Improving the Value of High-End Imaging

1,162 views
1,025 views

Published on

For more information on Group Health's high-end imaging improvements and innovations like this, please go to www.ghinnovates.org.

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,162
On SlideShare
0
From Embeds
0
Number of Embeds
165
Actions
Shares
0
Downloads
23
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • At the Epic user group meeting we heard the experience of some other multispecialty group practices have dealt with the increase in high end imaging costs What we saw suggested that there is a big opportunity. Because they use also use Epic, we can import their solution directly into our tool.
  • At the Epic user group meeting we heard the experience of some other multispecialty group practices have dealt with the increase in high end imaging costs What we saw suggested that there is a big opportunity. Because they use also use Epic, we can import their solution directly into our tool.
  • Matt Transition to how we implemented Starts with the case for change Case for change - Safety, Decision Support, Value
  • Bob Our implementation – like all implementations, started with that case for change (Matt will have just summarized it) We chose to adapt a decision support package that we identified as a best practice from a high performing group that uses the same electronic medical record (its Health Partners, but I wouldn’t say that). Like all decision support for radiology ordering, it is imperfect It is no better than the evidence base that exists, which is limited The American College of Radiology, from which this was adapted, is an “easy grader” Limitations and all, it is an important tool to help make sure that we are informing ordering, rather than reducing both inappropriate and appropriate imaging Feedback of ordering rates, with transparent comparison to peers has been helpful in promoting conversations to address clinical variation
  • Bob Here is what the clinical decision support looks like: Each of the questions represents a clinical issue that will almost always include the clinical issue you are work on with the patient.
  • Bob After clicking on a question, indications are grouped by appropriateness, and sometimes recommend a different exam for an indication Remember that the ACR 7,8,9 are “ A ” criteria – reasonable evidence to support the imaging study for the clinical indication ACR 4,5,6 are the “ B ” criteria - borderline evidence ACR 1,2,3 are the “ C ” criteria – no evidence to support
  • Bob Another resource available to clinicians is expert consultation through a “virtual consult” At any time, a clinician can send a message to their local radiologist asking a specific question to get a recommendation for ordering. Here is a mock up of one (I would read it) (transition is to a virtual consult in chart review)
  • ----- Meeting Notes (2/21/11 17:49) ----- Bob The virtual consult routes back to the clinician's inbasket, and is also visible int he chart. One click and anyone working with that patient can see the recommendation (transition is to the virtual consult)
  • ----- Meeting Notes (2/21/11 17:49) ----- Bob so here is a mock up of a virtual consult about imaging. Now, Matt made this mock up for us - I think more to make a larger point about this tool than to provide a representative sample. So what is our impact to date? (transition is to the overall GPD ordering rate)
  • First, when we look at ordering rates in our Group Practice, we should start with the fact that our rate was significantly lower than our wider network to begin with We have seen an important decrease in ordering, on the order of 20%. So where is that coming from? (Transition is to the primary care ordering rates)
  • Bob We have seen a pretty remarkable decrease in ordering of MRI and CT in primary care, now over 20% While we think that is good, there was some concern that this was just going to push the ordering into specialty, decreasing the efficiency of care delivery (Transition - Next slide is specialty ordering)
  • Bob We have seen a strong trend of lower rates of ordering in specialty, despite the fact that there is a large decrease in ordering in primary care. Not shown is our urgent care rate, which has not changed to date – a remaining opportunity Transition back to Matt: We chose a decision support model to help get engagement with clinicians – we think it has been necessary but insufficient Feedback of performance has been an essential part of the program Then Matt will introduce Kelly’s presentation
  • Matt ----- Meeting Notes (2/21/11 17:49) ----- Matt So what have we learned - it is a Kaiser Soze lesson: Implementation is not a binary event technical vs adaptive change Feedback matters the clinical wisdom of our group is a valuable resource Leadership matters
  • Improving the Value of High-End Imaging

    1. 1. Matt Handley, MD and Robert Karl, Jr., MD Group Health Physicians Kelly Weaver, MD The Everett Clinic Improving the Value of High-End Imaging: Engaging Providers With Feedback
    2. 2. Value Matters <ul><li>While administrative efforts can achieve some decreases in utilization, they can decrease both appropriate and inappropriate care </li></ul><ul><li>We cannot improve the value of the care we deliver without clinicians making different decisions with patients. </li></ul><ul><li>The decisions clinicians make drive roughly 84% of the costs of care </li></ul>
    3. 3. Case for Change <ul><li>The use of high end imaging (CT and MR) at GHC has more than doubled in the last 10 years (and with that increase, was lower than the community) </li></ul><ul><li>Imaging is not without risk – 1-2% of the cancer in the US is thought to be iatrogenic </li></ul><ul><li>Costs associated with imaging are rising rapidly (for purchasers, payors and patients) </li></ul>
    4. 4. Why High End Imaging Matters Clinically <ul><li>There are two main risks to High End Imaging: </li></ul><ul><li>Harm from Ionizing Radiation </li></ul><ul><ul><li>1-2% of the cancers in the US now caused by ionizing radiation </li></ul></ul><ul><ul><li>CTs done in 2007 will result in 29,000 cancers </li></ul></ul><ul><li>Harm from following and investigating “ Incidentalomas ” </li></ul><ul><ul><li>Up to 40% of studies have incidental findings, follow up recommended in 10 – 20% </li></ul></ul>
    5. 5. Clinical Variation as a Fractal <ul><li>A fractal is &quot;a rough or fragmented geometric shape that can be split into parts, each of which is (at least approximately) a reduced-size copy of the whole, ” a property called self-similarity. </li></ul>
    6. 6. High End Imaging Variation in PC Across All Clinics
    7. 7. Intra-Clinic Variation
    8. 8. High End Imaging Variation in Specialty Across Service Lines
    9. 9. The Toolkit for Changing Practice <ul><li>Engagement - case for change, alignment of values, involvement in generating solutions </li></ul><ul><li>Tactics </li></ul><ul><ul><li>Large and Small group CME </li></ul></ul><ul><ul><li>Feedback </li></ul></ul><ul><ul><li>Academic Detailing </li></ul></ul><ul><ul><li>Clinical Opinion leaders </li></ul></ul><ul><ul><li>Clinical Decision Support </li></ul></ul><ul><ul><li>Patient Specific decision support </li></ul></ul><ul><ul><li>Patient centered strategies </li></ul></ul><ul><ul><li>Clinical process redesign - workflow </li></ul></ul><ul><ul><li>Administrative/regulatory activities </li></ul></ul>
    10. 10. Feedback <ul><li>Effectiveness: </li></ul><ul><ul><li>Variable effectiveness in controlled trials </li></ul></ul><ul><ul><li>Peer comparison > Aggregate </li></ul></ul><ul><ul><li>Active > Passive </li></ul></ul><ul><ul><li>Concurrent > Delayed </li></ul></ul><ul><li>More effective with personal contact </li></ul>
    11. 12. Robert Karl, Jr., MD Group Health Physicians High End Imaging
    12. 13. The GHC Story <ul><li> Case for change—Safety, Decision Support, Value  </li></ul><ul><li>Focus on Clinical Decision Support </li></ul><ul><ul><li>Embed in EMR </li></ul></ul><ul><ul><li>Clinical tool isn’ t perfect </li></ul></ul><ul><ul><ul><ul><li>“ necessary but insufficient” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>One part of the intervention </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Easy access to specialty consultation </li></ul></ul></ul></ul>Feedback - active, peer comparison, quarterly, transparent
    13. 14. Integration of Clinical Decision Support into Epic
    14. 15. Headache Drop Down Options A: Evidence supports ordering for the clinical indication B: Equivocal evidence for the clinical indication C: (Not shown) No evidence for the clinical indication
    15. 16. Virtual Consults
    16. 18. Virtual Consult Documentation
    17. 19. Group Practice Ordering Rate
    18. 20. Primary Care Ordering Rates
    19. 21. Specialty Care Ordering Rates
    20. 22. Managing Advanced Imaging At The Everett Clinic Kelly Weaver, MD Advanced Imaging Center
    21. 23. Lumbar Spine Imaging
    22. 24. EMR Ordering Screen
    23. 25. EMR Ordering Screen
    24. 26. January 1, 2010 <ul><li>Criteria “Mandatory” </li></ul><ul><ul><ul><li>MRI Cervical Spine CT Chest </li></ul></ul></ul><ul><ul><ul><li>MRI Thoracic Spine CT Abdomen & Pelvis </li></ul></ul></ul><ul><ul><ul><li>MRI Lumbar Spine CT Sinus </li></ul></ul></ul><ul><ul><ul><li>MRI Knee MRI Shoulder </li></ul></ul></ul><ul><ul><ul><li>Cardiac Nuclear </li></ul></ul></ul>
    25. 27. # CT and MRI in 2009 Family Practice 800 700 600 500 400 300 200 100 0
    26. 28. Complete The Message <ul><li>What providers can’t do </li></ul><ul><li>VS. </li></ul><ul><li>What providers should do </li></ul>
    27. 29. 2010: The High Road <ul><li>Communication . . . </li></ul><ul><ul><li>Study Duplication </li></ul></ul><ul><ul><li>Radiation Exposure </li></ul></ul><ul><ul><li>Conservative Care First </li></ul></ul><ul><ul><li>Cost Of Care </li></ul></ul><ul><ul><ul><li>My $400.00 Normal Shoulder MRI </li></ul></ul></ul>
    28. 30. 2010: The Low Road <ul><li>“ Weaver” Graphs </li></ul>
    29. 31. # CT and MRI in 2009 Family Practice 800 700 600 500 400 300 200 100 0
    30. 32. # CT and MRI per 1000 Visits FP in 2009 120 100 80 60 40 20 0
    31. 36. July 1, 2010 <ul><li>Criteria “Mandatory” </li></ul><ul><ul><ul><li>MRI Cervical Spine CT Chest </li></ul></ul></ul><ul><ul><ul><li>MRI Thoracic Spine CT Abdomen & Pelvis </li></ul></ul></ul><ul><ul><ul><li>MRI Lumbar Spine CT Sinus </li></ul></ul></ul><ul><ul><ul><li>MRI Knee MRI Shoulder </li></ul></ul></ul><ul><ul><ul><li>Cardiac Nuclear </li></ul></ul></ul><ul><ul><ul><li>MRI Brain CT Brain </li></ul></ul></ul><ul><ul><ul><li>MRI Elbow MRI Ankle </li></ul></ul></ul><ul><ul><ul><li>MRI Wrist MRI Hip </li></ul></ul></ul>
    32. 37. Q4 2010 Results Compared to 2006
    33. 38. Take Home – “Engagement” <ul><li>Evidence Based Medicine – Good! </li></ul><ul><li>Education – Good! </li></ul><ul><li>Guilt – Better! </li></ul><ul><li>Ego – Best! </li></ul>
    34. 39. Learning Together <ul><li>While we are making progress in the “technical” aspects of change, we are just starting the “adaptive” aspects of change </li></ul><ul><li>How will we continue to improve? </li></ul><ul><ul><li>Transparency of performance </li></ul></ul><ul><ul><li>Collegial conversations </li></ul></ul><ul><ul><li>Change of Paradigm </li></ul></ul>From: Defensible ordering/Teach to the Test To: How likely is it that the result of the study will make an important change in clinical outcomes?

    ×