Pulse
A Good Choice
An electronic system that helps physicians make decisions about which high-tech diagnostic imaging tests to order has reduced unnecessary scans—and attracted national attention.
John Butler, M.D., won’t forget the subject line of the email he received one day. It read: “Mission Impossible.” Its message contained a challenge: Could Butler and others in HealthPartners’ informatics group come up with a better way to help physicians decide if their patients needed high-tech diagnostic imaging tests than having to call their patient’s health insurer?
To put the brakes on runaway imaging costs and help ensure that the most appropriate scan was being ordered, insurers were asking doctors to seek their approval before ordering imaging tests. Usage of MRI, CT, PET, and nuclear cardiology had been increasing in Minnesota by 8 percent annually. “This was adding to the cost of health care without evidence of improvement in patient outcomes,” says Cally Vinz, vice president of clinical products and strategic initiatives for the Institute for Clinical Systems Improvement (ICSI), a quality-improvement organization in Bloomington.
The reasons for the increasing use of high-tech imaging technologies were numerous. In some cases, physicians were erring on the side of caution, ordering tests so as to not miss a diagnosis. In others, patients were asking for certain tests they’d heard about. And with nonradiology practices buying their own equipment, scanners were becoming ubiquitous, making imaging services available in places they had not been before.
In order to curb inappropriate usage, Medica announced that starting in January 2007, physicians would have to call a radiology business management company, answer a series of questions, and get the company’s approval in order to ensure the health plan would pay for a scan. Soon after, HealthPartners and Blue Cross and Blue Shield of Minnesota announced similar plans.
The health plans’ move provoked indignation from physicians, who were frustrated by the idea of having to convince someone who might not have medical training why a particular patient needed a certain type of scan. “We’d had experience with preauthorization for medications, where various insurers have various formularies,” says Butler, who also practices internal medicine at HealthPartners’ Arden Hills clinic. “You would have to explain that you’ve tried different medications and why you felt this one was indicated for the patient. It was one more thing that you had to call in for and fill out paperwork for that was time-consuming.”
Physicians questioned whether the extra step of making a phone call really would save money and improve care. “If you put an obstacle in front of doctors, they usually figure out a way to get around it,” Butler says. “On the other hand, if you respectfully give them good information during the ordering process, they will do the right thing.”
Questions and Answers
Butler and others from the HealthPartners group created a decision-support tool that could be embedded in the Epic electronic medical record order-entry system that they and a number of other large medical groups in Minnesota use. Butler’s task was to work with the American College of Radiology guidelines and local experts to develop the set of questions that a physician would have to answer before ordering a scan. The questions about the patient’s symptoms and findings help determine whether a particular test is indicated and whether its utility is categorized as high, borderline or indeterminate, or low. In some cases, the system suggests an alternative.
Word Spreads
Since an Institute for Clinical Systems Improvement (ICSI)-sponsored pilot of decision support for high-tech diagnostic imaging ended in 2008, the participating medical groups are continuing to use it. ICSI also has been working with a vendor to create a more robust system that could be made available to all practices in Minnesota either through their electronic medical record system or a website.
“There is a lot of interest around the country in using this approach,” says Patrick Courneya, M.D., medical director for care delivery systems at HealthPartners. Courneya says he has talked with medical groups and state officials from Illinois, Washington, and Oregon that are interested in trying similar initiatives as well as representatives from the federal government. Next year, the Centers for Medicare and Medicaid Services will award $10 million in grants for demonstration projects on the appropriate use of diagnostic imaging services. ICSI plans to apply for funding to extend the use of decision support to providers who serve Medicare patients.
Courneya and John Butler, M.D., who helped design a system some medical groups tested in the pilot, both see decision support eventually replacing the need for having insurer approval before ordering a scan. “Prior authorization and prior notification are obstacles that create inefficiencies in the system,” Butler says. “They save short-term costs, but they make things harder to do. You think twice about doing things, and it makes people stay later at night and have less time to do the things they should be doing.”—K.K.
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HealthPartners shared what it was developing with a collaborative of medical groups and insurers convened by ICSI that was wrestling with the issue as well. The group then began planning a pilot of decision-support. The pilot eventually involved 2,300 providers from Allina Medical Clinic, Fairview Health Services, HealthPartners Medical Group, and SMDC Health System who agreed to use decision support before ordering the most common types of scans done in Minnesota. In exchange, the health plans agreed to exempt those providers from having to call them before ordering an imaging test.
Within months, participants were seeing results. ICSI conducted an audit of 300 charts belonging to patients from one large medical group whose primary care providers had ordered CTs and MRIs of the head and MRIs of the lumbar spine. The review found that 89 percent of tests ordered after the decision- support system was implemented fit the appropriateness criteria as compared with 79 percent of those ordered without decision support.
A comparison of claims sent to the major health plans in Minnesota (HealthPartners, Blue Cross and Blue Shield, Medica, and UCare) and the Minnesota Department of Human Services by the participating provider groups found the combination of using decision support and notifying the insurer of intent to scan reduced imaging claims by 3 percent in 2007. “We went from seeing an 8 percent annual increase in scans to zero,” Vinz says, adding that the decision-support initiative saved $25 million that first year and an estimated six lives as a result of reduced radiation exposure. Extrapolate that data to the entire state, she says, and there’s the potential to save more than 20 lives and $60 million annually.
Bonus Benefits
In addition to saving money and lives, decision support has other benefits. For one thing, doctors are accepting of it. Barry Bershow, M.D., vice president for quality at Fairview Health Services, says that since the Fairview clinics started using decision support, he hasn’t heard the sort of grumbling that he heard about having to seek approval from an insurance company. “A lot of physicians saw immediately, especially if they had experience calling the out-of-state vendors, that this was a far-superior method,” he says. “One said, ‘I don’t like it any more than the metered ramps on the freeway, but I understand why we have to have it.’”
Bershow says he’s also heard from physicians who believe it has improved their practice. “I got an email from a doc who found out he had been ordering one test for a hematuria workup when, in fact, the recommended test was something else,” he recalls.
Butler admits he has learned from the system as well. “I feel I’m a little more informed about which test is appropriate under certain circumstances,” he says. “If I ordered an MRI scan for a severe headache with suspected intracranial hemorrhage, decision support would say that in that case, a CT scan is better. But in most other cases, the more expensive MRI is more likely to be diagnostic.”
Butler has also found the system helps him educate his patients. For example, if a patient has back pain, he can show that in many cases, waiting six weeks to see if the symptoms improve may lead to better outcomes than testing and reacting to incidental findings that may not be the cause of the problem. In addition, decision support has the potential to help refine the criteria for ordering diagnostic imaging tests. “How you order diagnostic imaging is kind of a gestalt thing. It’s medical intuition,” Butler says, explaining that many of the guidelines for imaging tend to be based on expert opinion rather than outcomes data. “So as we get more defined decision support and it’s more widely used around the country, we will be able to say ordering this test under these circumstances has a certain utility based on real experience. Right now, we have a lot of ambiguity—we just don’t know if they help or not.”
He explains that the value of an imaging test should be judged on how often or under which circumstances it leads to an intervention that ultimately benefits the patient. “Making those connections is something we haven’t yet been able to do accurately,” he says.—Kim Kiser