“Radiologists have been talking about the value paradigm for a number of years,” says Jonathan B. Kruskal, MD, PhD, FACR, chairman, department of radiology and radiologist-in-chief, Beth Israel Deaconess Medical Center and chair of the American College of Radiology’s Quality Management Committee. “It is way past due that all radiologists embrace every component of this new reality of our world.”
According to Kruskal, the elements of value that a service provides are broken down into the value equation, which links quality, appropriateness and outcomes “inversely to cost.” In practical terms, radiologists need to approach the way that they manage measurements obtained when evaluating the quality of services that they provide. “This also means that we all must embrace appropriateness since an inappropriate study that we perform essentially is of absolutely no value to any stakeholder,” Kruskal emphasizes.
When it comes to issues regarding appropriateness and outcomes, radiology information technology does, and will continue to play a crucial role. IT can be used to demonstrate utilization and outcomes, and by extension appropriateness, says Jon Copland, Inland Imaging, Wash., CIO and CEO of the practice’s information technology services subsidiary.
As an example, he points out that it’s not unusual for primary care providers to utilize chest X-rays to see if a patient has pneumonia or tuberculosis, and it should be easy to track how often the imaging results in a negative result. If the percentage is relatively high, then there’s an appropriateness issue.
At the same time, Copland says, one can show that an eye, ear and nose physician who sends a large number of patients for a CT exam is a high utilizer of imaging, but that the number of exams that come up positive could be relatively high.
“We can do a statistical analysis of appropriateness of care,” Copland says, adding that it’s also a way of demonstrating value in a value-based healthcare model, as opposed to the traditional fee-for-service model in which “you get paid for services, whether they’re appropriate or not.”
This transition to a value-based model is one that organized radiology has long been preparing for, Kruskal says. “Organized radiology has taken many steps over many years to help practices prepare for the value-based payment schemes,” he says. “In particular, the American College of Radiology has played a yeoman’s role in not only making every effort to spread the concept and challenges and opportunities inherent in this paradigm through its Imaging 3.0 program, but they’ve also strived to develop and deploy a host of tools that can be utilized to measure quality, appropriateness and outcomes.” One of those tools is clinical decision support.
Clinical decision support
The concept of clinical decision support (CDS) has been around for quite a long time. For example, Massachusetts General Hospital—in the absence of readily available commercial computerized order-entry systems and CDS tools—developed its own decision support system in 2004 for advanced imaging examinations such as CT, MRI, nuclear medicine and PET.
The passage of the American Reinvestment and Recovery Act, and the accompanying Health Information Technology for Economic and Clinical Health Act, and its support for the concept of electronic health records, led to the broad implementation of EMRs, which, in turn, has created an environment favorable to the development and deployment of CDS.
“Hundreds of hospitals have de- ployed the technology,” says Keith Dreyer, DO, PhD, FACR, FSIIM, vice chair of radiology, and director, Center for Clinical Data Science, Massachusetts General Hospital, Boston. “It’s integrated into most all of the major electronic health records.”
With the fairly rapid deployment of EHRs into American health systems, and the fact that CDS has been shown to reduce inappropriate imaging—and by extension improve patient care and cut costs—a provision of the Protecting Access to Medicare Act (PAMA) requires physicians to use CDS tools and document their use whenever they order advanced imaging tests.
PAMA, which was signed into law by President Obama in April 2014, mandates that physicians utilize appropriate use criteria through CDS when ordering advanced imaging studies such as diagnostic MRI, CT, and nuclear medicine. It also only applies to outpatient settings such as physician offices, ambulatory surgical centers and hospital outpatient departments. Originally set