The Technology to Order the Right Imaging Test the First Time

I discussed the challenges of determining whether an imaging test is effective in last week's column, Measuring the Effectiveness of Imaging Tests Not Clear Cut. Today, I highlight a solution that is already addressing some of those concerns and is changing how imaging tests are being ordered in Minnesota.

The Imaging e-Ordering Coalition is an alliance of healthcare providers, technology companies, and diagnostic imaging organizations that have joined forces to promote health information technology-enabled decision support as a means to ensure patients are receiving medically appropriate diagnostic imaging tests.

Participants in The Coalition are the American College of Radiology, the Center for Diagnostic Imaging in Minneapolis (which operates 51 diagnostic imaging centers in nine states), GE Healthcare, Medicalis Corporation, Merge Healthcare, and Nuance Communications, Inc.

Recently, I spoke with Scott Cowsill, chair of The Coalition and senior product manager of diagnostic imaging at Nuance Healthcare, and Liz Quam, director of the Center for Diagnostic Imaging Institute and founding member of the Imaging e-ordering Coalition to discuss the goals of group.

The Coalition uses the radiology order entry technology developed at Boston's Massachusetts General Hospital (see How Many Slices Do You Really Need, HealthLeaders magazine, September 2009). "We have almost 15,000 clinical criteria guidelines in our database and that is one of the most, if not the most, robust comprehensive clinical criteria guidelines for high tech, diagnostic imaging, databases out there," says Cowsill, adding that the database is maintained through a proprietary relationship with MGH. The Coalition is striving to condense that information into a consumable, usable, and deployable mechanism for the private sector, he says.

For instance, if a patient comes to a primary-care physician complaining of headache, loss of hearing, and sinusitis, the technology factors in that information along with the patient's age and sex and provides a score based on a scale of one to nine as to whether the test being ordered will be effective. That score is based on the millions of exams that are run through the system, explains Cowsill.

And it provides all of that data in real time, says Quam. It doesn't just predict how effective that imaging modality may be, the decision-support technology also provides alternative suggestions. Based on the indications in the above scenario, a head MR may be offered as the better diagnostic modality, explains Cowsill.

"It is a consult for the physician at the time the physician is treating the patient," says Quam. "At the same time it doesn't erode the trust relationship between the physician and patient."

When physicians have to seek approval from radiology benefits managers, a patient may wonder whether they really need a test or if the test is denied because the physician wasn't persistent enough on their behalf, explains Quam. Under the RBM model, physicians can keep appealing a denial of coverage until they ultimately get approval, she says. But with e-ordering "patients and payers can be assured that the appropriate test was ordered."

So what do the payers think about e-Ordering as a substitute for the RBM model? In Minnesota, the large payers are already on board with the technology, says Quam. "We electronically can document that a decision-support tool was used by the family physician, so it is all in real time and that information goes back to the health plan," she says, adding that the health plan may require that you use the clinical decision support and then on backend they can analyze the data.

"Everybody in MN—health plans and providers—who are not always on same side—are vehement advocates of the clinical decision support, because we have seen it work," says Quam.

"Imaging is the most expensive element of care in this country," says Cowsill. So will e-Ordering help rein in those costs?

In a letter to the U.S. Senate Committee on Finance earlier this year, Barry A. Bershow, MD, medical director of quality & informatics for Minneapolis, MN-based Fairview Health Services claimed that it can.

"A number of provider groups were searching for an effective way to reduce costs and get good information to physicians ordering high tech diagnostic imaging. Calling an RBM vendor had proven to be time consuming, costly, interrupted work flow, and didn't help the patient and physician do shared decision making," Bershow wrote. "Working collaboratively with employers and health plans, as well as having our state's Department of Health and Human Services at the table, we developed a system for providing clinical decision support at the point of ordering by the primary-care physician."

Bershow noted that system had two major effects: "First, we saved 303 hours of labor per month at our system. The second was the right test was ordered the first time, while the patient was still in the exam room."