessary, when it is unnecessary, and in unnecessary amounts Transportation Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items.
24 Lean Thinking Processing Unnecessary processes and operations Traditionally accepted as necessary Time Waiting for people or services to be provided. Time when processes, people or equipment are idle. Defects Waste related to costs for inspection of defects in materials and processes, customer complaints and repairs Inventory Maintaining excessive amounts of supplies, materials, or information for any length of time. Having more on hand than what is needed and used. Waste Motion Unnecessary movement or movement that does not add value. Movement that is done too quickly or slowly. Overproduction Producing what is unnecessary, when it is unnecessary, and in unnecessary amounts Transportation Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items.
25 Choosing Wisely ACR Imaging for uncomplicated headache CTPA for low pre-test probability of PE CT in pediatric appendicitis prior to US ACEP CT head in minor head injury CT head for syncope CTPA for low pre-test probability of PE Lumbar imaging for non-traumatic back pain CT if known kidney stones
26 Computer Decision Support with Hard Stop Decision Support Implemented Reduction in imaging Headache: -23% Low back pain: -23% Sinusitis: -27% Blackmore, et al. JACR, 2011 Blackmore, JACR. 2011
27 Radiology Informatics 27
28 Clinician IMPLEMENTATION TOOLS Shared Decision Making Actionabl e Reporting Patient Correct Test Protocol Interpret Study Optimal Images Acquired Images
29 ADVANCING SOPHISTICATION OF IMAGING INFORMATICS AUTOMATION CDS COMMUNICATION EHR INTERPRETATION PACS INFORMATION RIS DIGITAL MODALITIES
30 TRADITIONAL RADIOLOGY REPORTING INTERPRETATION SPEECH RECOGNITION IMAGE DATA EXAM DATA PATIENT DATA INFORMATION RADIOLOGY REPORT NARRATIVE COMPONENT COMMUNICATION EHR/PHR
31 IMAGING 3.0 REPORTING INTERPRETATION SPEECH RECOGNITION CLINICAL DECISION SUPPORT IMAGE DATA NATURAL LANGUAGE PROCESSING EXAM DATA PATIENT DATA RADIOLOGIST DECISION SUPPORT ACTIONABLE FINDINGS INFORMATION RADIOLOGY REPORT NARRATIVE COMPONENT STRUCTURED COMPONENT MEDIA RICH REPORTS STANDARD LEXICON FINDINGS RECOMMENDATIONS COMMUNICATION EHR/PHR RESULTS MANAGEMENT ALERT NOTIFICATION SYSTEMS REGISTRIES REGISTRY REPORTING FOLLOW-UP MANAGEMENT
32 FROM MANY TO MANY 10,000 s 1,000 s 1, s MEDICAL LITERATURE REFERENCES CLINICAL IMAGING GUIDELINES CLINICAL SCENARIOS INDICATIONS EXAMS CDS 10 s 1,000 s 100,000 s 10,000,000 s 100,000,000 s EHRS HOSPITALS ORDERING PHYSICIAN MEDICAL IMAGING DECISIONS PATIENTS
33 SUCCESSFUL CDS REQUIRES MORE THAN JUST A SOFTWARE 10,000 s 1,000 s 1, s REFERENCED MEDICAL LITERATURE CLINICAL IMAGING GUIDELINES CLINICAL SCENARIOS INDICATIONS EXAMS CDS 10 s 1,000 s 100,000 s 10,000,000 s 100,000,000 s EHRS HOSPITALS ORDERING PHYSICIAN MEDICAL IMAGING DECISIONS PATIENTS
34 Improving Imaging Efficiency Summary: Systems Engineering Training at all levels in Lean and the Fryback & Thornbury Model Informatics Tools Clinical Decision Support at POC and Performance Feedback
35 Thank You!
36 Timeline for AUC Implementation 36 November 15, 2015 CMS must specify eligible AUCs April 1, 2016 CMS must identify eligible CDS mechanisms January 1, 2017 CMS will no longer pay TC for advanced imaging unless CDS has been consulted January 1, 2020 Pre-auth for outliers
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