In the past five years, no sector of healthcare has had as big a target on its back as advanced diagnostic imaging services has. Representatives of commercial insurance companies, politicians and even the media all have gravitated to using an MRI or CT service as the prime example of healthcare system waste. The resulting and calamitous reimbursement cuts the imaging industry has experienced, or been threatened with, has increased bankruptcies of providers and manufacturers while flooding venture capital into utilization management schemes.
Other healthcare sectors - some bleeding money from inefficiencies that were squeezed out of the imaging industry years ago – watch the cycle with knowing they could not survive the microscopic view imaging has been under.
The Patient’s Right to Know
Notably, patients’ voices have been absent from the ongoing target practice. The government officials and insurers who laud their goal of patient-centered care have not asked the patients if they wish to rely on their doctors’ best guesses of what’s wrong, or, obtain that picture which confirms what is or is not wrong. For most of us who have been patients, seeing is believing. For a patient, it can bring relief, or understanding of the need for lifestyle changes or help combat the denial that can come with the cruel reality of a positive finding. To the patient, a picture is often more comprehensible than thousands of the doctor’s words.
Solutions are necessary that balance the patient’s right to know with the concern regarding using the limited healthcare dollar only on what is clinically appropriate.
One such solution is e-ordering, sometimes referred to as electronic clinical decision support. E-ordering offers real-time access to evidence-based, clinical guidance regarding appropriate imaging studies for specific presenting conditions. The entire imaging industry – minus several utilization management vendors – should loudly and proudly embrace e-ordering. This is a way to document the appropriateness of the care provided while generating back-end data which offers indications of success, as well as if “waste” is occurring with imaging, and if so, who the perpetrators are. Even if seeing (evidenced-based data) isn’t necessarily believing for all politicians and insurers, at least our patients will have the assurance that their care has been data-driven, clinically appropriate: the right test has been done at the right time.
A New Coalition is Formed
Early this year, the Imaging e-Ordering Coalition was formed to promote evidenced-based, electronic decision-support for imaging. While computerized physician order entry will eventually happen in most arenas, e-ordering can also be accomplished through online portals or, for those not currently electronically connected, an efficient and physician-friendly phone call to an entity that is electronically connected.
While the singular goal of the e-Ordering Coalition is to promote clinical decision-support as a “value-add” solution for healthcare, the interests of the Coalition members are broad, ranging from providers’ intense dislike of the “value-subtract” radiology benefits management (RBM) vendors bring to companies promoting specific e-Ordering tools.
Why Part of Best-Practices
Why e-Ordering should be considered a part of best-practices for ordering imaging exams are the many benefits it offers.
Some of these benefits include the following:
1. Because the ordering clinician is given advice regarding appropriateness, it avoids the inefficient inconsistencies that the RBM model has with denials that result in appeals (some patients have a clinician with the tenacity to pursue an appeal until the order is granted, others have to accept the initial denial);
2. It’s an educational approach, not a barrier approach;
3. An electronic record is created of the interaction, which can be attached to the claim as an authorization requirement or, in the future, for PQRI reporting;
4. This electronic record allows aggregated analysis of the data for credible, comparative measurement;
5. The process is consistent with national HIT goals of interoperability and interconnectivity and “meaningful use”;
6. Real-time, clinically-based information is available to the ordering clinician at the time it is needed; and,
7. The exercise offers assurance to the patient and whoever is paying that the most appropriate test has been provided.
E-Ordering Gives “Meaning” to RIS
The Coalition has been aggressive with its education of Members of Congress, officials at CMS who are overseeing a demonstration project on e-ordering for radiology, as well as with relevant HIT workgroup members. While the initial language of the federal stimulus package referred to clinical decision-support when appropriating funds to promote electronic medical record adoption, continuity in execution was non-existent. The initial draft of “meaningful use” excluded ambulatory information systems for radiology. The e-Ordering Coalition formed a radiology user Provider Roundtable. The group communicated with Dr. David Blumenthal, the HIT Coordinator, about meaningful use for radiology in a widely circulated letter. The group also created and submitted a matrix for defining meaningful use for ambulatory information systems for radiology.
Imaging Must Promote Solutions
Viable solutions must be embraced by the imaging industry if the current death spiral is to be broken and the industry can again turn its attention to innovation in patient care rather than its own survival. Rapid adoption of e-ordering is a solution which offers a credible defense against the forces that have targeted the industry. For information about the Imaging e-Ordering Coalition, contact Robert Bradner, Holland & Knight law firm: 202.457.7004.
Authors: Scott Cowsill & Liz Quam are co-founders of the Imaging e-Ordering Coalition, a group of organizations that support electronic ordering of diagnostic imaging services through the use of computerized clinical decision-support tools. Coalition members include the American College of Radiology, the Center for Diagnostic Imaging, GE Healthcare, Medicalis, Merge Healthcare and Nuance Communications.
Scott Cowsill is chair of the Imaging e-Ordering Coalition, and senior product manager of the diagnostic imaging team, Nuance Healthcare; RadPort is Nuance’s e-Ordering Solution. Liz Quam is chair of the Imaging e-Ordering Coalition and Executive Director of CDI Quality Institute, Center for Diagnostic Imaging.