Minnesota’s groundbreaking Institute for Clinical Systems Improvement (ICSI) has reached an agreement with Nuance, Burlington, Massachusetts, to license its decision-support and analytics software for a statewide electronic utilization management initiative to ensure delivery of clinically indicated high-tech diagnostic imaging. The statewide initiative builds on an earlier, successful pilot that brought high-tech imaging growth down to zero in 2007, saving the state $28 million. ImagingBiz spoke with Scott Cowsill, MBA-HCM, chair of the Imaging e-Ordering Coalition and senior product manager of diagnostic solutions, Nuance.ImagingBiz: The ICSI statewide project follows an earlier pilot in the Minneapolis area. What was accomplished in the smaller project that ICSI hopes to duplicate on a larger scale?Cowsill: The ICSI pilot program, although it was smaller, was still significant in size. From what they tell me, it represented 50% of the high-tech diagnostic imaging ordering clinicians. What they gleaned from the pilot was that if they could do this statewide (and they extrapolated much of the savings), they could save $60 million dollars by eliminating unnecessary or inappropriate high-tech imaging, once it was rolled out statewide to all ordering clinicians. Beyond the savings, the pilot proved that there are other solutions besides an RBM that work. Not only do they work, but they are more user-friendly for all of the players: Providers like using clinical decision-support because it is more user-friendly: more educative, less of a barrier, and a zero-penalty approach. Payors like it because it is more streamlined and more cost-effective: It is less than what the RBMs charge them per-member, per-month. And the patients like it because now there is not a third-party intermediary between them trying to get a high-tech diagnostic imaging exam, there is no one in between the physician–patient relationship.ImagingBiz: Was this an outpatient-only pilot?Cowsill: I am pretty sure it was based on ambulatory care, outpatient settings, but there may have been some inpatient involvement. I don’t think the new project will be restricted to just outpatient imaging, but the majority of it initially will be targeted at outpatient use. ImagingBiz: This win has been a long time coming for radiology decision-support software, and it appears that a key was ICSI’s ability to align the incentives of payors, providers, and patients. As the president of the e-ordering initiative, do you see any other organizations with the alignment and the will to take on such a project?Cowsill: Actually, I do, now that Minnesota has done it. Everybody has been watching Minnesota for the past three-and-a-half, four years, and they say that, “OK, if they did it, we can do it.” You’d be surprised at the traction this is getting across the country and in other states, and I can speak to a few of these. One, specifically, is the state of Washington. They actually passed legislation, that’s House Bill 2105 by Rep. Eileen Cody (D-34th district). In the legal verbiage, it addresses ICSI by name, and in a high-level summary basically says we want to do the same thing that Minnesota did. They put together a group there and they are in the process of bringing together all of the payors and the providers to find a common solution to use. That’s one state that has legislation, and I can tell you that there are a couple other states that we have spent time in recently that are not far behind. In the pecking order, Minnesota has done it, I would say Washington will be next, and then there are probably two or three states right behind Washington that are on the verge of having all of the players come to the table and say yes, this is the solution. As the states sign on, I think you will see this happen very quickly.ImagingBiz: In addition to licensing Nuance’s decision-support software, the larger initiative will deploy RadCube, the analysis tool. Was this used in the pilot, and if so, how? What type of analysis would the software enable and who will have access to the tool?Cowsill: As far as I know RadCube was not used in the pilot: They did their raw data extraction on their own and it wasn’t as all-inclusive as what they are looking for in the broader initiative now that we are rolling out across the state. So, no, it wasn’t used, but obviously they had output data that they did report on and publish. With the cube in the broader initiative, the objective is to be able to report on patient disease states at a very high level. They have an organization called Minnesota Community Measurement, which develops a lot of benchmark, baseline, evidence-based guidelines for different organizations in Minnesota. What they are hoping is to do the same thing in a different niche, specifically high-tech diagnostic imaging. They are hoping to show the payors, the insurance companies who are paying for all of this in Minnesota, that the investment they’ve made—since they are paying for this tool for their provider networks—is effective. Objectively, if it’s a closed system, you can do something on the front end all day, but if you can’t measure it or see what you are doing on the backend, then what’s the value? We can deploy clinical decision-support, and we can do the right test for the patient the first time, but what is that really doing on the back end? I don’t just mean utilization trends—are we doing more, are we doing less, are we forcing one modality to another, or high tech to low tech, or low tech to high tech—I mean using the RadCube to look at clinical outcomes, so are we finding more pathologies? If I am not mistaken, ICSI (in their initial pass at this) found that they were having better clinical outcomes from studies in the pilot: They were doing less high-tech imaging but finding more clinical diagnosis that helped the patients in their health care clinical pathway. So those are the kinds of things we want to be able to look at and as far as I know, we haven’t been able to do this in the past. This is closing the entire loop and hopefully getting a lot more granular with what we are able to see; putting all the pieces together so we have a much broader picture of what we are doing and how effective it can be.ImagingBiz: Providers and payors are represented in ICSI. Is it just the payors who are financing the licensing of the software?Cowsill: Yes that is correct. It is more along the traditional model of how the RBMs work: The payors pay for the RBMS, why wouldn’t it go along the same lines? The objective was to not put the burden back on the using clinician. So yes, they are paying for it, but it is significantly less expensive and a lot more streamlined: We have taken the extra step to incorporate this into the EMR, into computerized physician order-entry workflow. We are working through the vendors, trying to hit all of them, but we are currently in Epic. ImagingBiz: Radiology providers clearly lose volume with such an initiative. What do they stand to gain?Cowsill: Radiologists tend to look at this and say: Gee, I am going to be cutting my own throat from a revenue-stream standpoint, but that is not necessarily true. If you have a multimodality-imaging center and you are using clinical guidelines to determine the right test for the patient at the right time, you are not losing volume, it is simply pushed into another modality. If you have an imaging center with one modality, then yes, there would be a revenue impact for you. More importantly, radiologists are looking at this and saying, we know we need to do the right thing. If we don’t step up and take the initiative to do the right thing for the patients, somebody is going to step up and tell us what to do. ImagingBiz: What are the patient benefits?Cowsill: The patient side to me is the most exciting side of the story. No matter if you work in health care or not, we are all patients in this grand scheme of things. If you are not a patient, your tax dollars are paying for patients, whether through Medicare- or Medicaid-type financing. Imagine you twist your knee and your primary care provider thinks you need a CT of the knee. So you have to take Monday off work, even if you don’t have any paid time off. That is lost revenue for you and lost productivity for the employer. Maybe you have to get a babysitter and you need a ride to the exam, and of course there is a deductible and a co-pay, and it comes back inconclusive and your primary care physician says the radiologist recommends a follow up MRI. So now you have to take another day off from work. I haven’t done the math, but I would think that these costs would even surpass the actual hard-core spending on what we are saving in not doing certain exams, which is in the billions of dollars. It’s your money, it’s your time, and it’s your state of mind. People should have the right test based on evidence-based guidelines the first time. That’s a simple thing; the question is how do we make that happen and make it actionable and consumable for everybody, and I think clinical decision support is the answer to that.